Conduct disorder

A gut reaction? The role of the microbiome in aggression

Recent research has unveiled conflicting evidence regarding the link between aggression and the gut microbiome. Here, we compared behavior profiles of control, germ-free (GF), and antibiotic-treated mice, as well as re-colonized GF mice to understand the impact of the gut microbiome on aggression using the resident-intruder paradigm. Our findings revealed a link between gut microbiome depletion and higher aggression, accompanied by notable changes in urine metabolite profiles and brain gene expression. This study extends beyond classical murine models to humanized mice to reveal the clinical relevance of early-life antibiotic use on aggression. Fecal microbiome transplant from infants exposed to antibiotics in early life (and sampled one month later) into mice led to increased aggression compared to mice receiving transplants from unexposed infants. This study sheds light on the role of the gut microbiome in modulating aggression and highlights its potential avenues of action, offering insights for development of therapeutic strategies for aggression-related disorders.

Adolescent delinquency following co-occurring childhood head injuries and conduct problem symptoms: findings from a UK longitudinal birth cohort

Childhood conduct problems and head injuries share a bidirectional association, but how this affects the risk of adolescent delinquency is unknown. Due to their similar underlying mechanisms (i.e. increased impulsivity), this study aims to identify whether their co-occurrence increases the risk of adolescent delinquency. Data was obtained from 11,272 children at age 14 and 10,244 at age 17 years enrolled in the UK Millennium Cohort Study. Conduct problem symptoms (via the Strengths and Difficulties Questionnaire) and head injuries were parent reported from ages 3 to 14 years. Delinquency was self-reported at ages 14 and 17 including substance use, criminality, and antisocial behaviour. Incident rate ratios (IRR) were estimated for delinquency at ages 14 and 17 by childhood conduct problem and head injury status. Co-occurring head injuries and high conduct problem symptoms presented the greatest risk for overall delinquency and substance use at age 14 compared to those with the presence of one or neither (IRRs from 1.20 to 1.60). At age 17, conduct problems (with or without co-occurring head injuries) presented the greatest risk for overall delinquency, substance use, and antisocial behaviour. There was no evidence for an increased risk of delinquency at ages 14 or 17 following a head injury only. Whilst these findings suggest childhood head injuries alone do not increase the risk of adolescent delinquency, when co-occurring alongside high conduct problem symptoms there is a heightened earlier risk. These results provide further insight into adolescent delinquency and the outcomes of co-occurring childhood head injury and conduct problem symptoms.

Cortical structure and subcortical volumes in conduct disorder: a coordinated analysis of 15 international cohorts from the ENIGMA-Antisocial Behavior Working Group

BACKGROUND

Conduct disorder is associated with the highest burden of any mental disorder in childhood, yet its neurobiology remains unclear. Inconsistent findings limit our understanding of the role of brain structure alterations in conduct disorder. This study aims to identify the most robust and replicable brain structural correlates of conduct disorder.

METHODS

The ENIGMA-Antisocial Behavior Working Group performed a coordinated analysis of structural MRI data from 15 international cohorts. Eligibility criteria were a mean sample age of 18 years or less, with data available on sex, age, and diagnosis of conduct disorder, and at least ten participants with conduct disorder and ten typically developing participants. 3D T1-weighted MRI brain scans of all participants were pre-processed using ENIGMA-standardised protocols. We assessed group differences in cortical thickness, surface area, and subcortical volumes using general linear models, adjusting for age, sex, and total intracranial volume. Group-by-sex and group-by-age interactions, and DSM-subtype comparisons (childhood-onset vs adolescent-onset, and low vs high levels of callous-unemotional traits) were investigated. People with lived experience of conduct disorder were not involved in this study.

FINDINGS

We collated individual participant data from 1185 young people with conduct disorder (339 [28·6%] female and 846 [71·4%] male) and 1253 typically developing young people (446 [35·6%] female and 807 [64·4%] male), with a mean age of 13·5 years (SD 3·0; range 7-21). Information on race and ethnicity was not available. Relative to typically developing young people, the conduct disorder group had lower surface area in 26 cortical regions and lower total surface area (Cohen's d 0·09-0·26). Cortical thickness differed in the caudal anterior cingulate cortex (d 0·16) and the banks of the superior temporal sulcus (d -0·13). The conduct disorder group also had smaller amygdala (d 0·13), nucleus accumbens (d 0·11), thalamus (d 0·14), and hippocampus (d 0·12) volumes. Most differences remained significant after adjusting for ADHD comorbidity or intelligence quotient. No group-by-sex or group-by-age interactions were detected. Few differences were found between DSM-defined conduct disorder subtypes. However, individuals with high callous-unemotional traits showed more widespread differences compared with controls than those with low callous-unemotional traits.

INTERPRETATION

Our findings provide robust evidence of subtle yet widespread brain structural alterations in conduct disorder across subtypes and sexes, mostly in surface area. These findings provide further evidence that brain alterations might contribute to conduct disorder. Greater consideration of this under-recognised disorder is needed in research and clinical practice.

FUNDING

Academy of Medical Sciences and Economic and Social Research Council.

Does behavioural parent training reduce internalising symptoms (or not) among children with externalising problems? Systematic review and meta-analysis

Behaviour parent training (BPT) is known to effectively reduce child externalising problems. However, evidence for BPT to have secondary benefits for reducing internalising symptoms remains unclear. To address this, electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, and SCOPUS) were systematically searched for studies examining internalising outcomes from BPT among children aged 2-12 years with clinically elevated externalizing problems. Outcomes for internalising problems following BPT were analysed by meta-analysis. Of 9105 studies identified, 24 studies met the eligibility criteria. Results from meta-analysis demonstrated a significant small treatment effect size (g = - 0.41) for reducing internalising symptoms immediately after treatment. Studies showed moderate heterogeneity (I2 = 44%). Moderation analyses indicated that the overall treatment effect was robust against variations in treatment and study design characteristics. However, a review of individual study methods indicate that these results are limited by significant heterogeneity and limitations in clinical assessment. Overall, the results suggest that BPT programmes for reducing externalising problems have the potential to improve internalising outcomes, but that there is limited information to determine the reliability of these effects, highlighting the need for further investigation.

Callousness, exploitativeness, and tracking of cooperation incentives in the human default network

Human cognitive capacities that enable flexible cooperation may have evolved in parallel with the expansion of frontoparietal cortical networks, particularly the default network. Conversely, human antisocial behavior and trait antagonism are broadly associated with reduced activity, impaired connectivity, and altered structure of the default network. Yet, behaviors like interpersonal manipulation and exploitation may require intact or even superior social cognition. Using a reinforcement learning model of decision-making on a modified trust game, we examined how individuals adjusted their cooperation rate based on a counterpart's cooperation and social reputation. We observed that learning signals in the default network updated the predicted utility of cooperation or defection and scaled with reciprocal cooperation. These signals were weaker in callous (vs. compassionate) individuals but stronger in those who were more exploitative (vs. honest and humble). Further, they accounted for associations between exploitativeness, callousness, and reciprocal cooperation. Separately, behavioral sensitivity to prior reputation was reduced in callous but not exploitative individuals and selectively scaled with responses of the medial temporal subsystem of the default network. Overall, callousness was characterized by blunted behavioral and default network sensitivity to cooperation incentives. Exploitativeness predicted heightened sensitivity to others' cooperation but not social reputation. We speculate that both compassion and exploitativeness may reflect cognitive adaptations to social living, enabled by expansion of the default network in anthropogenesis.

Age of onset and alcohol and cannabis use disorders among Mexican American young adults: Robust substance-specific effects of early use as a risk factor

We investigated the substance-specific and cross-substance risk associated with early onset (before age 15) of drunkenness and cannabis use in the subsequent development of alcohol (AUD) and cannabis use disorder (CUD) in Mexican American young adults. Survival analyses employed Cox proportional hazards models for AUD and CUD, separately. In cross-risk analyses, we modeled estimates for those participants reporting lifetime use of both substances. Early onset of drunkenness and early onset of cannabis use were associated with shorter time to AUD and CUD, respectively, even after accounting for psychiatric disorders. While there were no cross-risk associations, adjusting for psychiatric disorders and early onset cannabis use attenuated the association of early drunkenness with AUD.

