<ct>Disruptive Behavior Disorders

<au>Jennifer L. Allen, Suhlim Hwang, and Jorg Huijding

<af>University College London, UK

<ab>Disruptive behavior is a heterogeneous construct that encompasses a variety of
symptoms including tantrums, lying, cheating, noncompliance, theft and assault. If these
symptoms are severe, persistent, and accompanied by impairment in social contexts (e.g.,
family, peers, school), the individual may meet the criteria for one of the two diagnoses for
disruptive behavior disorders (DBDs): oppositional defiant disorder (ODD) and conduct
disorder (CD). Although ODD and CD tend to share risk and protective factors, evidence
supports the status of ODD and CD as distinct diagnoses, with ODD typically emerging prior
to CD and showing links with the emergence of later emotional disorders. Different
developmental pathways have been identified for DBDs, focusing on the age of onset and the
presence of psychopathic features. Current research priorities include a multimethod
approach to explore disruptive behavior at neural, genetic, and environmental levels across
multiple domains (affective, cognitive, social, and behavioral) in diverse populations.
<k>aggression; antisocial behavior; conduct disorder; conduct problems; disruptive behavior;
oppositional defiant disorder

<a>Background and Classification

<pf>Disruptive behavior disorders have been the subject of concern and controversy for
centuries, although their classification as psychological disorders has occurred only since
1968. Disruptive behavior is a heterogeneous construct that encompasses a wide variety of
symptoms ranging from mild (e.g., tantrums, noncompliance) to severe (e.g., theft, violence).
Various terms fall under the broad umbrella of disruptive behaviors including conduct
problems, oppositional behavior, aggression, antisocial behavior, and delinquency. Mild
disruptive behaviors tend to emerge first, whereas more severe behaviors emerge later in
development, as the individual develops increased physical strength, cognitive abilities, and
sexual maturity. Disruptive behaviors are widely prevalent and a common reason for referrals
to child and adolescent mental health services. These behaviors can exert a substantial
physical, emotional, and economic burden on the perpetrators, their family, their victims, and
society. For example, antisocial behavior is strongly associated with bullying, school dropout,
truancy, and poor academic achievement. Long-term outcomes of antisocial behavior in
youth include unemployment, poor marital relationships, and involvement in crime. Public
concern and scholarly interest has propelled extensive study of the presentation, diagnosis,
and risk and protective factors to inform prevention and intervention for disruptive behavior.
In particular, adolescence has been a central focus for researchers, practitioners, and policy
makers because of the significant rise in antisocial behavior during this stage of development.
When disruptive behaviors occur in a severe, frequent, and persistent pattern and are
accompanied by impairment in family, peer, educational, or occupational settings, a diagnosis
of one of the two forms of disruptive behavior disorders (DBDs) may be warranted:
oppositional defiant disorder (ODD) and conduct disorder (CD). ODD refers to an enduring
pattern of uncooperative, negativistic, defiant, disobedient, and hostile behavior toward
authority figures (e.g., parents, teachers), while CD reflects a repetitive and persistent pattern
of behavior involving violations of the basic rights of others or of societal norms. ODD is
viewed as a developmental precursor to CD because of its milder presentation and earlier age
of onset. The International Classification of Diseases (10th rev., ICD-10; World Health
Organization, 1992) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
DSM-IV; American Psychiatric Association [APA], 2000) describe ODD as a subtype of CD,
with an ODD diagnosis possible only if the criteria for CD are not met. ODD tends to emerge
first, followed by the later onset of more severe CD symptoms. However, many children with
ODD do not have CD or do not go on to develop CD later (Rowe et al., 2010). Conversely, a
minority of children with CD meet the criteria for ODD, with the proportion of youth with
CD and without ODD increasing from childhood to adolescence. Furthermore, ODD is a
significant predictor of adjustment problems in adolescence and adulthood, particularly
emotional disorders, even when controlling for CD symptoms (Rowe et al., 2010). Therefore,
on the basis of the research supporting a distinction between the two disorders, the DSM-5
(APA, 2013) revised the diagnostic criteria, and it is now possible to apply both diagnoses to
the same individual.

