Journal of Child Psychology and Psychiatry 55:12 (2014), pp 1311–1313

doi:10.1111/jcpp.12345

Commentary: Something old, something new: reflections on behavioural heterogeneity in conduct disorders and Klahr & Burt (2014) Stephen Scott King’s College London, Institute of Psychiatry and National Academy for Parenting Research, London, UK

The review by Klahr and Burt (this issue; 2014) is most welcome as it covers a condition that is the commonest in child and adolescent mental health, but one that is usually met with woefully inadequate availability of interventions despite an excellent evidence base of effective treatments. Antisocial behaviour in childhood is much researched in terms of cause and course, and the review covers two long-standing ways of carving it up, and two newer ones. The term antisocial behaviour may be preferable to conduct disorder, as many of the studies described in the review did not use conduct disorder as an inclusion criterion, and whilst in ICD 10 conduct disorder includes oppositional defiant disorder (ODD), thus covering the majority of severely antisocial young children, DSM IV and V explicitly exclude ODD, thus leaving it with restricted usefulness when researching origins in younger children. The first long-standing way of dividing antisocial behaviour is called aggressive versus rule breaking in the review, sometimes also called overt versus covert. Seventy years ago in an analysis of 500 clinic cases, Jenkins and Hewitt (1944) uncovered two particular clusters in problem behaviour, one they labelled unsocialised aggressive, who were abrasive in moment-to-moment social interactions and were experienced by others as aversive, and one labelled socialised delinquent, which described rule-breaking behaviours that were not obviously a reaction to someone else’s behaviour – these youths exhibited lying and stealing, truanting and staying out at night. This division appeared in numerous subsequent studies, reviewed by Quay (1964). The aggressive versus delinquent division was reflected in ICD 9 which included categories for socialised and unsocialised conduct disorder, and is still present in the questionnaires devised by Achenbach following his own empirical studies (Achenbach, 1966). The problem, then as now, was that the children had not read the text books. In other words, whilst one could get separation using factor analysis, the correlation between factors was often very high; for example, it approached 1.0 in the studies by Oregon Social Learning Center (Patterson, Reid, & Dishion, 1992, p. 31). Thus, many children with lying and stealing are also defiant and oppositional, and a fair proportion (over half in Patterson, Reid, & Dishion, 1982

series, p. 32) of aggressive children also display covert behaviours. Furthermore, nearly 50 years ago Robins (1966) showed that it was not any particular pattern of symptoms that predicted poorer outcomes, but rather their severity and variety. Klahr and Burt rightly call for better targeted treatments to be tested for the range of subtypes, all of which are recommended to have parent training as the first line, as it has a very strong evidence base with scores of trials (see for example, NICE, 2013). However, within the parent training programmes, different elements may be more appropriate for the different subtypes (for those pure cases where they truly do not have the other sort of behaviour). Reducing moment-to-moment coercive interactions is likely to be more effective for aggressive behaviours, whereas, as Klahr and Burt suggest, for covert behaviours such as lying and stealing, teaching parents how to monitor the youth closely and apply consequences rapidly and consistently is most likely to work. Whether or not self-regulation training will help lying or stealing is worth testing; it is probably more likely to be effective for the irritable and moody subtype of oppositional defiant disorder. This subtype is not discussed in the review but is of interest as it has stronger continuity to later mood disorders (Stringaris & Goodman, 2009). Promoting positive child and youth self-esteem are a core part of parent training programmes but have not been properly tested as isolated components. The second well-established subdivision of antisocial behaviour in the review concerns ADHD. Hyperkinetic conduct disorder was recognised as a separate diagnostic term in ICD 9. The pioneering epidemiological follow-up studies led by Eric Taylor showed that the combination of ADHD with antisocial behaviour was worse than either condition alone, both in the shorter and the longer term (Taylor, Chadwick, Heptinstall, & Danckaerts, 1996). As the review notes, parent training should be instigated and then for cases with more severe ADHD, stimulants are usually very effective, with a large effect size and a plethora of randomised controlled trials to back this up. Whilst methylphenidate has been around for a long time, newer second-line drugs such as atomoxetine and lisdexamfetamine (a pro-drug), are enabling a greater proportion of

© 2014 Association for Child and Adolescent Mental Health. Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