Examining Conduct Problems in a Community Sample during Middle Childhood: The Role of Frontal EEG Asymmetry, Temperament, and Working Memory

Previous literature shows that aspects of temperament, executive functioning, and EEG frontal asymmetry are related to externalizing behaviors in children. We examined whether frontal EEG asymmetry measured at age 6 would moderate the impact of negative affectivity, attentional control, and working memory at age 6 on conduct problems at age 9. Behavioral tasks were given to assess children's attentional control and working memory. Parents completed questionnaires about their children's negative affectivity and conduct problems. Results showed that greater negative affectivity reported at age 6 predicted for more conduct problems reported at age 9, regardless of EEG frontal asymmetry. Lower levels of attentional control and working memory at age 6 predicted for more conduct problems reported at age 9 when children also exhibited greater left EEG frontal asymmetry, which has been linked to approach motivation. These findings illustrate the importance of assessing multiple intrinsic factors, both independent and interactive, that contribute to children's conduct problems.

Does the Relationship between Age and Brain Structure Differ in Youth with Conduct Disorder?

Conduct disorder (CD) is characterised by persistent antisocial and aggressive behaviour and typically emerges in childhood or adolescence. Although several authors have proposed that CD is a neurodevelopmental disorder, very little evidence is available about brain development in this condition. Structural brain alterations have been observed in CD, and some indirect evidence for delayed brain maturation has been reported. However, no detailed analysis of age-related changes in brain structure in youth with CD has been conducted. Using cross-sectional MRI data, this study aimed to explore differences in brain maturation in youth with CD versus healthy controls to provide further understanding of the neurodevelopmental processes underlying CD. 291 CD cases (153 males) and 379 healthy controls (160 males) aged 9-18 years (Mage = 14.4) were selected from the European multisite FemNAT-CD study. Structural MRI scans were analysed using surface-based morphometry followed by application of the ENIGMA quality control protocols. An atlas-based approach was used to investigate group differences and test for group-by-age and group-by-age-by-sex interactions in cortical thickness, surface area and subcortical volumes. Relative to healthy controls, the CD group showed lower surface area across frontal, temporal and parietal regions as well as lower total surface area. No significant group-by-age or group-by-age-by-sex interactions were observed on any brain structure measure. These findings suggest that CD is associated with lower surface area across multiple cortical regions, but do not support the idea that CD is associated with delayed brain maturation, at least within the age bracket considered here.

A Digital Microintervention Supporting Evidence-Based Parenting Skills: Development Study Using the Agile Scrum Methodology

BACKGROUND

Conduct disorder increases risks of educational dropout, future mental illness, and incarceration if untreated. First-line treatment of conduct disorder involves evidence-based parenting skills programs. Time-outs, a frequent tool in these programs, can be effective at improving behavior, and recent apps have been developed to aid this process. However, these apps promote the use of time-outs in inconsistent or developmentally inappropriate ways, potentially worsening behavior problems. Digital microinterventions like these apps could guide parents through high-quality time-outs in the moment, but current time-out apps lack features promoting adherence to the evidence-based best practice. Agile scrum is a respected approach in the software development industry.

OBJECTIVE

We aimed to explore the feasibility of using the agile scrum approach to build a digital microintervention to help parents deliver an evidence-based time-out.

METHODS

The agile scrum methodology was used. Four sprints were conducted. Figma software was used for app design and wireframing. Insights from 42 expert stakeholders were used during 3 sprint reviews. We consulted experts who were identified from councils around the Midlands region of the United Kingdom and charities through personal contacts and a snowballing approach.

RESULTS

Over 4 development sprints from August 2022 to March 2023, the app was iteratively designed and refined based on consultation with a diverse group of 42 experts who shared their knowledge about the content of common parenting programs and the challenges parents commonly face. Modifications made throughout the process resulted in significant app enhancements, including tailored timer algorithms and enhanced readability, as well as an onboarding zone, mindfulness module, and pictorial information to increase inclusivity. By the end of the fourth sprint, the app was deemed ready for home use by stakeholders, demonstrating the effectiveness of our agile scrum development approach.

CONCLUSIONS

We developed an app to support parents to use the evidence-based time-out technique. We recommend the agile scrum approach to create mobile health apps. Our experience highlights the valuable role that frontline health and social care professionals, particularly those working with vulnerable families, can play as experts in scrum reviews. There is a need for research to both evaluate the impact of digital microinterventions on child behavioral change and also create digital microinterventions that cater to non-English speakers and individuals who participate in parenting programs in settings outside the United Kingdom.

Involving Parents in Cognitive Behavioral Therapy for Children and Adolescents with Conduct Problems: Goals, Outcome Expectations, and Normative Beliefs About Aggression are Targeted in Sessions with Parents and Their Child

Children and adolescents with conduct problems participate in Cognitive Behavioral Therapy (CBT), either in individual or group format, in view of learning social problem-solving skills that enable them to behave in more independent and situation-appropriate ways. Parents must support their child's learning processes in everyday life and therefore these processes need attention in CBT sessions in which parents and their child participate. The social problem-solving model of CBT previously described (Matthys & Schutter, Clin Child Fam Psychol Rev 25:552-572, 2022; Matthys & Schutter, Clin Child Fam Psychol Rev 26:401-415, 2023) consists of nine psychological skills. In this narrative review we propose that instead of addressing each skill separately in sessions with both parents and their child, therapists work on three schemas (latent mental structures): (1) goals, (2) outcome expectations, and (3) normative beliefs about aggression. Based on social-cognitive and cognitive neuroscience studies we argue that these three schemas affect five core social problem-solving skills: (1) interpretation, (2) clarification of goals, (3) generations of solutions, (4) evaluation of solutions, and (5) decision-making. In view of tailoring CBT to the individual child's characteristic schemas and associated social problem-solving skills, we suggest that children and adolescents participate in individual sessions with their parents. The therapist uses Socratic questioning in order to find out characteristic schemas of the child, encourage reflection on these schemas, and explore alternative schemas that had previously been outside the child's attention. The therapist functions as a model for parents to ask their child questions about the relevant schemas with a view of achieving changes in the schemas.

The Effects of Online Behavioral Parenting Interventions on Child Outcomes, Parenting Ability and Parent Outcomes: A Systematic Review and Meta-analysis

The twenty-first century has seen the development and delivery of online programs of behavioral family intervention for disruptive child behavior. Typically, programs evaluate outcomes in terms of change in child functioning and change in parenting ability. Existing research has also articulated the importance of parent-child relational capacity and its role in facilitating change in child functioning, and the importance of parent emotion regulation in the interests of ensuring optimal child development. These factors were explored in a meta-analysis of k = 14 prospective longitudinal research studies of online parenting interventions for disruptive child behavior. Peer reviewed randomized controlled trials with inactive control groups that were published in English between 2000 and 2022 were included in the review if they were delivered online; offered parent self-directed treatment; included as participants families who were screened as having child behavioral difficulties on validated psychometric assessment measures; and assessed child treatment outcomes, parenting ability and parent treatment outcomes. The protocol for this study was pre-registered with PROSPERO (CRD42020215947). Statistical analyses employed random effects models and reported pooled effect sizes (Hedge's g) within and between groups. Results emphasize the importance of child outcomes and parenting ability in program assessment, however, suggest that parents' capacity to develop optimal parent-child relationships and regulate emotion may not be sufficiently reflected in program content. Identified continuous and categorical moderators of treatment outcome were also assessed. Results of the review are discussed in terms of their potential to influence the future development of online programs of behavioral family intervention and, therefore, child development.

Moving forward. Use of the START NOW skills training program for female youth with ODD and CD - a commentary on Stadler et al. (2024)

Female youth with oppositional defiant disorder (ODD) and conduct disorder (CD) are an under studied and underserved population at high risk for poor adjustment in later life. Stadler et al. (2024) attempt to redress this situation for adolescent females with CD or ODD with an adapted version of the skills training program START NOW. They describe the results of an ambitious randomized control trial, comparing START NOW with standard care in youth welfare settings in Germany, Switzerland, and The Netherlands. The findings appear promising, but the paper is especially valuable for the spotlight it shines on the needs of this underserved population and those caring for them, together with the importance of undertaking such trials despite their challenges. This commentary seeks to encourage readers to engage with the START NOW trial.

The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders

BACKGROUND

The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression.

METHODS

A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires.

RESULTS

Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression.

CONCLUSIONS

These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Impaired Punishment Learning in Conduct Disorder

OBJECTIVE

Conduct disorder (CD) has been associated with deficits in the use of punishment to guide reinforcement learning (RL) and decision making. This may explain the poorly planned and often impulsive antisocial and aggressive behavior in affected youths. Here, we used a computational modeling approach to examine differences in RL abilities between CD youths and typically developing controls (TDCs). Specifically, we tested 2 competing hypotheses that RL deficits in CD reflect either reward dominance (also known as reward hypersensitivity) or punishment insensitivity (also known as punishment hyposensitivity).