<a>Oppositional Defiant Disorder

<pf>The diagnosis of ODD has been featured in the DSM since 1980, but remains a subject
of controversy despite its long-standing inclusion. For many years this disorder was viewed
as a relatively benign, transient, childhood-limited condition that chiefly served as a risk
factor for the more serious condition of CD. The controversy revolves around two concerns.
First, there are concerns that the diagnosis of ODD may pathologize normal behavior given
that oppositional, noncompliant, and argumentative behaviors are common in typically
developing children, particularly during the toddler and early preschool years, and in
adolescence. Second, as ODD is often comorbid with other disorders, in particular attention-
deficit/hyperactivity disorder (ADHD), CD, anxiety, and depression, there were concerns that
this diagnosis was merely a nonspecific marker of general adjustment problems rather than a
distinct entity in its own right. However, there is evidence to support ODD as a distinct,
significant condition that predicts a range of mental disorders, including anxiety and
depressive disorders, CD, and antisocial personality disorder even when accounting for the
symptoms of others forms of psychopathology (Loeber, Burke, & Pardini, 2009).
Furthermore, although ODD has generally been viewed as a disorder of childhood, recent
evidence indicates that it can persist into adolescence and make a unique contribution to
problems in peer and romantic relationships and occupational functioning in young adulthood
(Burke, Rowe, & Boylan, 2014).
These concerns have been addressed through refinements to the diagnostic criteria in
DSM-5. First, criteria provide guidance on the frequency and persistence of symptoms
typically needed for a behavior to be considered symptomatic of the disorder. To meet the
diagnostic criteria, behaviors should be severe enough to lead to impairment in social or
academic functioning for at least 6 months, and clinicians should consider whether the
frequency and intensity of the behaviors are outside a range that is normal for the individual’s
developmental level, gender, and culture. The DSM-5 also includes a specifier for severity
for ODD, reflecting research indicating that severity is strongly related to the degree of
pervasiveness of symptoms across settings. For example, when symptoms are confined to the
home setting (one setting), the disorder is considered mild. However, if symptoms are present
in two settings, such as at home and at school, the disorder is considered moderate; if they
occur in three or more settings, a specifier of severe is applied. Nonetheless, this still leaves
the diagnostic category open to criticisms that, in its mild form, it risks labeling a child who
has a poor parent–child relationship and/or has experienced dysfunctional parenting as
suffering from a mental disorder. This relates to the more general criticism of the medical
approach to conceptualizing disorders that are characterized by significant interpersonal
impairment as existing within individuals in the form of a diagnosis. In contrast, alternative
perspectives such as attachment theory conceptualize clinical problems and strengths as
existing between the individual and significant others, chiefly the child’s caregivers.
<b>Developmental Pathways for ODD
<pf>The onset of ODD typically occurs before the age of 8 years, with a mean age of onset
of 6 years. Once present, ODD shows moderate to high stability across childhood and
adolescence. Its prevalence varies, ranging from 2.6% to 15.6% in community samples and
from 28% to 65% in clinical samples (Boylan, Vaillancourt, Boyle, & Szatmari, 2007).
Prevalence rates are inconsistent across studies, particularly regarding gender differences, but
most evidence suggests a similar prevalence for both genders during the toddler and early
preschool years, with girls showing similar rates to boys of externalizing behaviors including
physical and verbal aggression. Later in development there are gender differences in the type
of disruptive behaviors, with girls showing more covert and relational aggression (e.g., lying,
rumor spreading, ostracism) and boys greater levels of physical aggression and property
destruction. This has led to concerns that disruptive behaviors may be underidentified in girls
because of the nature of the behaviors used to define DBDs, cultural expectations around
gender and behavior, as well as the ease of detecting overt versus covert forms of antisocial
behavior.
<b>Heterogeneity in ODD Symptoms: Temperament Dimensions
<pf>ODD is generally considered a behavioral disorder, despite the fact that it encompasses
behavioral (headstrong, defiance) and emotional symptoms (anger, irritability), is commonly
comorbid with internalizing problems, and is a risk factor for later emotional disorders. In
recent years, substantial evidence has emerged supporting a multidimensional
conceptualization of the symptom criteria for ODD. Stringaris and Goodman (2009)
identified three distinct temperament dimensions of ODD: irritability, headstrong
(argumentative/defiant behavior), and hurtfulness (spiteful and vindictive behaviors).