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Commentary: Stephen Scott

children who do not respond satisfactorily to methylphenidate to be helped. The review of nonpharmacological treatments by Sonuga-Barke et al. (2013)1 was disappointing for psychosocial treatments, insofar as they did not seem to generalise outside the context where the treatment was delivered (e.g. from home to school), and their measured effectiveness was reduced and sometimes abolished when more objective measures such as direct observations were used. In this vein, further studies of the limitations of effectiveness need to be carried out before one could recommend widespread application of interventions such as neuro-feedback; in the systematic review by Evans, Owens, and Bunford (2014) it was only rated as possibly efficacious. The worse prognosis of early-onset antisocial behaviour has also been established for a long time (see, for example, Glueck & Glueck, 1959) but is now a much better characterised through population-based longitudinal surveys. Whilst the review authors are right that retrospective recall of date of onset can be shaky, this criticism cannot be levelled at prospective surveys, which nonetheless show very marked differences between early and late onset cases, with very high rates of adult dysfunction in the early-onset group (Fergusson, Horwood, & Ridder, 2005). However, while the early-onset group was initially seen as having a universally poor prognosis, the Dunedin group later subdivided it on the basis of family history, whereby children with a strong family history of antisocial behaviour (for example a violent or criminal father) were more likely to persist, whereas those without had a better chance of growing out of it (Odgers et al., 2007). Should therefore, more resources be given to those with higher risk factors such as a strong family history? Interestingly, the evidence does not suggest that this group do worse in treatment; thus, a recent moderation analysis of several trials of one of the best evidence-based programmes, the Incredible Years, found equal effectiveness for those with and without a family history (Presnall, Webster-Stratton, & Constantino, 2014). This example makes the point that we should not automatically assume that different subtypes of antisocial behaviour necessarily need different treatments; rather, we need to conduct trials to test the notion out before making this presumption. This point is also valid for the last main division that the reviewers discuss the presence or absence of callous-unemotional (CU) traits. This has been the subject of intense research activity in the last decade, and can be now reliably identified aged 7. Such children have a much high heritability than those without (0.8 vs. 0.3 in the large twin study by Viding, Jones, Frick, Moffitt, & Plomin, 2008), have less ability to recognise fear and have hypofunctioning amygdala. These children also seem to look at their parents’ eyes considerably less, which could be a treatment target – the idea being that if they look at

J Child Psychol Psychiatr 2014; 55(12): 1311–3

their parents’ eyes more during emotional interchanges, they may become more emotionally sensitive (Dadds et al., 2014). However, again, we need to be cautious before abandoning normal treatment, and the systematic review by Waller, Gardner, and Hyde (2013) found that in a number of studies, parent training was just as effective for antisocial children with CU traits as those without, once initial severity of behaviour problems was controlled for. Because of the high overlap between some of the characteristics of psychopathic traits such as impulsivity with ADHD, we now need studies that see whether the effect of stimulants is in fact to treat unmeasured ADHD. With respect to practice, the review authors are surely right to emphasise the need for multiinformant assessment, for which they recommend the Achenbach system. It is worth also mentioning the Strengths and Difficulties Questionnaire (SDQ) and its accompanying interview, the Development and Well Being Assessment (DAWBA) which have the merit of being free of charge and are widely validated (Goodman & Goodman, 2009); the SDQ is available in over 100 languages (www.sdqinfo.org). Level of fidelity and skill make a large difference to outcomes, so we need to encourage widespread training in evidence-based approaches, as, for example, occurred in the training of 4000 practitioners in evidence-based parenting programmes in England’s National Academy for Parenting Practitioners (Scott, 2010) and that continues in the Increasing Access to Psychological Therapies initiative (www.cypiapt.org). It is encouraging that follow-up studies into adolescence of early parenting interventions for clinical cases show not only reduction in antisocial behaviour at home but also improvements in CU/antisocial personality traits (Scott, Briskman, & O’Connor, 2014). However, in that study and others, the benefits did not necessarily carry over to school and community settings. Therefore, the time has now surely come to configure services so that intervention is routinely offered in these contexts, since otherwise treatment will have been at best partial. For example, classroom management programmes for teachers have been shown to reduce antisocial behaviour in schools (Baker-Henningham, Scott, Jones, & Walker, 2012; Hutchings, Martin-Forbes, Daley, & Williams, 2013). Further gains in disruptive children’s psychosocial functioning can successfully be achieved by interventions that target additional risk factors such child reading attainment (Scott et al., 2010). Antisocial behaviour and conduct disorders are often the poor relation in services for children with mental health disorders, perhaps because the children are seen as unpleasant and blamed for ‘choosing’ to misbehave, and perhaps because parents feel ashamed to come forward and agitate for better services. Therefore, the Practitioner Review by Klahr and Burt is especially welcome in highlighting the © 2014 Association for Child and Adolescent Mental Health.

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heterogeneity of the problems and in making suggestions for further research in treatment approaches, many of which are already proven effective. In the light of this evidence, there is no justification for the deplorable practice of excluding cases with antisocial behaviour and conduct disorders from child and adolescent mental health services.