METHOD

The study included 92 CD youths and 130 TDCs (aged 9-18 years, 48% girls) who completed a probabilistic RL task with reward, punishment, and neutral contingencies. Using computational modeling, we investigated the extent to which the 2 groups differed in their learning abilities to obtain reward and/or to avoid punishment.

RESULTS

RL model comparisons showed that a model with separate learning rates per contingency explained behavioral performance best. Importantly, CD youths showed lower learning rates than TDCs specifically for punishment, whereas learning rates for reward and neutral contingencies did not differ. Moreover, callous-unemotional (CU) traits did not correlate with learning rates in CD.

CONCLUSION

CD youths have a highly selective impairment in probabilistic punishment learning, regardless of their CU traits, whereas reward learning appears to be intact. In summary, our data suggest punishment insensitivity rather than reward dominance in CD. Clinically, the use of punishment-based intervention techniques to achieve effective discipline in patients with CD may be a less helpful strategy than reward-based techniques.

Examining intergenerational risk factors for conduct problems using polygenic scores in the Norwegian Mother, Father and Child Cohort Study

The aetiology of conduct problems involves a combination of genetic and environmental factors, many of which are inherently linked to parental characteristics given parents' central role in children's lives across development. It is important to disentangle to what extent links between parental heritable characteristics and children's behaviour are due to transmission of genetic risk or due to parental indirect genetic influences via the environment (i.e., genetic nurture). We used 31,290 genotyped mother-father-child trios from the Norwegian Mother, Father and Child Cohort Study (MoBa), testing genetic transmission and genetic nurture effects on conduct problems using 13 polygenic scores (PGS) spanning psychiatric conditions, substance use, education-related factors, and other risk factors. Maternal or self-reports of conduct problems at ages 8 and 14 years were available for up to 15,477 children. We found significant genetic transmission effects on conduct problems for 12 out of 13 PGS at age 8 years (strongest association: PGS for smoking, β = 0.07, 95% confidence interval = [0.05, 0.08]) and for 4 out of 13 PGS at age 14 years (strongest association: PGS for externalising problems, β = 0.08, 95% confidence interval = [0.05, 0.11]). Conversely, we did not find genetic nurture effects for conduct problems using our selection of PGS. Our findings provide evidence for genetic transmission in the association between parental characteristics and child conduct problems. Our results may also indicate that genetic nurture via traits indexed by our polygenic scores is of limited aetiological importance for conduct problems-though effects of small magnitude or effects via parental traits not captured by the included PGS remain a possibility.

The Interplay between Fear Reactivity and Callous-Unemotional Traits Predicting Reactive and Proactive Aggression

Research has indicated that youths with CU traits are fearless, and this fearlessness plays a bidirectional role in both the development of CU traits and engagement in aggressive behavior. However, research specifically testing the role of fear in the association between CU traits and aggression is scarce. The goal of the current study was to test if fear reactivity, both conscious (self-report) and automatic (skin conductance reactivity; SCR), moderated the association between CU traits and aggression subtypes (reactive and proactive aggression). Participants included 161 adolescents (Mage = 15 years) diagnosed with conduct disorder. CU traits were assessed using the self-report Inventory of Callous-Unemotional Traits. Conscious and automatic fear reactivity were measured during a virtual reality rollercoaster using the Self-Assessment Manikin and skin conductance reactivity (SCR), respectively. Hierarchical regressions found that high fear reactivity on SCR moderated the link between CU traits and reactive aggression, while feeling more excited during fear induction moderated the link between CU traits and proactive aggression. Overall, a possible explanation of our divergent findings between conscious and automatic fear may be the difference between the instinctual biological response to threat versus the cognitive and emotional appraisal and experience of threat. Implications for intervention strategies targeting emotional recognition and regulation in reducing aggression in CD populations are discussed.

Deficits in emotion recognition and processing in children with high callous-unemotional traits: the role of the MAOA gene

Children with high Callous-Unemotional (CU) traits show deficits in recognizing and processing facial expressions. Alterations in emotion recognition have been linked to a higher synaptic concentration of monoaminergic neurotransmitters. The current study investigated the relationship between the MAOA-Low-activity alleles and the ability to recognize and process facial expressions in 97 male children (8-12 years old) diagnosed with disruptive behavior disorder. Participants completed a computerized emotion-recognition task while an eye-tracking system recorded the number (Fixation Count, FC) and length (Fixation Duration, FD) of fixations to the eye region of the emotional stimuli. Children with high CU traits exhibited lower scores in recognition of sadness and anger, and lower FC and FD for sadness and fear than children with low CU traits. Children carrying the MAOA-Low-activity alleles displayed lower FD for sadness, and FD and FC for fear than those carrying the MAOA-High-activity alleles. These genetic effects appeared even stronger in children with CU traits. Moderation analysis revealed that CU traits were associated with lower FC and FD for fear, and lower FD for sadness, probably due to the MAOA-Low-activity alleles. Our findings, although to be replicated, suggest MAOA-Low-activity alleles as potential genetic biomarkers to identify CU children in need of training focused on emotion processing.

The High Rates of Comorbidity among Neurodevelopmental Disorders: Reconsidering the Clinical Utility of Distinct Diagnostic Categories

The boundaries between neurodevelopmental disorders are often indistinct, even among specialists. But do these boundaries exist, or do experts struggle to distinguish and categorize symptoms in order to arrive at a dominant diagnosis while comorbidity continually leaves questions about where each disorder ends and begins? What should be reconsidered? The introduction of the term 'spectrum of neurodevelopmental disorders' could pave the way for a re-appraisal of the clinical continuum of neurodevelopmental disorders. This study aims to highlight the problems that emerge in the field of the differential diagnosis of neurodevelopmental disorders and propose a renegotiation of the distinctiveness criteria.

Medication Treatment for Youth in Substance Use Disorder Residential Treatment

OBJECTIVE

Residential is a common treatment setting for youth with high-severity substance use disorders (SUD). This study evaluated the prevalence of psychiatric symptoms and medication for youth in residential SUD treatment.

METHODS

Youth in Massachusetts state licensed and funded SUD residential programs completed questionnaires assessing demographics, primary substance of use, and psychopathology symptoms (Youth Self Report [YSR]/Adult Self Report [ASR]). De-identified medication lists were provided by the programs. Descriptive statistics were used to describe the sample.

RESULTS

Among the 47 youth who participated, 51.1% were male, 72.3% white, 83% non-Hispanic, mean age 20.7 years. Opioids were the most common primary substance identified by youth (51.1%), and 75% had at least one clinically elevated subscale on the YSR/ASR. Most youth were prescribed at least one medication (89.4%) with a mean of 2.9 medications.

CONCLUSION

Youth in SUD residential treatment frequently have clinically elevated psychiatric symptoms, and psychotropic medication was commonly prescribed.

Developmental trajectories of conduct problems and time-varying peer problems: the Bergen child study

BACKGROUND

While it is increasingly acknowledged that conduct problems and peer problems often co-occur in development, less is known about the ways in which peer problems may alter the developmental course of conduct problems for distinct subgroups.

METHODS

Using data from a large population-based study in Norway (the Bergen Child Study/youth@hordaland; 47.4% males), we estimated group-based trajectories of conduct problems and the presence of time-varying peer problems on the developmental progression of conduct problems between seven and 19 years of age. Risk factors for group membership were also examined.

RESULTS

A 3-group model of conduct problems best fit the data (non-engagers, low-engagers, moderate-stable). The presence of peer problems increased the estimated level of conduct problems for both the low-engagers and moderate-stable groups across adolescence. No differences in conduct problems were observed when peer problems were present in childhood or preadolescence for these two groups, nor for the non-engagers group at any point. Being male, having lower perceived economic wellbeing, and lower levels of parental education predicted group membership for the moderate-stable group, whilst lower paternal education predicted membership for the low-engagers group.

CONCLUSIONS

Support for developmental 'turning points' was found, suggesting that adolescence is a particularly salient time for those with conduct problems. In particular, the presence of peer problems can increase observed conduct problems at this stage in development.