However the ODD symptoms that reflect these different underlying dimensions are also
highly correlated, which supports their inclusion within ODD as a single diagnostic construct.
Interestingly, while many children show symptoms belonging to the headstrong dimension
without anger/irritability, it is unusual for children to show high levels of irritability without
behavioral symptoms. The symptom criterion “is often spiteful and vindictive” does not tend
to cluster with the other ODD symptom criteria and is predictive of more severe antisocial
behavior (Rowe et al., 2010).
The temperament dimensions of ODD provide clinically meaningful information for
predicting later outcomes, as all three dimensions are related to CD, but the irritable
dimension is also related to emotional disorders, the headstrong dimension to ADHD, and the
spiteful/vindictive symptom to callous and unemotional (CU) traits. Therefore the presence of
dominant symptoms of anger–irritability may designate a subgroup of children with ODD
who have difficulty regulating emotions, placing them at risk of later CD and emotional
disorders (Frick & Morris, 2004). Thus ODD may predict internalizing and/or externalizing
problems because it consists of underlying dimensions reflecting headstrong/defiant behavior,
negative affect, or a combination of these two symptom clusters. The DSM-5 now groups
ODD symptom criteria into three groups: angry/irritable mood, argumentative/defiant
behavior, and vindictiveness in order to highlight that this disorder encompasses emotional
and behavioral symptoms, and to facilitate research on different risk factors, prognosis, and
treatment outcomes for children with different ODD temperament profiles.

<a>Conduct Disorder
<pf>Conduct disorder is considered an important diagnosis because of its strong relationship
with violent and criminal behavior, other mental disorders (depression, substance abuse),
marital problems, and impairment in educational and occupational settings. The DSM-5
distinguishes four groups of CD symptoms: aggression toward people and animals (e.g.,
bullying others, being physically cruel to people or animals, forcing someone into sexual
activity); destruction of property (e.g., starting fires, destroying others’ property);
deceitfulness or theft (e.g., breaking into a house or car, lying, stealing); and serious rule
transgressions (e.g., running away from home, truancy). CD is diagnosed when three or more
of these symptoms are present over the past 12 months with at least one symptom evident
within the past 6 months. Similar to ODD, CD is accompanied by a severity specifier. If few
conduct problems exist in excess of those symptoms, and harm to others is minor, the
diagnosis is considered mild; if many conduct problems occur in excess of those, or if they
cause significant harm to others, the disorder is specified as severe. If the number of conduct
problems and their associated impact ranges between mild and severe, CD severity is
considered moderate.
Once diagnosed, CD shows moderate to high stability. Its prevalence in community
samples ranges from 1.8% to 16% for boys and from 0.8 to 9.2% for girls (Loeber et al.,
2009). In contrast to ODD, which maintains a steady rate of prevalence across childhood and
adolescence, the prevalence of CD increases from the primary school years to adolescence,
reaching a peak in mid to late adolescence (Maughan, Rowe, Messer, Goodman, & Meltzer,
2004). It is more common for boys to be diagnosed with CD than girls, with this gap
narrowing from the middle school years to adolescence. Males tend to show more overt
symptoms (e.g., breaking and entering, fighting, vandalism), but covert antisocial behavior is
more common in girls (e.g., shoplifting, lying, running away). However, some girls follow a
similar pathway to boys if they show an early onset of physical aggression. Most girls with
CD do not show severe antisocial behavior until adolescence, and this is more frequently
accompanied by comorbid anxiety or depression compared to boys with CD. In comparison
to boys with severe CD, girls show higher rates of comorbid ADHD, emotional disorders,
and suicide attempts, and tend to come from more adverse family backgrounds, including
higher rates of parental psychopathology, criminality, and physical and sexual abuse.
<b>Developmental Pathways for CD
<pf>Different subtypes of CD have been proposed to help us understand the substantial
variation in the presentation, developmental course, correlates, and prognosis for antisocial
behavior. The most commonly used criterion for subtyping CD is the distinction based on age
of onset, commonly referred to as the life-course-persistent versus adolescence-limited
pathways (Moffitt, 2018). A second pathway focuses on the presence of CU traits, a
temperament dimension characterized by low empathy, guilt, and emotionality that has a
similar presentation as, and correlates with psychopathy in adults (Frick & Morris, 2004).
