Base rates of conduct disorder in different clinical settings and populations

Note: 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.

ICD-11 Criteria

Conduct-dissocial disorder is characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms, rules, or laws are violated such as aggression towards people or animals; destruction of property; deceitfulness or theft; and serious violations of rules. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. To be diagnosed, the behaviour pattern must be enduring over a significant period of time (e.g., 12 months or more). Isolated dissocial or criminal acts are thus not in themselves grounds for the diagnosis.

• Note: The ICD-11 lists 8 additional subcategories of conduct-dissocial disorder. They can be found here.

Diagnostic strategy

The current strategy of diagnosis for Conduct Disorder is the Multistage Strategy for Evidence-Based Assessment of Conduct Disorder. ^{[7] [8]}

Stage 1:

The first stage of diagnosis uses any of the following evidence based assessments: Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR). These are used to broadly identify behaviors relevant to conduct disorder as outlined by the DSM. Both the Inventory of Callous Unemotional Traits and the Antisocial Process Screening Device (APSD) is assess whether child or adolescent is displaying callous and unemotional (CU) traits, a recently added symptom of conduct disorder as outlined by the DSM-5. There are multiple assessments taken by informants due to the covert nature of many conduct disorder problems.

Stage 2:

The second stage of diagnosis involves interviews with the patient. The Structured Diagnostic Interview (KSADS) is used to assess the potential comorbidity of conduct disorders. A semi-structured diagnostic interview (KSADS) is recommended due to its flexibility. The tool has been shown to gain client-specific information vital for case conceptualization and treatment planning, including clear descriptions of the child's behavior, peer relationships, and social skills. It also helps assess comorbidity. Age of onset of conduct problems is established in this phase, which helps determine developmental pathways.

Part of this stage of diagnosis also involves standardized intelligence tests and academic achievement screeners. Developmental and medical history is also obtained through clinical interviews. For children, clinicians may utilize observational analogues, including parent-child interactions through child's games, parent's games, and clean up. Parents will also submit a parent daily report for observation measures. Clinicians utilize this data to assess the level of functional impairment or adaptive disability according to scales such as the Child and Adolescent Functional Assessment Scale

Stage 3:

The third stage of diagnosis examines the patient's broader social and environmental context through Neighborhood Questionnaire, Community Interaction Checklist, and "Things I Have Seen and Heard" interviews. Assessment of social informational processing could yield important information relevant to the “three P’s”. Social information processing can be tested through an Intention-Cue Detection Task. It is also important to assess for familial risk factors through an antisocial behavior checklist. Further assessments specific to the symptomatology of the child or adolescent also should be conducted through assessments.

Covert conduct problem behaviors are difficult to assess, and the clinical utility of some innovative observational paradigms needs to be demonstrated. Research points to the “recent proliferation of research concerning girls and CP and suggest that this “should facilitate the development of evidence-based guidelines that are applicable to girls in the near future.” ^[7] 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.

Rating scales for conduct problems

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Observational Coding Systems

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Semi-structured and Structured Diagnostic Interviews

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Change in likelihood of conduct disorder based on rating scale scores

Note: “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^[10]; The Kahn et al., 2012 paper used 4 items from the APSD that mapped onto the DSM-V “Limited Prosocial Emotions” specifier.^[11] Of these items , those that were scored as definitely true were rated as present and the presence of two of the four items met the specifier threshold

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 scores.

Outcome and severity measures

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*

Note: “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