The Affective Side of Disruptive Behavior: Toward Better Understanding, Assessment, and Treatment

Historically, much of the progress made in youth mental health research can be classified as focusing on externalizing problems, characterized by disruptive behavior (e.g. aggression, defiance), or internalizing problems, characterized by intense negative affect (e.g. depression, anxiety). Until recently, however, less attention has been given to topics that lie somewhere in between these domains, topics that we collectively refer to as the affective side of disruptive behavior. Like the far side of the moon, the affective side of disruptive behavior captures facets of the phenomenon that may be less obvious or commonly overlooked, but are nonetheless critical to understand. This affective side clarifies socially disruptive aspects of traditionally "externalizing" behavior by elucidating proximal causation via intense negative affect (traditionally "internalizing"). Such problems include irritability, frustration, anger, temper loss, emotional outbursts, and reactive aggression. Given a recent explosion of research in these areas, efforts toward integration are now needed. This special issue was developed to help address this need. Beyond the present introductory article, this collection includes 4 empirical articles on developmental psychopathology topics, 4 empirical articles on applied treatment/assessment topics, 1 evidence base update review article on measurement, and 2 future directions review articles concerning outbursts, mood, dispositions, and youth psychopathology more broadly. By deliberatively investigating the affective side of disruptive behavior, we hope these articles will help bring about better understanding, assessment, and treatment of these challenging problems, for the benefit of youth and families.

START NOW: a cognitive behavioral skills training for adolescent girls with conduct or oppositional defiant disorder - a randomized clinical trial

BACKGROUND

Conduct disorder (CD) and oppositional defiant disorder (ODD) both convey a high risk for maladjustment later in life and are understudied in girls. Here, we aimed at confirming the efficacy of START NOW, a cognitive-behavioral, dialectical behavior therapy-oriented skills training program aiming to enhance emotion regulation skills, interpersonal and psychosocial adjustment, adapted for female adolescents with CD or ODD.

METHODS

A total of 127 girls were included in this prospective, cluster randomized, multi-center, parallel group, quasi-randomized, controlled phase III trial, which tested the efficacy of START NOW (n = 72) compared with standard care (treatment as usual, TAU, n = 55). All female adolescents had a clinical diagnosis of CD or ODD, were 15.6 (±1.5) years on average (range: 12-20 years), and were institutionalized in youth welfare institutions. The two primary endpoints were the change in number of CD/ODD symptoms between (1) baseline (T1) and post-treatment (T3), and (2) between T1 and 12-week follow-up (T4).

RESULTS

Both treatment groups showed reduced CD/ODD symptoms at T3 compared with T1 (95% CI: START NOW = -4.87, -2.49; TAU = -4.94, -2.30). There was no significant mean difference in CD/ODD symptom reduction from T1 to T3 between START NOW and TAU (-0.056; 95% CI = -1.860, 1.749; Hedge's g = -0.011). However, the START NOW group showed greater mean symptom reduction from T1 to T4 (-2.326; 95% CI = -4.274, -0.378; Hedge's g = -0.563). Additionally, secondary endpoint results revealed a reduction in staff reported aggression and parent-reported irritability at post assessment.

CONCLUSIONS

Although START NOW did not result in greater symptom reduction from baseline to post-treatment compared with TAU, the START NOW group showed greater symptom reduction from baseline to follow-up with a medium effect size, which indicates a clinically meaningful delayed treatment effect.

An 'embedded brain' approach to understanding antisocial behaviour

Antisocial behaviour (ASB) incurs substantial costs to the individual and society. Cognitive neuroscience has the potential to shed light on developmental risk for ASB, but it cannot achieve this potential in an 'essentialist' framework that focuses on the brain and cognition isolated from the environment. Here, we present the case for studying the social transactional and iterative unfolding of brain and cognitive development in a relational context. This approach, which we call the study of the 'embedded brain', is needed to fully understand how risk for ASB arises during development. Concentrated efforts are required to develop and unify methods to achieve this approach and reap the benefits for improved prevention and intervention of ASB.

Behavioral Parent Training for School-Aged Children With ADHD: A Systematic Review of Randomized Control Trials

BACKGROUND

All guidelines for the treatment of ADHD in children include behavioral parent training in combination with other strategies. In the past, several systematic reviews have been carried out that were either outdated or not sufficiently specific to ADHD. We wanted to conduct a new review focusing on a specific ADHD population of school age (4-12 years) and on behavioral and cognitive programs. We aimed to test our hypothesis that behavioral parent training would improve parents' difficulties, children's symptomatology, and the quality of life of families with ADHD.

METHODS

PUBMED, PsychInfo, Web of Science, ERIC, and Cochrane databases were searched for original articles on randomized control trials on behavioral parent training group for children with ADHD aged from 4 to 12 years until July 2023.

RESULTS

A total of 20 studies were included in the systematic review. The results were divided into four categories: parent data, child data collected by parents, teachers, or researchers. A qualitative analysis revealed for parents, effects on parental stress, feelings of parental efficacy, and negative parental educational behavior. As regard children, only effects are noted for parental assessment, on ADHD symptomatology, externalized disorders, and social skills.

CONCLUSION

Despite the heterogeneity or small number of studies in some categories, BPTs have positive effects on both parents and children. There are no convincing results to support the generalization of progress. This would seem to indicate that it remains essential to consider actions specific to each problematic environment for the child.

Conduct disorder - a comprehensive exploration of comorbidity patterns, genetic and environmental risk factors

Conduct disorder (CD), a common mental disorder in children and adolescents, is characterized by antisocial behavior. Despite similarities with antisocial personality disorder (ASPD) and possible diagnostic continuity, CD has been shown to precede a range of adult-onset mental disorders. Additionally, little is known about the putative shared genetic liability between CD and adult-onset mental disorders and the underlying gene-environment interplay. Here, we interrogated comorbidity between CD and other mental disorders from the Norwegian Mother, Father and Child Cohort Study (n = 114 500) and investigated how polygenic risk scores (PRS) for mental health traits were associated with CD/CD traits in childhood and adolescence. Gene-environment interplay patterns for CD was explored with data on bullying and parental education. We found CD to be comorbid with several child and adult-onset mental disorders. This phenotypic overlap corresponded with associations between PRS for mental disorders and CD. Additionally, our findings support an additive gene-environment model. Previously conceptualized as a precursor of ASPD, we found that CD was associated with polygenic risk for several child- and adult-onset mental disorders. High comorbidity of CD with other psychiatric disorders reflected on the genetic level should inform research studies, diagnostic assessments and clinical follow-up of this heterogenous group.

Which Clinical and Demographic Factors are Related to Incarceration in Male Patients With Antisocial Personality Disorder?

Antisocial Personality Disorder (APD) is a condition largely represented in detention centers where can reach a prevalence of 60% in male prisoners. The objective of this study is to identify the clinical and demographic factors that differentiate subjects with APD and hosted in penitentiary with respect to those are treated in outpatient psychiatric clinics. We recruited 65 male patients affected by APD, whose 26 were followed up in community mental health services and 39 were serving their sentence in a detention center located in Monza. Socio-demographic and clinical data were obtained through a review of the clinical charts, and interviews with patients or their relatives (if available). We performed descriptive analyses on the total sample, then we compared the two groups identified by the type of setting (outpatient clinic vs. penitentiary) by independent sample t tests (quantitative variables) or χ2 tests (qualitative ones). For qualitative variables odds ratios (ORs) were also calculated. Outpatients with APD (with respect to those hosted in the detention center) resulted: to be older (p = .02), to be less likely married (p = .01), to have more pre-onset psychiatric comorbidity (p = .05), to have more pre-onset substance poly-misuse (p = .01), to have more previous psychiatric hospitalizations (p < .01), and to be less likely to have received lifetime psychotherapy (p < .01). Globally, the results of this study show how the presence of psychiatric comorbidity or substance abuse (with the probable access to psychiatric services) before the onset of APD prevents imprisonment. This aspect is even more surprising when we consider that the two groups of patients show no differences in the frequency of crimes. Future research will have to confirm if early mental health care can really limit the access to penitentiary of subjects affected by APD.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): a feasibility study

Conduct disorder (CD) is a common psychiatric disorder in youth characterized by persisting norm-violating or aggressive behavior. Considering high individual and societal burden, feasible and effective psychotherapeutic treatment is desirable. Yet, treatments and research in this patient group are scarce. This study investigates the feasibility of mentalization-based treatment for adolescents with CD (MBT-CD) in terms of acceptability of MBT-CD and scientific assessments by participants as well as necessary organizational resources to conduct a consecutive randomized controlled trial (RCT). Recruitment, adherence and treatment session numbers were descriptively analyzed. Treatment evaluation interviews were qualitatively analyzed. A subset of sessions of therapists without prior MBT experience was rated for MBT adherence. Quantitative data were used to plan a consecutive RCT. Pre to post treatment changes in diagnosis and self-reported aggression, mentalizing and personality functioning were preliminarily analyzed. N = 45 adolescents with CD were recruited. 43% dropped out. Acceptance of scientific assessments was somewhat lower than therapy adherence (questionnaires filled out by ~ 80% of adolescents in treatment), and low at follow-up (25% of treatment completers). Mean session number was 30.3. Most treatment completers were satisfied with MBT-CD. Referrals mainly came from child and youth services and psychiatry. Nine of 16 sessions rated for MBT adherence were adherent. A priori sample size estimation for a prospective RCT with a drop-out rate of 43% yielded a sample of N = 158 to detect an effect f = .15 with 80% power in a repeated measures ANOVA. Pre-post analyses revealed diagnostic improvement in 68%. Of self-reported data, empathy pathology improved. Findings provide a sound basis for a consecutive feasibility and pilot RCT. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02988453, November 30, 2016, https://clinicaltrials.gov/ct2/show/NCT02988453.