<b>Childhood- Versus Adolescent-Onset CD
<pf>The DSM-5 (APA, 2013) includes a specifier that differentiates between the childhood-
onset type, in which one or more CD symptoms emerge prior to the age of 10, and the
adolescent-onset type, in which symptoms are absent prior to 10 years and start to emerge
around the onset of adolescence. The childhood-onset group may display conduct problems
in the preschool or early school years, and their disruptive behaviors progress in both
frequency and severity from childhood to adolescence. Early onset conduct problems predict
later CD, antisocial personality disorder, substance-related disorders, and criminal
convictions in adolescence and adulthood. The conduct problems displayed by this group
tend to begin in the home, showing strong links with adverse family circumstances including
family instability, family conflict, and ineffective parenting strategies. The childhood-onset
group is associated with male gender, greater temperamental risk (e.g., impulsivity, poor
emotion regulation), deficits in social cognition (e.g., hostile attribution bias), and
neuropsychological deficits (e.g., low verbal ability, deficits in executive functioning).
However, it is important to recognize that most antisocial children do not become antisocial
adults.
 In contrast to the childhood-onset subtype, the adolescent-onset subtype is
characterized by lower levels of aggression, fewer prior difficulties related to disruptive
behavior, and a more even balance of males and females. The adolescent-onset subtype is
strongly associated with deviant peer group affiliation and with poor parental monitoring and
supervision. It may be that parents of youth with adolescent-onset CD were capable of
managing their child’s behavior in the early and primary school years, but lack the skills and
resources to cope with the different challenges of adolescence. In the long term, children in
this group are less likely to have persistent CD or to develop antisocial personality disorder in
adulthood. This group was previously thought to desist in their antisocial behavior between
adolescence and adulthood, hence, the term adolescence-limited pathway, but recent evidence
indicates that this group shows elevations in impulsivity, substance abuse, and dependence
compared to the norm (Moffitt, 2018).
Moffitt (2018) outlined different causal mechanisms relating to both endogenous and
environmental factors in order to explain the different risk factors and outcomes for these two
subtypes. The development of disruptive behavior problems in the childhood-onset group is
attributed to a transactional process between child vulnerability due to cognitive deficits and
temperamental risk, and dysfunctional or inadequate family or school environments (e.g.,
harsh parental discipline, poor-quality education). The interplay between the child’s
characteristics and the environment leads to poor-quality relationships with parents, siblings,
peers, and teachers. These impaired relationships then lead to enduring vulnerabilities that
disrupt the child’s psychosocial and cognitive development. In contrast, the antisocial
behavior of the adolescent-onset group is driven by rebelliousness and rejection of traditional
values and status hierarchies. For these individuals, antisocial behavior is a way of asserting
their independence and breaking away from their parents. Their disruptive behaviors are
learned from antisocial models, who are copied in an attempt to gain a sense of maturity. The
antisocial behavior of this group therefore represents an exaggeration of the normative
process of autonomy seeking in adolescence rather than enduring vulnerability factors (e.g.,
impulsivity, verbal deficits), and is therefore limited to adolescence. However, although the
adolescent-onset subtype is associated with fewer risk factors than the childhood-onset group,
the consequences of adolescent antisocial behavior such as school dropout, a criminal record,
or substance abuse can cause impairment that may persist into adulthood and place the
individual on an unhealthy antisocial lifestyle trajectory.
While there is substantial research to support the age-of-onset distinction for CD, it is
less clear what age should be used to differentiate the two groups, with suggested cut-off
points for the childhood-onset problems group ranging from prior to 10 years to prior to 14
years of age. As such, a dimensional approach to the assessment of the age of onset
distinction may be warranted. Another limitation of this distinction is that it does not explain
the vast heterogeneity in presentation, correlates, and outcomes within the childhood-onset
group. That is, there are children in the childhood-onset group whose disruptive behavior
problems are mild and transient, and others for whom antisocial behavior persists into
adolescence and adulthood. Psychopathic features have been introduced into the DSM-5 in
the form of a specifier for CD as a means to delineate different pathways to antisocial
behavior for children with an early onset of conduct problems.

