Conduct disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), identifies individuals with “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” (see Table 7.1) (1). These behaviors manifest as aggression to people and animals (e.g., physical fights, cruelty to animals), destruction of property (e.g., fire setting), deceitfulness, or theft (e.g., breaking into someone’s house), and/or other serious violations of rules (e.g., often truancy from school). To meet DSM-IV criteria for the disorder, at least three of 15 possible behaviors must have been present in the past 12 months, with at least one in the past six months. Specifiers include type, based on age of onset (childhood onset or adolescent onset), and severity, based on number or harmfulness of symptoms (mild, moderate, severe). Conduct disorder differs from delinquency, which refers to involvement with the police and/or court system for breaking the law. Delinquents make up a portion of the individuals with conduct disorder.
In this chapter, we focus on girls with conduct disorder, a group that has been understudied. The aim of this chapter is to present updated prevalence estimates, review biologic and psychosocial risk and protective factors, and outline course and long-term outcomes.
TABLE 7.1 DSM-IV Diagnostic Criteria for Conduct Disorder
A.
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
is often truant from school, beginning before age 13 years
B.
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C.
If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
Specifiers
1.
Type based on age at onset:
a.
Childhood-onset type: onset of at least one criterion characteristic of conduct disorder prior to age 10 years
b.
Adolescent-onset type: absence of any criteria characteristic of conduct disorder prior to age 10 years
2.
Severity:
a.
Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others
b.
Moderate: number of conduct problems and effect on others intermediate between “mild” and “severe”
c.
Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others
Adapted from American Psychiatric Association, Diagnostic and Statistical Modified Manual of Mental Disorders 4th Ed. Washington, DC: 1994:90-91.
PREVALENCE AND IMPAIRMENT
PREVALENCE
The prevalence of conduct disorder varies according to populations sampled (clinical or community), age of child, gender, and the informant. Within clinical populations, conduct disorder is among the most common reasons for referral. Data collected using the Brief Child and Family Phone Interview (2) on over 10,000 children and adolescents 6 to 18 years old who were referred to a children’s mental health center in Ontario between March 2000 and June 2003 demonstrate that 37.7% of parents endorse behaviors consistent with conduct disorder at the time of intake (see Table 7.2). Rates vary slightly by gender, with girls demonstrating slightly higher rates (girls 39.7%, 40.0%, and 39.3% for 6-18, 6-11, and 12-18 years, respectively; boys 36.4%, 36.3%, and 36.5% for the same age ranges).
General population estimates based on epidemiologic studies of behavior problems for children and adolescents 4-18 years old throughout the world range from 0.0 to 11.9% (median 2.0%) (3). Canadian data from the Ontario Child Health Study, a community-based study of 4- to 16-year-olds in Ontario completed in 1983 with follow-up in 1987, estimated prevalence at 5.5% for 4- to 16-year-olds in Ontario. Prevalence rates vary by age and gender, with higher rates reported for boys than girls and in older than younger children (girls 2.7%, 1.8%, and 4.1% for 4-16, 4-11, and 12-16 years, respectively; boys 8.1%, 6.5%, and 10.4% for the same ages) (4).
Although the prevalence of conduct disorder in the general or in specific populations is important, several issues must be recognized. First, the prevalence of a disorder depends on the threshold and therefore is somewhat arbitrary. For example, DSM-IV requires three of 15 symptoms for diagnosis (1). Changing the threshold to two or four of 15 symptoms will increase or lower the prevalence of disorder respectively. Second, within the system of psychiatric classification, diagnostic criteria for conduct disorder have changed over time, as some criteria have been modified and others added or withdrawn. Changing the behaviors required to meet criteria for conduct disorder can also influence prevalence.
Understanding differences in the rates of conduct disorder between girls and boys has been of interest to researchers in the field. It has been suggested that these differing rates reflect true differences in conduct disorder between girls and boys that arise because of differing social and cultural expectations for each sex (5). Others have argued that the establishment of DSM criteria for conduct disorder came primarily from studies of boys, and that a different definition should be used for girls with conduct disorder (6). For example, in a sample of girls representative of the general population in Quebec who demonstrated persistent antisocial behaviors from ages 6 to 10 years, only 3% met DSM-III-R criteria for conduct disorder (7), prompting the investigators to question the adequacy of the definition or criteria for conduct disorder for girls. Ideas for modification of the definition include setting gender-specific thresholds for conduct disorder or including different behaviors in the criteria for disorder (6). One investigation testing the prevalence of conduct disorder using gender-specific thresholds among children with comorbid attention deficit hyperactivity did not support a difference in diagnostic threshold by gender (8).
TABLE 7.2 Rates of Conduct Disorder and Other DisordersaAmong Children Referred to Children’s Mental Health Clinics in Ontario (May 2000 to June 2003)
aClassification of disorder based on scores on Brief Child and Family Phone Interview set at >2 standard deviations above mean score of general population sample of children aged 6-18 years.
Many of the behaviors included in conduct disorder reflect physical or direct aggression, which is more common among boys and in minor forms considered normal. Up to about 4 years of age, girls and boys generally show equal rates of aggressive behaviors. After that, rates of physically aggressive behaviors increase in boys. Data from the 1994 National Longitudinal Survey of Children and Youth (NLSCY), a long-term survey of child development and well-being in Canada, that examined physical aggression among girls and boys, suggest that differences among girls and boys may emerge earlier, since mean physical aggression scores were found to be elevated among boys as early as ages 2 to 3 years (9).
The concept of indirect or social aggression (harm caused in the context of social relationships) is thought to better represent female aggression. Peer interactions for girls in early and middle childhood are generally with other girls, and formation of close relationships is important during this developmental stage, so attempts to hurt others through disruption or control of peer relationships are potent aggressive behaviors. Girls rate social aggression as being more harmful than boys do, and rate it as harmful as physical aggression (10). In interpersonal problem situations, aggressive girls prefer relationally or indirectly aggressive solutions, whereas aggressive boys prefer overtly physical or directly aggressive solutions.
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