Parenting boys with conduct problems and callous-unemotional traits: parent and child perspectives

Parenting children with conduct problems (CP) is challenging, yet very little research has examined parenting using both quantitative and qualitative methods, from the perspective of the child and their parent/caregiver, and separately for those with high vs. low levels of callous-unemotional traits (HCU vs. LCU). One hundred and forty-six boys aged 11-16 [Typically developing (TD) n = 31; CP/HCU n = 35; CP/LCU n = 35] and their parents/caregivers completed the Alabama Parenting Questionnaire and provided a written qualitative statement describing their respective experiences of parenting/being parented. Parents/caregivers of CP/HCU boys reported more difficulty with child monitoring and supervision than parents of TD boys. This was echoed in qualitative reports of parents of CP/HCU boys reporting concerns regarding their child's safety. Parents/caregivers of both groups of CP boys reported more inconsistent discipline than parents of TD boys. Parental qualitative descriptions of challenging behavior in CP/HCU boys, and difficulties with setting boundaries and motivating CP/LCU boys, provided further insight to the potential triggers for inconsistent discipline. Qualitative reports from boys with CP indicated that they understood the parenting challenges their parents/caregivers faced. These findings replicate and extend previous work on the associations between parenting and CP. Children with CP/HCU and CP/LCU show some commonalities and differences in their parenting experiences and CP children and their parents/caregivers do not necessarily share all the same perceptions or concerns. CP interventions often involve parent/family engagement and this research highlights the continued importance of examining both parent and child perspectives.

Retrospective audit of a school-based integrated health-care model in a specialised school for children with externalising behaviour

AIM

Problematic externalising behaviours in adolescents are associated with high individual and societal burden. A school-based multidisciplinary health clinic, Ngaramadhi Space (NS), was developed at Yudi Gunyi School, a specialised behavioural school in Sydney, Australia, to improve access to holistic health-care and behavioural support. This evaluation aimed to describe the demographics, clinic attendance, health screening, recommendations made, and changes in Strengths and Difficulties Questionnaire (SDQ) scores of students attending the clinic.

METHODS

Retrospective evaluation of students including changes in SDQ scores using descriptive statistics (26 July 2016 to 14 May 2019; n = 79).

RESULTS

Prior to the assessment, few students engaged with a paediatrician or mental health professional (22.8%; 27.8%, respectively). Child protection services were involved with 76%. NS attendance was high (failure-to-attend = 7.6%; cancellations = 8.9%). New issues found at the assessment included: parental separation (31.6%); trauma history (27.8%); substance use (19%); emotional wellbeing concerns (16.5%), learning difficulties (12.7%), domestic violence (12.7%) and medical conditions (10.1%). SDQ teacher reports showed a significant decrease in total difficulties scores (M = 6.2, SD = 6.165, P < 0.05, eta squared = 1.013 (large effect)) and all subsets. No significant differences in parent and self-reported SDQ.

CONCLUSIONS

Students with problematic externalising behaviour have unmet health and social needs. The NS school-based integrated health-care model offers a novel, convenient and innovative way to engage these students. This approach has high initial attendance rates with teacher-reported SDQ results showing some behavioural improvement. Further qualitative studies are required.

Reduced grey matter volume in adolescents with conduct disorder: a region-of-interest analysis using multivariate generalized linear modeling

BACKGROUND

Conduct disorder (CD) involves a group of behavioral and emotional problems that usually begins during childhood or adolescence. Structural brain alterations have been observed in CD, including the amygdala, insula, ventrolateral and medial prefrontal cortex, anterior cingulate cortex, and fusiform gyrus. The current study developed a multivariate generalized linear model (GLM) to differentiate adolescents with CD from typically developing (TD) adolescents in terms of grey matter volume (GMV).

METHODS

The whole-brain structural MRI data were collected from 96 adolescents with CD (mean age = [Formula: see text] years; mean IQ = [Formula: see text]; 63 males) and 90 TD individuals (mean age = [Formula: see text] years; mean IQ = [Formula: see text]; 59 males) matched on age, IQ, and sex. Region-wise GMV was extracted following whole-brain parcellation into 68 cortical and 14 subcortical regions for each participant. A multivariate GLM was developed to predict the GMV of the pre-hypothesized regions-of-interest (ROIs) based on CD diagnosis, with intracranial volume, age, sex, and IQ serving as the covariate.

RESULTS

A diagnosis of CD was a significant predictor for GMV in the right pars orbitalis, right insula, right superior temporal gyrus, left fusiform gyrus, and left amygdala (F(1, 180) = 5.460-10.317, p < 0.05, partial eta squared = 0.029-0.054). The CD participants had smaller GMV in these regions than the TD participants (MCD-MTD = [- 614.898] mm3-[- 53.461] mm3).

CONCLUSIONS

Altered GMV within specific regions may serve as a biomarker for the development of CD in adolescents. Clinical work can potentially target these biomarkers to treat adolescents with CD.

Reduced Grey Matter Volume in Adolescents with Conduct Disorder: A Region-of-Interest Analysis Using Multivariate Generalized Linear Modeling

Background

Conduct disorder (CD) involves a group of behavioral and emotional problems that usually begins during childhood or adolescence. Structural brain alterations have been observed in CD, including the amygdala, insula, ventrolateral and medial prefrontal cortex, anterior cingulate cortex, and fusiform gyrus. The current study developed a multivariate generalized linear model (GLM) to differentiate adolescents with CD from typically developing (TD) adolescents in terms of grey matter volume (GMV).

Methods

The whole-brain structural MRI data were collected from 96 adolescents with CD (mean age = years; mean IQ = ; 63 males) and 90 TD individuals (mean age = years; mean IQ = ; 59 males) matched on age, IQ, and sex. Region-wise GMV was extracted following whole-brain parcellation into 68 cortical and 14 subcortical regions for each participant. A multivariate GLM was developed to predict the GMV of the pre-hypothesized regions-of-interest (ROIs) based on CD diagnosis, with intracranial volume, age, sex, and IQ serving as the covariate.

Results

A diagnosis of CD was a significant predictor for GMV in the right pars orbitalis, right insula, right superior temporal gyrus, left fusiform gyrus, and left amygdala (F(1, 180) = 5.460 - 10.317, p < 0.05, partial eta squared = 0.029 - 0.054). The CD participants had smaller GMV in these regions than the TD participants (MCD - MTD = [-614.898] mm3 - [-53.461] mm3).

Conclusions

Altered GMV within specific regions may serve as a biomarker for the development of CD in adolescents. Clinical work can potentially target these biomarkers to treat adolescents with CD.

Joint Developmental Trajectories of Conduct Problems and Hyperactivity/Inattention: Antecedent Risk Markers for Group Membership

This study investigated joint trajectories of conduct problems and hyperactivity/inattention from age three to nine in a cohort of 7,507 children in Ireland (50.3% males; 84.9% Irish). The parent-reported Strengths and Difficulties Questionnaire was used to collect information on conduct problems (CP) and hyperactivity/inattention (HI). Information regarding risk markers was collected when participants were nine-months-old via parent report and standardised assessments. Using a person-centred approach (i.e., group-based multi trajectory modelling), six trajectories were identified: no CP/low HI, low-stable CP/HI, low-declining CP/stable HI, desisting co-occurring CP/HI, pure-increasing HI, and high chronic co-occurring CP/HI. Specific risk markers for group membership included: male sex; birth complications; perceived difficult temperament; lower primary caregiver age and education level, and higher stress level; prenatal exposure to smoking, and indicators of lower socioeconomic status. Primary caregiver-child bonding and having siblings were protective markers against membership in elevated groups. Results suggest support for both 'pure' HI and co-occurring trajectories of CP and HI emerging in toddlerhood. However, no support was found for a 'pure' CP trajectory, which may support the suggestion that children on a persistent CP trajectory will have coexisting HI. Intervention efforts may benefit from starting early in life and targeting multiple risk markers in families with fewer resources.