<a>Psychopathic Features: “Limited Prosocial Emotions”

<pf>Over the last two decades there has been a surge in interest in identifying psychopathic
traits in youth in an attempt to explain the heterogeneous nature of and differing pathways to
antisocial behavior. Three dimensions of child temperament congruent with the multifaceted
model of psychopathic traits in adults have been identified in children: callous–unemotional
traits (affective dimension), narcissism (interpersonal dimension), and impulsivity
(behavioral dimension). CU traits are considered to be the hallmark feature of child
psychopathy, with high levels of these traits predictive of a more varied, violent, and chronic
pattern of antisocial behavior. CU traits are associated with an early onset of conduct
problems and show relative stability from childhood to adolescence, and from adolescence to
adulthood. CU traits can be reliably identified and assessed from as early as the preschool
years onwards. However, in the toddler years, the term callous–unemotional behaviors is not
applied in recognition of the fact that there is little evidence that CU behaviors show the
properties considered to define traits in this developmental period (e.g., high stability,
resistance to environmental influence).
In addition to the utility of CU traits in predicting the variety, severity, and
persistence of antisocial behavior, there are differences between youth with high and those
with low levels of CU traits in several domains (see Frick & Moffitt, 2010). There is a strong
body of evidence that suggests that CU traits have a biological basis, including a moderate to
strong genetic influence, and relatively distinctive neurological and biological correlates. CU
traits are associated with deficits in processing negative emotional stimuli, and children with
CU traits show reduced recognition and responsiveness to the distress cues of others,
including reduced amygdala response to fearful faces. They are insensitive to punishment,
particularly when in pursuit of a reward, and tend to show higher levels of fearlessness and
thrill seeking. Youth with CU traits have more positive expectations about the outcomes of
aggression and lack concern for the consequences of their behavior in terms of punishment,
anticipated feelings of remorse, or victim suffering. Finally, CU traits are not associated with
deficits in verbal ability that are commonly present in antisocial youth (Allen, Briskman,
Humayun, Dadds, & Scott, 2013).
In terms of family risk factors, the conduct problems of children high in CU traits
appear to be less strongly related to harsh parental discipline than those low in CU traits.
However, harsh, inconsistent parental discipline and poor parental monitoring are associated
with an increased severity of CU traits and antisocial behavior over time. Thus the
dysfunctional parenting practices associated with CU traits appear to be largely due to child-
driven effects, with child temperamental characteristics eliciting poor parenting. In contrast,
both parent- and child-driven effects are present for antisocial children low in CU traits, with
poor parenting eliciting child disruptive behavior and vice versa. This insensitivity to parental
or societal sanctions and poor arousal to the distress cues of others is thought to obstruct
avoidance learning from occurring through preventing the internalization of moral and social
norms. Importantly, parental warmth and positive parenting practices (e.g., praise, spending
quality time with the child) appear to exert a protective effect against antisocial behavior for
children high in CU traits. Frick and Morris (2004) outlined different developmental
pathways to antisocial behavior, with emotion dysregulation and deficits in executive
functions and verbal ability coupled with inadequate socialization underlying the disruptive
behaviors of those on the hostile–reactive pathway, and a fearless and uninhibited
temperament affecting the optimal development of conscience underlying the callous–
unemotional pathway.
CU traits have been incorporated into the DSM-5 under the term “limited prosocial
emotions” (LPE) because of evidence supporting their role in identifying a high-risk
subgroup of antisocial children and to facilitate further investigation and application of CU
traits/LPE specifier in research, clinical, and forensic contexts. The LPE specifier is applied
to a diagnosis of CD when an individual has demonstrated two or more of the following
characteristics persistently over at least 12 months and across multiple relationships and
settings: (1) lack of remorse or guilt when they do something wrong; (2) callousness and lack
of empathy toward others; (3) lack of concern about performance (e.g., school, work); and (4)
shallow or deficient affect. Although CU traits and the LPE specifier reflect the same
underlying characteristics, the term limited prosocial emotions was applied because of
concerns about the potential stigmatizing effect of the term CU traits.
 While the study of psychopathic traits in children has always been controversial, the
LPE specifier has generated a new set of concerns. One criticism is that a categorical
specifier suggests that there is a qualitative difference between antisocial youth that do or do
not meet the criteria for LPE, whereas the majority of research evidence indicates that CU
traits reflect a dimensional construct, with these characteristics occurring on a continuum.