Acknowledgements This Commentary was invited by the Editors of JCPP and has been the subject of internal review. S.S. was Chair of the NICE Guidelines Development Group for Conduct Disorders in Children & Young People (NICE, 2013) and is a member of the NICE Guidelines Development Group for Children’s Attachment, due to produce a draft guideline in May 2015. He has declared that he has no competing or potential conflicts of interest in relation to this commentary article.

Note 1. Citations in italics are referenced in Klahr and Burt (2014).

References Achenbach, T.M. (1966). The classification of children’s psychiatric symptoms: A factor analytic study. Psychological Monographs, 80, 1–37. Baker-Henningham, H., Scott, S., Jones, K., & Walker, S. (2012). Reducing child conduct problems and promoting social skills in a middle-income country: Clusterrandomised controlled trial. The British Journal of Psychiatry, 201, 101–108. Evans, S.W., Owens, J., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 43, 527–551. Fergusson, D.M., Horwood, L.J., & Ridder, E.M. (2005). Show me a child at seven: Consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal of Child Psychology and Psychiatry, 46, 837–849. Glueck, S., & Glueck, E. (1959). Predicting delinquency and crime. Cambridge, MA: Harvard University Press. Goodman, A., & Goodman, R. (2009). Strengths and difficulties questionnaire as a dimensional measure of child mental health. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 400–403. Hutchings, J., Martin-Forbes, P., Daley, D., & Williams, M.E. (2013). A randomized controlled trial of the impact of a teacher classroom management program on the classroom behavior of children with and without behavior problems. Journal of School Psychology, 51, 571–585. Jenkins, R.L., & Hewitt, L. (1944). Types of personality structure encountered in child guidance clinics. American Journal of Orthopsychiatry, 14, 84–94.

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Klahr, A.M., & Burt, S.A. (2014). Practitioner Review: Evaluation of the known behavioral heterogeneity in conduct disorder to improve its assessment and treatment. Journal of Child Psychology and Psychiatry, 55, 1300–1310. NICE (2013). Antisocial behaviour and conduct disorders in children and young people: Recognition, intervention and management. Clinical Guideline 158. London: National Institute for Health and Clinical Excellence. Odgers, C., Milne, B.J., Caspi, A., Crump, R., Poulton, R., & Moffitt, T.E. (2007). Predicting prognosis for the conduct-problem boy: Can family history help? Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1240–1249. Patterson, G.R., Reid, J.B., & Dishion, T.J. (1982). Coercive family process. Eugene, OR: Castalia Publishing. Patterson, G.R., Reid, J.B., & Dishion, T.J. (1992). Antisocial boys. Eugene, OR: Castalia Publishing. Presnall, N., Webster-Stratton, C., & Constantino, J. (2014). Parent training: Equivalent improvement in externalising behaviour for children with and without familial risk. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 879–887. Quay, H.C. (1964). Dimensions of personality in delinquent boys as inferred from the factor analysis of case history data. Child Development, 35, 479–484. Robins, L.N. (1966). Deviant children grown up. Baltimore: Williams and Wilkins. Scott, S. (2010). National dissemination of effective parenting programmes to improve child outcomes. The British Journal of Psychiatry, 196, 1–3. Scott, S., Briskman, J., & O’Connor, T.G. (2014). Early prevention of antisocial personality: Long-term follow-up of two randomized controlled trials comparing indicated and selective approaches. The American Journal of Psychiatry, 171, 649–657. Scott, S., Sylva, K., Doolan, M., Price, J., Jacobs, B., Crook, C., & Landau, S. (2010). Randomized controlled trial of parent groups for child antisocial behaviour targeting multiple risk factors: The SPOKES project. Journal of Child Psychology and Psychiatry, 51, 48–57. Stringaris, A., & Goodman, R. (2009). Longitudinal outcome of youth oppositionality: Irritable, headstrong, and hurtful behaviors have distinctive predictions.Journal of the American Academy of Child and Adolescent Psychiatry, 48, 404–412. Taylor, E., Chadwick, O., Heptinstall, E., & Danckaerts, M. (1996). Hyperactivity and conduct problems as risk factors for adolescent development. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1213– 1226. Viding, E., Jones, A.P., Frick, P.J., Moffitt, T.E., & Plomin, R. (2008). Heritability of antisocial behaviour at 9: Do callous-unemotional traits matter? Developmental Science, 11, 17–22. World Health Organisation (1978). International classification of diseases, 9th Revision. Geneva: WHO.

Accepted for publication: 15 September 2014 Published online: 13 October 2014

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