Parenting practices, bullying perpetration, and conduct problems among Ukrainian children

BACKGROUND

Positive and consistent parenting practices are associated with the positive mental health of children. However, little is understood about the implications of the Russian military invasion on family dynamics in Ukraine.

OBJECTIVE

This research aims to estimate the prevalence of childhood conduct disorder (CD) and bullying perpetration and their association with parenting practices among Ukrainian children living in proximity to the war.

PARTICIPANTS AND SETTING

The sample included 2763 Ukrainian children ranging in age from 10 to 17 years (M = 12.6, SD = 1.23), 56.23 % girls. Children attended public secondary schools in Eastern Ukraine, mostly in Kharkiv and Kharkiv oblasts (regions).

METHODS

Children reported on sociodemographic characteristics, parenting practices, CD, and bullying perpetration using smartphones, computers, or tablets, at home or in school IT classrooms. Data were collected on a secure online platform.

RESULTS

Children reported teasing (23.68 %), spreading rumors (24.51 %), helping to harass (17.31 %), threatening to hurt or hit (21.65 %) other students, breaking rules (28.13 %), getting in fights (17.13 %), cheating (43.16 %), and being spanked by parents (30 %). Also, 1.83 % of girls and 3.43 % of boys met a borderline cutoff for CD. Lack of parent involvement was associated with increased CD and bullying risks. Poor parent monitoring, inconsistent discipline, and corporal punishment were associated with increasaed CD but not with bullying. CD mediated the association of poor monitoring, inconsistent discipline, and corporal punishment with bullying.

CONCLUSION

Parental involvement, monitoring, consistent discipline, and avoidance of physical punishments are important practices that can reduce disruptive behavior and aggressive tendencies among Ukrainian children affected by the Russian war.

Empathy deficits, callous-unemotional traits and structural underpinnings in autism spectrum disorder and conduct disorder youth

Distinct empathy deficits are often described in patients with conduct disorder (CD) and autism spectrum disorder (ASD) yet their neural underpinnings and the influence of comorbid Callous-Unemotional (CU) traits are unclear. This study compares the cognitive (CE) and affective empathy (AE) abilities of youth with CD and ASD, their potential neuroanatomical correlates, and the influence of CU traits on empathy. Adolescents and parents/caregivers completed empathy questionnaires (N = 148 adolescents, mean age = 15.16 years) and T1 weighted images were obtained from a subsample (N = 130). Group differences in empathy and the influence of CU traits were investigated using Bayesian analyses and Voxel-Based Morphometry with Threshold-Free Cluster Enhancement focusing on regions involved in AE (insula, amygdala, inferior frontal gyrus and cingulate cortex) and CE processes (ventromedial prefrontal cortex, temporoparietal junction, superior temporal gyrus, and precuneus). The ASD group showed lower parent-reported AE and CE scores and lower self-reported CE scores while the CD group showed lower parent-reported CE scores than controls. When accounting for the influence of CU traits no AE deficits in ASD and CE deficits in CD were found, but CE deficits in ASD remained. Across all participants, CU traits were negatively associated with gray matter volumes in anterior cingulate which extends into the mid cingulate, ventromedial prefrontal cortex, and precuneus. Thus, although co-occurring CU traits have been linked to global empathy deficits in reports and underlying brain structures, its influence on empathy aspects might be disorder-specific. Investigating the subdimensions of empathy may therefore help to identify disorder-specific empathy deficits.

Association Patterns of Antisocial Personality Disorder across Substance Use Disorders

There is a high prevalence of antisocial personality disorder (ASPD) in individuals affected by substance use disorders (SUD). However, there is limited information on the specific patterns of association of ASPD with SUD severity and specific SUD diagnostic criteria. We investigated the association of alcohol, cannabis, cocaine, opioid, and tobacco use disorders (AUD, CanUD, CocUD, OUD, and TUD, respectively) in 1,660 individuals with ASPD and 6,640 controls matched by sex (24% female), age, and racial/ethnic background in a sample ascertained for addiction-related traits. Generalized linear regressions were used to test the association of ASPD with the five DSM-5 SUD diagnoses, their severity (i.e., mild, moderate, severe), and their individual diagnostic criteria. We found that ASPD is associated with the diagnosis and severity of AUD (Odds Ratio, ORs=1.89 and 1.25), CanUD (ORs=2.13 and 1.32), and TUD (ORs=1.50 and 1.21) ( ps <.003). Of the specific diagnostic criteria, the "hazardous use" criterion showed the strongest association with ASPD across the five SUDs investigated (from OR TUD =1.88 to OR CanUD =1.37). However, when criteria of different SUDs were included in the same model, ASPD was independently associated only with TUD "hazardous use" and CocUD "attempts to quit". Attempting to quit cocaine was inversely related to the presence of ASPD and remained significant (OR=0.57, 95% confidence interval = 0.36-0.89) after controlling for interactive effects with sex. The current work provides novel insights into how different SUDs, their severity, and their diagnostic criteria associate with ASPD, potentially furthering our understanding of the impact of polysubstance addiction on mental health.

Linked head injury and conduct problem symptom pathways from early childhood to adolescence and their associated risks: Evidence from the millennium cohort study

Conduct problems and head injuries increase the risk of delinquency and share a bidirectional association. However, how they link across development is unknown. The present study aimed to identify their linked developmental pathways and associated risk factors. Latent class analysis was modeled from Millennium Cohort Study data (n = 8,600) to identify linked pathways of conduct problem symptoms and head injuries. Head injuries were parent-reported from ages 3 to 14 and conduct problems from ages 3 to 17 using the Strengths and Difficulties Questionnaire (SDQ). Multinomial logistic regression then identified various risk factors associated with pathway membership. Four distinct pathways were identified. Most participants displayed low-level conduct problem symptoms and head injuries (n = 6,422; 74.7%). Three groups were characterized by clinically relevant levels of conduct problem symptoms and high-risk head injuries in childhood (n = 1,422; 16.5%), adolescence (n = 567; 6.6%), or persistent across development (n = 189; 2.2%). These clinically relevant pathways were associated with negative maternal parenting styles. These findings demonstrate how pathways of conduct problem symptoms are uniquely linked with distinct head injury pathways. Suggestions for general preventative intervention targets include early maternal negative parenting styles. Pathway-specific interventions are also required targeting cumulative risk at different ecological levels.

A Randomized Community-Based Trial of Behavior Therapy vs. Usual Care for Adolescent ADHD: Secondary Outcomes and Effects on Comorbidity

Though behavior therapy (BT) for ADHD in adolescence is evidence-based, almost no work examines its implementation and effectiveness in community settings. A recent randomized community-based trial of an evidence-based BT for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND; N = 278) reported high clinician, parent, and youth acceptability but variable implementation fidelity. Primary outcome analyses suggested no significant differences between STAND and usual care (UC) unless the clinician delivering STAND was licensed. The present study reports secondary outcomes for this trial on indices of comorbidity (anxiety, depression, oppositional defiant disorder, conduct disorder) and ADHD outcomes not targeted by the active treatment (social skills, sluggish cognitive tempo). We also examine whether therapist licensure moderated treatment effects (as in primary outcome analyses). Using intent-to-treat and per protocol linear mixed models, patients randomized to STAND were compared to those randomized to UC over approximately 10 months of follow-up. Group × Time effects revealed that, overall, STAND did not outperform usual care when implemented by community clinicians. However, a Group × Time × Licensure interaction revealed a significant effect on conduct problems when STAND was delivered by licensed clinicians (d = .19-.47). When delivered in community settings, behavior therapy for adolescent ADHD can outperform UC with respect to conduct problems reduction. Community mental health clinics should consider: (1) assigning adolescent ADHD cases to licensed professionals to maximize impact and (2) choosing psychosocial approaches when ADHD presents with comorbid conduct problems. There is also a need to reduce implementation barriers for unlicensed clinicians in community settings.

Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses

BACKGROUND

Children with callous-unemotional (CU) traits are at high lifetime risk of antisocial behavior. It is unknown if treatments for disruptive behavior disorders are as effective for children with CU traits (DBD+CU) as those without (DBD-only), nor if treatments directly reduce CU traits. Separate multilevel meta-analyses were conducted to compare treatment effects on DBD symptoms for DBD+CU versus DBD-only children and evaluate direct treatment-related reductions in CU traits, as well as to examine moderating factors for both questions.