Other concerns relate to its potential misuse and abuse in the legal system. For example,
psychopathic traits have traditionally been viewed as resistant to intervention, despite ample
evidence that behavioral family interventions successfully reduce CU traits and antisocial
behavior in children (see Hawes, Price, & Dadds, 2014). This view may influence court
decision making concerning whether the child or adolescent is tried through the juvenile or
adult system, the length of sentence, and access to rehabilitation programs. There is also the
risk that a young person will be labeled psychopathic for displaying a feature of a transient
developmental process that will not be characteristic of them in adulthood. Adolescence is a
time of rapid change and is characterized by egocentrism, experimentation in personal
identity and social relationships, risk taking, and autonomy seeking in pursuit of an adultlike
identity. If adolescent behavior is not viewed through the lens of normal development, it is
possible that youth could be incorrectly identified as meeting the criteria for LPE.

<a>Treatment and Prevention of Disruptive Behavior Disorders

<pf>The most effective interventions for disruptive behaviors are cognitive–behavioral in
nature. Intervention typically focuses on children and families but, because of the
pervasiveness of disruptive behavior, treatment often targets multiple levels including peers
and school. The focus of therapy and levels targeted generally reflect the child’s
developmental level and the setting in which disruptive behaviors are causing impairment.
Thus interventions for early behavioral problems tend to focus on parents, while programs
directed at older children and adolescents may be delivered to families or be solely child- or
adolescent-focused. Prevention and intervention programs for disruptive behavior are
delivered by a wide range of educational, services, social services, and health professionals
(psychologists, social workers, school counselors, teachers, school- or community-based
mentors or advocates), and are provided through a variety of formats (group, individual, self-
directed), modes of delivery (bibliotherapy, technology-assisted programs), and settings
(home, clinic, school, parents’ workplace, juvenile detention centers). The duration of
programs varies considerably, from relatively brief treatments or even one-off treatment
sessions to programs that span many years.
 The models that have received the strongest support in explaining the contribution of
family processes to the developmental course of conduct problems are those based on social
learning theory (operant) principles. In particular, Gerard Patterson’s (1982) model of
coercive family processes has been a major influence on the field of behavioral family
intervention. This model emphasizes the role of reciprocal coercive exchanges between
parents and children. According to this model, children learn coercive behaviors such as
whining, nagging, tantrums, or aggression within the family setting, and these behaviors then
generalize to other social contexts. The two main family processes that contribute to conduct
problems in children are direct imitation of the coercive behaviors of parents or siblings (e.g.,
yelling, smacking) and escape–avoidance reinforcement “traps” (e.g., a child whines, the
parent gives in, and the child learns to repeat their misbehavior to obtain a desired outcome).
Conversely, these coercive processes also shape and alter parent behavior. In the preceding
example, the parent also learns that giving in allows them to escape the child’s whining.
Meanwhile, prosocial behavior is ignored and warm/nurturing family interactions are
extinguished. These coercive exchanges tend to be repeated and to escalate over time and
may cause significant disruption to family relationships.
Patterson’s model forms the basis for behavioral parent training interventions such as
The Triple P–Positive Parenting Program (Sanders, 2012) and the Incredible Years (Webster-
Stratton, 2001). These programs emphasize the use of reward-based parenting strategies
(praise, affection) to improve parent–child relationship quality and to prevent misbehavior,
and of consistent, nonphysical discipline to address misbehavior when it occurs (e.g., time-
out, removal of privileges). Often parent training programs include Parent–Child Interaction
Therapy (PCIT; Eyberg & Matazzo, 1986), which uses covert therapist feedback to coach
parents to provide their child with positive and supportive verbal and nonverbal attention
during parent–child play interaction. These strategies are highly effective in promoting a
warm, positive parent–child relationship which in turn promotes child compliance and
reduces misbehavior as a means of seeking parental engagement. For older children and
adolescents, programs often include components targeting child-specific risk factors in
emotional, social, cognitive, and academic domains. For example, the Coping Power Program
(Lochman & Lenart, 1993) includes strategies such as goal setting and problem solving,
study skills, social skills, anger management, resisting peer pressure, and gaining access to
prosocial peer groups. While parenting continues to contribute to antisocial behavior
trajectories across later childhood and adolescence, there is a shift in focus from the
regulation of child behavior in the family setting to the regulation of children’s peer activities
outside the home. As such, interventions for older children and adolescents often focus on
skills training related to self-regulation, while also promoting parental skills in monitoring
and supervision.
