User:Ongmianli/Portfolios/Conduct disorder

Demographic Information and Overview of Recommendations for Evidence-Based Assessment

Overview of Multistage Strategy for Evidence-Based Assessment of Conduct Disorder(adapted from McMahon and Frick, 2005; 2007)

Stage 1:

• Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR);
  • Used to broadly identify behaviors relevant to conduct disorder;
• Antisocial Process Screening Device (APSD);
  • Used to determine whether child or adolescent is displaying callous and unemotional (CU) traits;
    • See Diagnostic Changes to Conduct Disorder for DSM-5: additional specifier for CU.

Stage 2:

• Structured Diagnostic Interview
  • (Available online: KSADS: http://www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/ksads-pl.pdf);
  • Helps to assess potential comorbidity;
• Standardized intelligence test and academic achievement screener;
• Developmental and medical history obtained through clinical interview;
• Observational analogues, including parent-child interactions – examples:
  • Child’s Game;
  • Parent’s Game;
  • Clean Up;
• Parent observation measures;
  • E.g., Parent Daily Report;
• Level of functional impairment or adaptive disability determined through interviews or ratings;
  • E.g., Child and Adolescent Functional Assessment Scale;
• Age of onset of conduct problems established through clinical or structured interviews with parent or youth;
  • Helps determine developmental pathway (see Moffitt’s (1993) seminal article “Adolescent-limited and life-course persistent antisocial behavior: A developmental taxonomy”), which has implications for the “three P’s”;
  • Helps determine temporal ordering of potential comorbid disorders (e.g., did anxiety problems precede conduct problems, or vice-versa?), which also has implications for “three P’s”.

Stage 3:

• Broader social and environmental context should be assessed;
  • E.g., Neighborhood Questionnaire, Community Interaction Checklist, Things I Have Seen and Heard;
• Assessment of social informational processing could yield important information relevant to the “three P’s”;
  • E.g., Intention-Cue Detection Task;
• Parental/personal adjustment assessment to assess for familial risk factors;
  • E.g., Antisocial Behavior Checklist;
• Further assessments specific to the symptomatology of the child or adolescent should be conducted;
  • E.g., assessments specific to fire-setting behaviors.

Additional Notes:

• Covert conduct problem behaviors are difficult to assess, and the clinical utility of some innovative observational paradigms needs to be demonstrated;
• McMahon & Frick (2005) point to the “recent proliferation of research concerning girls and CP (p. 496) and suggest that this emerging research “should facilitate the development of evidence-based guidelines that are applicable to girls in the near future.” For the time being, they recommend following the same guidelines for girls as for boys, with the addition of a measure of relational aggression in girls.

Table 1. Base Rates of Conduct Disorder in different clinical settings

Setting	Reference	Base Rate	Demography	Diagnostic Method
Nationally representative large-scale study (N=9282) - adult retrospective report	Nock, Kazdin, Hiripi, & Kessler, 2006	9.5% overall: 12% males, 7% females	All of U.S.A.	CIDIr
The Great Smoky Mountains Study – longitudinal, population-based study of community sample	Costello, Mustillo, Erkanli, Keeler, Angold, 2003	9.0% overall: 14% males, 4% females	Western North Carolina	CAPAp,y
Incarcerated adolescents	Karnik, Soller, Redlick, Silverman, Kraemer, Steiner, 2009	93% males, 92% females	California, Division of Juvenile Justice (DJJ)	SCID-IVy
Community samples – summary of past findings	Farrington, 2008	6-16% males, 2-9% females	Various locations across USA	Varied

^p Parent interviewed as part of diagnostic assessment; ^y youth interviewed as part of diagnostic assessment; ^r adult interviewed for retrospective report as part of diagnostic assessment.

Notes: CIDI = World Health Organization (WHO) Composite International Diagnostic Interview; CAPA = Child and Adolescent Psychiatric Interview; SCID-IV = Structured Clinical Interview for DSM-IV.

Despite a plethora of studies assessing prevalence of comorbidity of conduct disorder with other disorders (e.g., substance abuse, bipolar, ADHD), searches outlined below did not yield a single study providing a prevalence of conduct disorder alone in an outpatient or community clinic setting.

Diagnosis

Diagnostic Criteria for Conduct Disorder

Appendix 1: DSM-IV criteria for diagnosis of conduct disorder: The essential feature of Conduct Disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal rules are violated. Three behaviors must have been present during the past 12 months with at least one present in the past 6 months

1. Often bullies, threatens or intimidates others
2. Often initiates physical fights
3. Has used a weapon
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity
8. Has deliberately engaged in fire setting
9. Has deliberately destroyed others' property
10. Has broken into someone else's house, building or car
11. Often lies to con others
12. Has stolen items of nontrivial value without confronting the victim
13. Often out late without permission, starting before age 13
14. Has run away from home overnight at least twice
15. Often truant from school, starting before age 13

Diagnostic Changes in DSM-5

The same 4 domains of symptoms are used in DSM-IV as in DSM-5, and of these, 3 of the 4 must have been present in the last twelve months for diagnosis:

• aggression to people or animals;
• destruction of property;
• deceitfulness or theft;
• serious violations of rules.

The changes in DSM-5 to conduct disorder are as follows:

1. A descriptive specifier has been added for individuals who meet full criteria for the disorder;
2. This specifier applies to those with conduct disorder who show a callous and unemotional interpersonal style across multiple settings and relationships.

Table 2. Areas Under the Curve (AUCs) and Likelihood Ratios for Potential Screening Measures for Conduct Disorder

Screening Measure "(Primary Reference)"	Area under curve (AUC) and Sample Size	LR+ "(Score)"	LR- "(Score)"	Citation
Children and Adolescents (6-18 Years)
CBCL Aggression T-Score	.801 "(N=370)"	4.18 "(55+)"	.35 "(<55)"	Hudziak, Copeland, Stanger, (2004)

• “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes offormulation(Sackett et al., 2000)

• Searches(specified below)did not yield any data about sensitivity, specificity, AUC, or ROC for the Antisocial Process Screening Device, or for the Externalizing scale of the CBCL. Searches also did not yield data about TRF or YSR scales for Aggression or Externalizing: Achenbach and Rescorla (2001) provide data about clinically referred vs. non-referred samples but not about samples with conduct disorder specifically; thus, only AUC and LRs for the Aggression scale are reported. No studies were found that provide information about the likelihood of children or adolescents referred for conduct disorder receiving TRF or YSR Aggression or Externalizing scaled scores of a specific level versus non-CD youth receiving those score

Treatments

See Effective Child Therapy, a website sponsored by The Society for Child and Adolescent Psychology (APA, Division 53) and the Association for Behavioral and Cognitive Therapies (ABCT), for current summary of evidence-based treatments.

Process and Outcome Measures

Table 3. Statistically Significant Change Benchmarks with Common Instruments

Measure	Subscale	Cut-off scores*			Critical Change (unstandardized scores)
		A	B	C	95%	90%	SEdifference
Benchmarks Based on Published Norms
CBCL T-scores (2001 Norms)	Externalizing	49	70	58	7	6	3.4
Conduct Disorder Samples Were Not Found in Searches*

• “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean
• Search terms:(1)“antisocial process screening device,” (2) antisocial process screening device AND benchmarks, searches previously mentioned.

Process Measures

See Table 1 in Section 1.1 for overview of evidence-based measures to use depending on etiology, symptomatology and conduct problems

See Also

• Antisocial personality disorder
• Bullying
• Challenging behavior
• Oppositional defiant disorder
• Parental alienation