METHODS

We systematically searched PsycINFO, PubMed, Cochran Library (Trials), EMBASE, MEDLINE, APA PsycNet, Scopus, and Web of Science. Eligible studies were randomized controlled trials, controlled trials, and uncontrolled studies evaluating child-focused, parenting-focused, pharmacological, family-focused, or multimodal treatments.

RESULTS

Sixty studies with 9,405 participants were included (Mage  = 10.04, SDage  = 3.89 years, 25.09% female, 44.10% racial/ethnic minority). First, treatment was associated with similar reductions in DBD symptoms for DBD+CU (SMD = 1.08, 95% CI = 0.45, 1.72) and DBD-only (SMD = 1.01, 95% CI = 0.38, 1.64). However, DBD+CU started (SMD = 1.18, 95% CI = 0.57, 1.80) and ended (SMD = 0.73, p < .001; 95% CI = 0.43, 1.04) treatment with more DBD symptoms. Second, although there was no overall direct effect of treatment on CU traits (SMD = .09, 95% CI = -0.02, 0.20), there were moderating factors. Significant treatment-related reductions in CU traits were found for studies testing parenting-focused components (SMD = 0.21, 95% CI = 0.06, 0.35), using parent-reported measures (SMD = 0.16, 95% CI = 0.04, 0.28), rated as higher quality (SMD = 0.26, 95% CI = 0.13, 0.39), conducted outside the United States (SMD = 0.19, 95% CI = 0.05, 0.32), and with less than half the sample from a racial/ethnic minority group (SMD = 0.15, 95% CI = 0.002, 0.30).

CONCLUSIONS

DBD+CU children improve with treatment, but their greater DBD symptom severity requires specialized treatment modules that could be implemented alongside parenting programs. Conclusions are tempered by heterogeneity across studies and scant evidence from randomized controlled trials.

Changes in body mass index and behavioral health among adolescents in military families during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

Widely published findings from the COVID-19 pandemic show adverse effects on body mass index (BMI) and behavioral health in both adults and children, due to factors such as illness, job loss, and limited opportunity for physical and social activity. This study investigated whether these adverse effects were mitigated in adolescents from military families, who are universally insured with consistent access to healthcare, and who generally have at least one parent who must adhere to physical and mental fitness as a condition of employment.

METHODS

We conducted a cohort study using two groups of adolescents receiving care in the U.S. Military Health System during the COVID-19 pandemic; one for changes in Body Mass Index (BMI) and the second for changes in behavioral health diagnoses, using TRICARE claims data. Beneficiaries (160,037) ages 13 to 15 years in fiscal years 2017-2018, were followed up during October 2020 to June 2021.

RESULTS

Among the BMI cohort, 44.32% of underweight adolescents moved to healthy weight, 28.48% from overweight to obese, and 3.7% from healthy weight to underweight. Prevalence of behavioral disorders showed an overall 29.01% percent increase during the study period, which included in mood (86.75%) and anxiety (86.49%) disorders, suicide ideation (42.69%), and suicide attempts (77.23%). Decreases in percent change were observed in conduct disorders (-15.93%) and ADD/ADHD (-8.61%).

CONCLUSIONS

Adolescents in military families experienced adverse health outcomes during the pandemic at approximately the same rates as those in non-military families, suggesting that universal insurance and military culture were not significantly mitigating factors. Obesity and underweight present significant opportunities to intervene in areas such as exercise and food access. Decreased conduct disorders and ADD/ADHD may reflect lower prevalence due to favorable home environment, or lower rates of diagnosis and referral; however, increased rates of anxiety, mood disorders, suicide ideation and attempt are especially concerning. Care should be taken to ensure that adolescents receive consistent opportunity for physical activity and social interaction, and those at risk for suicide should receive active monitoring and appropriate referral to behavioral healthcare providers.

Negative Parenting Mediates the Longitudinal Association between Parental Internalizing Symptoms and Child Oppositional Symptoms

Research has pointed to both cross-sectional and longitudinal associations between parental internalizing symptoms and child externalizing symptoms. This study analyzed whether the association is mediated by negative parenting behavior in view of previous reports that both parental internalizing symptoms and child externalizing symptoms are related to parenting behaviors. Longitudinal data for the current analyses were derived from a randomized controlled trial on the efficacy of a web-assisted self-help intervention for parents of children with elevated levels of externalizing symptoms. Two different mediation models were analyzed, one using attention-deficit/hyperactivity disorder (ADHD) symptoms as the dependent variable and the other using oppositional defiant disorder (ODD) symptoms. Both models included parental internalizing symptoms as the independent variable, negative parenting behavior as a mediator, and study condition as a confounder. The longitudinal analyses support the mediating role of negative parenting behavior in the association between early parental internalizing symptoms and later child ODD symptoms.

Association between postnatal environmental tobacco smoke exposure controlling for prenatal exposure and conduct problems in children: A systematic review

Prenatal exposure to environmental tobacco smoke (ETS) is commonly associated with conduct problems in children. However, there is limited research on the effects of postnatal ETS exposure on the development of conduct problems, and many studies focusing on the postnatal period fail to control for the effects of prenatal ETS. This systematic review explores the association between postnatal ETS exposure and child conduct problems in studies that control for prenatal ETS exposure. Of the thirteen studies identified, nine reported a significant positive association of postnatal ETS exposure and child conduct-related behavior problems when controlling for prenatal ETS exposure. Results from tests of dose-response relationships were mixed. These findings highlight the significance of postnatal ETS exposure in conferring risk for conduct problems over and above prenatal ETS, and thus provide important information for guiding public health recommendations.

Contemporary diagnosis and treatment of conduct disorder in youth

INTRODUCTION

Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories.

AREAS COVERED

The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators.

EXPERT OPINION

Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Age-related brain deviations and aggression

BACKGROUND

Disruptive behavior disorders (DBD) are heterogeneous at the clinical and the biological level. Therefore, the aims were to dissect the heterogeneous neurodevelopmental deviations of the affective brain circuitry and provide an integration of these differences across modalities.

METHODS

We combined two novel approaches. First, normative modeling to map deviations from the typical age-related pattern at the level of the individual of (i) activity during emotion matching and (ii) of anatomical images derived from DBD cases (n = 77) and controls (n = 52) aged 8-18 years from the EU-funded Aggressotype and MATRICS consortia. Second, linked independent component analysis to integrate subject-specific deviations from both modalities.

RESULTS

While cases exhibited on average a higher activity than would be expected for their age during face processing in regions such as the amygdala when compared to controls these positive deviations were widespread at the individual level. A multimodal integration of all functional and anatomical deviations explained 23% of the variance in the clinical DBD phenotype. Most notably, the top marker, encompassing the default mode network (DMN) and subcortical regions such as the amygdala and the striatum, was related to aggression across the whole sample.

CONCLUSIONS

Overall increased age-related deviations in the amygdala in DBD suggest a maturational delay, which has to be further validated in future studies. Further, the integration of individual deviation patterns from multiple imaging modalities allowed to dissect some of the heterogeneity of DBD and identified the DMN, the striatum and the amygdala as neural signatures that were associated with aggression.

Linking heart rate variability to psychological health and brain structure in adolescents with and without conduct disorder

Aims

Heart rate variability (HRV) measures have been suggested in healthy individuals as a potential index of self-regulation skills, which include both cognitive and emotion regulation aspects. Studies in patients with a range of psychiatric disorders have however mostly focused on the potential association between abnormally low HRV at rest and specifically emotion regulation difficulties. Emotion regulation deficits have been reported in patients with Conduct Disorder (CD) however, the association between these emotion regulation deficits and HRV measures has yet to be fully understood. This study investigates (i) the specificity of the association between HRV and emotion regulation skills in adolescents with and without CD and (ii) the association between HRV and grey matter brain volumes in key areas of the central autonomic network which are involved in self-regulation processes, such as insula, lateral/medial prefrontal cortices or amygdala.

Methods

Respiratory sinus arrhythmia (RSA) measures of HRV were collected from adolescents aged between 9-18 years (693 CD (427F)/753 typically developing youth (TD) (500F)), as part of a European multi-site project (FemNAT-CD). The Inverse Efficiency Score, a speed-accuracy trade-off measure, was calculated to assess emotion and cognitive regulation abilities during an Emotional Go/NoGo task. The association between RSA and task performance was tested using multilevel regression models. T1-weighted structural MRI data were included for a subset of 577 participants (257 CD (125F); 320 TD (186F)). The CerebroMatic toolbox was used to create customised Tissue Probability Maps and DARTEL templates, and CAT12 to segment brain images, followed by a 2 × 2 (sex × group) full factorial ANOVA with RSA as regressor of interest.