From early adolescence onwards, many disruptive behaviors are likely to relate to
law breaking. Therefore programs targeting multiple levels or systems consisting of
combinations of family-, school-, and adolescent-focused interventions tend to be more
effective for this age group. Multisystemic therapy (MST; Henggeler, Schoenwald, Borduin,
Rowland, & Cunningham, 2009) is composed of intervention components aimed at
addressing systemic risk factors (poor-quality family relationships, association with problem
peers, academic difficulties) as well as cognitive–behavioral interventions to address
individual risk factors for antisocial behavior in adolescents (cognitive biases, impulsivity)
and their caregivers (parent psychopathology, substance abuse). In recognition of the severe
strain that youth with antisocial behavior can place on the family, MST is an intensive,
individualized family- and community-based treatment in which therapists are on call 24
hours a day, 7 days a week. In MST, caregivers are viewed as the primary conduits of change
and are coached in effective parenting practices (e.g., conflict management, nurturance,
monitoring) to improve adolescent functioning across family, peer, school, and community
contexts. In addition, MST supports and encourages caregivers to access positive social
support from their extended family, school, and community. Positive social support is viewed
as crucial in relieving caregivers of the stresses of raising an antisocial adolescent, in
promoting the healthy adjustment of youth and caregivers, and in successfully maintaining
treatment gains.
In terms of prevention approaches, the Promoting Alternative Thinking Strategies
(PATHS) curriculum (Kusche & Greenberg, 1994) is a well-known universal social–
emotional learning program, aimed at promoting children’s emotional awareness and
communication, self-control skills, positive self-concept, friendship skills, and interpersonal
problem-solving skills. PATHS is a multiyear universal prevention program delivered by
teachers and school counselors and features different versions for preschool/kindergarten and
elementary school children. Prevention programs may also take a targeted/indicated
approach, where children are selected on the basis of subclinical levels of behavior problems
or the presence of risk factors (e.g., social disadvantage). In the multidimensional 10-year
Fast Track program commencing in 1991 (Conduct Problems Prevention Research Group,
1992), children were selected on the basis of elevated conduct problems in kindergarten. In
elementary school (Grades 1–5), all children received PATHS. High-risk children also
participated in social skills training groups, tutoring in reading, and classroom-based peer
pairing to promote friendships. Parents of high-risk children participated in parent training
groups, while parents of the children considered most vulnerable received home visits to
foster their problem-solving, self-efficacy, and life management skills. In Grade 4, children
were provided with a one-on-one adult mentoring program to promote the positive identity
development. The adolescent phase (Grades 6–10) includes parent–youth group meetings to
support children in the transition to high school, while individualized services included home
visits, family problem solving, and liaison with school and community agencies. Evidence to
date indicates that the intervention was successful in improving parenting, social–cognitive
skills, peer relationships, academic skills, and a nondeviant peer social ecology (Dodge et al.,
2014). It significantly reduced aggressive behavior throughout elementary school, delinquent
behaviors in high school, juvenile and adult arrests at the age of 21, and adult violent crime
and drug-related arrests, and risky sexual behavior, and improved well-being by the age of
25. However, the impact of the intervention was minimal at Grade 8, with the intervention
achieving significant positive change only for several outcomes for the highest-risk group of
kindergarteners.

<a>Current Emphases in Research and Future Directions

<pf>Now that effective treatments have been established for disruptive behaviors, attention
has shifted to exploring what works best for whom in order to meet the individual needs of
children and their families. For example, the Triple P program (Sanders, 2012) is framed
within a public health model, consisting of multiple levels of prevention/intervention that
range in intensity from parent information campaigns to behavioral family intervention across
individual, group, and self-directed modes of delivery. It also features different versions
depending on the child’s developmental stage, conduct problem severity, family risk
(maltreatment, parental psychopathology), and common comorbid problems (chronic illness,
developmental delay). The development of personalized treatments based on child
temperamental risk is another approach aimed at providing a better fit for children and
families. For example, current research aims to promote parent and child shared eye gaze
during emotionally intimate interactions as a way to overcome the eye gaze and emotion
recognition deficits in antisocial children with CU traits (Dadds et al., 2014). Key remaining
challenges for prevention and intervention include removing the stigma associated with
treatment, increasing access to services, providing high-quality professional training and
implementation, and ensuring the sustainability of programs in a cost-effective manner.
 Current emphases in research have been driven by advances in technology, statistical
methods, and the availability of cohort study data (see Moffitt, 2018). In particular, new and
improved methods in genetics (heritability of traits and molecular genetics) and neuroscience
(neuroimaging) have greatly enhanced our understanding of the biological processes
underlying antisocial behavior. Innovations in statistical methods have also advanced the
field. For example, group-based trajectory methods enable the detection of theoretically
predicted groups with distinct trajectories of antisocial behavior within a population,
confirming the validity of the age of onset distinction in predicting trajectories of criminal
offending. Since the first decade of the 21st century, cohort studies following children
through to adulthood have become available, and as a result we now know that those on the
life-course-persistent pathway continue to have higher rates of offending later in life, along
with an increased risk of incarceration, poor physical health, and premature mortality
compared to the adolescence-limited group.
While many types of disruptive behavior have been the subject of public concern and
consternation for centuries, societal change and technological advancements have led to new
forms of youth antisocial behavior that often have serious consequences, including online
bullying, school shootings, and involvement in terrorist activities. Since the 1980s, the
traditional milestones of adulthood such as leaving home, completing education, obtaining a
secure job, homeownership, marriage, and starting a family have been pushed back by many
years compared to previous generations. This change parallels shifts to a slightly older age at
which crime peaks and an older age of desistance from crime, but the reasons for these shifts
are not entirely clear (Moffitt, 2018). Thus, as society changes, new challenges also arise for
the identification, understanding, and treatment of antisocial behavior. The way forward for
research on disruptive behavior is likely to lie in a multimethod interdisciplinary approach to
elucidating the interaction between multiple risk and protective factors operating at neural,
genetic, and environmental levels, coupled with an acknowledgment of the contribution of
individual differences including gender, temperament, and cognitive ability.
<xref>SEE ALSO:
Aggression and youth violence; Delinquency; Risky behavior; Parent–child relationships;
Family context; Abuse and neglect of the adolescent.
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<rh>Further Reading
Frick, P. J., & Nigg, J. T. (2012). Current issues in the diagnosis of attention deficit
hyperactivity disorder, oppositional defiant disorder, and conduct disorder. Annual
Review of Clinical Psychology, 8, 77–107.
Moffitt, T. E. (2018). Male antisocial behavior in adolescence and beyond. Nature Human
Behavior, 2, 177–186. doi:10.1038/s41562-018-0309-4
<bio>Jennifer Allen (PhD, Macquarie University, 2006) is an Associate Professor and
Clinical Psychologist in the Department of Psychology and Human Development, University
College London, UK. Her research focuses on how the family and school environments relate
to antisocial behavior and callous–unemotional traits and how findings in this area can be
translated into more effective family- and school-based interventions. She is co-editor
of Family-based Intervention for Child and Adolescent Mental Health: A Core Competencies
Approach (Cambridge University Press) with Cecilia Essau (PhD, University of
Roehampton) and David Hawes (Phd, University of Sydney), and has published over 30
journal and book articles on emotional and behavioral problems in children and adolescents.
<bio>Suhlim Hwang is a PhD student at the Department of Psychology and Human
Development, UCL Institute of Education, UK, and has many years’ experience working as a
teacher in elementary schools in South Korea. Her doctoral research focuses on cross-
sectional and longitudinal associations between factors that serve as risk or protective factors
for the poor academic performance of antisocial children with callous–unemotional traits. Her
proposed mechanistic, longitudinal research helps to inform individualized school-based
interventions for antisocial children with or without callous–unemotional traits by identifying
specific risk and protective factors for poor school engagement and academic outcomes.
<bio>Jorg Huijding (PhD, University of Groningen, 2006) is an Associate Professor at the
University of Utrecht, Netherlands. His research focuses on the role of information
processing in the onset and maintenance of aggression and anxiety, and how information
processing affects parenting. In addition he is interested in the development of emotion
regulation and is currently leading a research program examining self-regulation in children
and adolescents using data from the YOUth cohort study. He has published over 60 articles
on aggression, anxiety, and addiction in adults and youth.