Results

There were no significant associations between RSA and task performance, neither during emotion regulation nor during cognitive regulation trials. RSA was however positively correlated with regional grey matter volume in the left insula (pFWE = 0.011) across all subjects.

Conclusion

RSA was related to increased grey matter volume in the left insula across all subjects. Our results thus suggest that low RSA at rest might be a contributing or predisposing factor for potential self-regulation difficulties. Given the insula's role in both emotional and cognitive regulation processes, these brain structural differences might impact either of those.

Classifying Conduct Disorder Using a Biopsychosocial Model and Machine Learning Method

BACKGROUND

Conduct disorder (CD) is a common syndrome with far-reaching effects. Risk factors for the development of CD span social, psychological, and biological domains. Researchers note that predictive models of CD are limited if the focus is on a single risk factor or even a single domain. Machine learning methods are optimized for the extraction of trends across multidomain data but have yet to be implemented in predicting the development of CD.

METHODS

Social (e.g., family, income), psychological (e.g., psychiatric, neuropsychological), and biological (e.g., resting-state graph metrics) risk factors were measured using data from the baseline visit of the Adolescent Brain Cognitive Development Study when youth were 9 to 10 years old (N = 2368). Applying a feed-forward neural network machine learning method, risk factors were used to predict CD diagnoses 2 years later.

RESULTS

A model with factors that included social, psychological, and biological domains outperformed models representing factors within any single domain, predicting the presence of a CD diagnosis with 91.18% accuracy. Within each domain, certain factors stood out in terms of their relationship to CD (social: lower parental monitoring, more aggression in the household, lower income; psychological: greater attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms, worse crystallized cognition and card sorting performance; biological: disruptions in the topology of subcortical and frontoparietal networks).

CONCLUSIONS

The development of an accurate, sensitive, and specific predictive model of CD has the potential to aid in prevention and intervention efforts. Key risk factors for CD appear best characterized as reflecting unpredictable, impulsive, deprived, and emotional external and internal contexts.

Associations of Internalizing and Externalizing Problems in Childhood and Adolescence With Adult Labor Market Marginalization

Importance

Mental health problems in early life are associated with labor market marginalization, especially in youths with persistent internalizing and externalizing problems. However, previous research has not adjusted for familial (genetic and shared environmental) factors.

Objective

To examine associations of early-life internalizing and externalizing problems with adulthood unemployment and work disability, adjusting for familial factors.

Design, Setting, and Participants

This population-based prospective cohort study included Swedish twins who were born in 1985-1986 and surveyed at 4 consecutive waves across childhood and adolescence until 2005. Through linkage to nationwide registries, participants were followed up from 2006 to 2018. Data analyses were conducted between September 2022 and April 2023.

Exposures

Internalizing and externalizing problems, assessed with the Child Behavior Checklist. Participants were differentiated regarding duration of internalizing and externalizing problems (persistent, episodic, and noncases).

Main Outcomes and Measures

Unemployment (180 days or more of being unemployed) and work disability (60 days or more of being sickness absent or disability pensioned) during follow-up. Cox proportional hazards regression models were calculated to obtain cause-specific hazard ratios (HRs) with 95% CIs in the whole cohort and exposure-discordant twin pairs.

Results

Of 2845 participants, 1464 (51.5%) were female. Incident unemployment was experienced by 944 (33.2%) and incident work disability by 522 (18.3%) participants. Compared with noncases, persistent internalizing problems were associated with unemployment (HR, 1.56; 95% CI, 1.27-1.92) and work disability (HR, 2.32; 95% CI, 1.80-2.99). Similarly, compared with noncases, persistent externalizing problems were associated with unemployment (HR, 1.87; 95% CI, 1.55-2.26) and work disability (HR, 2.38; 95% CI, 1.87-3.03). Persistent cases had overall higher risks of adverse outcomes than episodic cases. After adjustment for familial factors, associations with unemployment were no longer statistically significant, whereas associations with work disability remained or were only slightly reduced.

Conclusions and Relevance

In this cohort study of young Swedish twins, familial factors explained the associations between early-life persistent internalizing and externalizing problems and unemployment; such factors were comparatively less important for the association with work disability. This suggests nonshared environmental factors may be important for the risk of future work disability among young individuals with persistent internalizing and externalizing problems.

Fearlessness as an Underlying Mechanism Leading to Conduct Problems: Testing the Intermediate Effects of Parenting, Anxiety, and callous-unemotional Traits

This study investigates whether the longitudinal association between fearlessness and conduct problems (CP) is mediated by warm and harsh parenting, parent-child conflict, anxiety, and callous-unemotional (CU) traits. The constructs under investigation were assessed at five different time points, spanning a period of eight years. A multi-informant approach was followed, collecting data from parents and teachers (N = 2,121; 47% girls). The structural equation model pointed to both direct and indirect pathways between fearlessness and CP. Specifically, findings suggested that Time 1 fearlessness (age 3-5 years) increased the likelihood of Time 2 (age 4-6 years) harsh parenting and Time 3 (age 5-7 years) parent-child conflict. Further, fearlessness was positively associated with Time 4 (age 8-10) callous-unemotional traits and Time 5 (age 11-13) CP. The total indirect effect from fearlessness to CP through these variables was significant, although the specific indirect effect from fearlessness to CU traits to CP accounted for most of the variance. Warm parenting and anxiety did not mediate the association between fearlessness and CP. In addition to the identified pathways connecting fearlessness to CP, findings pointed to the existence of multiple developmental pathways to future CP, as well as gender differences in longitudinal associations.

Examining the clinical correlates of conduct disorder in youth with bipolar disorder

BACKGROUND

Conduct Disorder (CD) is highly comorbid with Bipolar Disorder (BP) and this comorbidity is associated with high morbidity and dysfunction. We sought to better understand the clinical characteristics and familiality of comorbid BP + CD by examining children with BP with and without co-morbid CD.

METHODS

357 subjects with BP were derived from two independent datasets of youth with and without BP. All subjects were evaluated with structured diagnostic interviews, the Child Behavior Checklist (CBCL), and neuropsychological testing. We stratified the sample of subjects with BP by the presence or absence of CD and compared the two groups on measures of psychopathology, school functioning, and neurocognitive functioning. First-degree relatives of subjects with BP +/- CD were compared on rates of psychopathology in relatives.

RESULTS

Subjects with BP + CD compared to BP without CD had significantly more impaired scores on the CBCL Aggressive Behavior (p < 0.001), Attention Problems (p = 0.002), Rule-Breaking Behavior (p < 0.001), Social Problems (p < 0.001), Withdrawn/Depressed clinical scales (p = 0.005), the Externalizing Problems (p < 0.001), and Total Problems composite scales(p < 0.001). Subjects with BP + CD had significantly higher rates of oppositional defiant disorder (ODD) (p = 0.002), any SUD (p < 0.001), and cigarette smoking (p = 0.001). First-degree relatives of subjects with BP + CD had significantly higher rates of CD/ODD/ASPD and cigarette smoking compared to first-degree relatives of subjects without CD.

LIMITATIONS

The generalization of our findings was limited due to a largely homogeneous sample and no CD only comparison group.

CONCLUSIONS

Given the deleterious outcomes associated with comorbid BP + CD, further efforts in identification and treatment are necessary.

The role of perceived threats on mental health, social, and neurocognitive youth outcomes: A multicontextual, person-centered approach

Perceived threat in youth's environments can elevate risk for mental health, social, and neurocognitive difficulties throughout the lifespan. However, few studies examine variability in youth's perceptions of threat across multiple contexts or evaluate outcomes across multiple domains, ultimately limiting our understanding of specific risks associated with perceived threats in different contexts. This study examined associations between perceived threat in youth's neighborhood, school, and family contexts at ages 9-10 and mental health, social, and neurocognitive outcomes at ages 11-12 within a large US cohort (N = 5525) enrolled in the Adolescent Brain Cognitive DevelopmentSM Study (ABCD Study®). Latent profile analysis revealed four distinct profiles: Low Threat in all contexts, Elevated Family Threat, Elevated Neighborhood Threat, and Elevated Threat in all contexts. Mixed-effect models and post hoc pairwise comparisons showed that youth in Elevated Threat profile had poorer mental health and social outcomes 2 years later. Youth in the Elevated Family Threat profile uniquely showed increased disruptive behavior symptoms, whereas youth in the Elevated Neighborhood Threat profile predominantly displayed increased sleep problems and worse neurocognitive outcomes 2 years later. Together, findings highlight the importance of considering perceptions of threat across multiple contexts to achieve a more nuanced developmental picture.