Systematic and empirical results on conduct disorders in childhood and adolescence

The article gives an overview on conduct disorders in childhood and adolescence. After a summary of empirical results concerning symptoms, classification and comorbid disorders, risk factors and maintaining factors are discussed. An overview on therapeutic approaches, the indications and efficacy is given. The treatment of aggressive and oppositional behavioral disturbances in children and adolescents presents a particular challenge for the clinical practice, as these disorders have high prevalence rates, often persist from childhood to adolescence and are usually difficult to treat. Besides biologically co-determined disturbances of impulse control (inhibition) and empathy (callous-unemotional traits), psychosocial factors, especially family interactions and disturbance of social cognitive information processing, are important factors in the development of the disorder. For the treatment of aggressive and oppositional behavioral disorders, an evidence-based approach should be chosen. Patient-centered, family-centered and preschool or school-centered interventions, and additionally peer-centered interventions, if necessary, are first line interventions which can be combined with pharmacotherapy in rare cases, if indicated. Evaluated German language treatment manuals are presented

Reliability and Validity of Teacher-Rated Symptoms of Oppositional Defiant Disorder and Conduct Disorder in a Clinical Sample

Background/Aims: It is recommended to use information from multiple informants when making diagnostic decisions concerning oppositional defiant disorder (ODD) and conduct disorder (CD). The purpose of this study was to investigate the reliability and validity of teacher-rated symptoms of ODD and CD in a clinical sample. Methods: The sample comprised 421 children (84% boys; 6-17 years) diagnosed with ODD, CD, and/or attention deficit hyperactivity disorder (ADHD). Teachers completed a standardized ODD/CD symptom rating scale and the Teacher Report Form (TRF). Results: The reliability (internal consistency) of the symptom rating scale was high (alpha = 0.90). Convergent and divergent validity were demonstrated by substantial correlations with similar TRF syndrome scales and low-to-moderate correlations with dissimilar TRF scales. Discriminant validity was shown by the ability of the symptom rating scale to differentiate between children with ODD/CD and those with ADHD. Factorial validity was demonstrated by principal component analysis, which produced a two-factor solution that is largely consistent with the two-dimensional model of ODD and CD proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR, although some CD symptoms representing aggressive behavior loaded on the ODD dimension. Conclusion: These findings suggest that DSM-IV-TR-based teacher rating scales are useful instruments for assessing disruptive behavior problems in children and adolescents. (C) 2014 S. Karger AG, Base

Child-based treatment of oppositional defiant disorder: mediating effects on parental depression, anxiety and stress

Previous research has shown that child-oppositional defiant disorder (ODD) and conduct disorders (CD) are associated with parental symptoms of depression, anxiety and/or stress, probably in a bidirectional relationship with mutual influences. It is, therefore, reasonable to assume that in child-centered treatment, a decrease in child-oppositional behavior problems constitutes (at least in part) a mechanism of change for a subsequent reduction in parental psychopathology. The aim of the present study (Clinical trials.gov Identifier: NCT01406067) was to examine whether the reduction in ODD symptoms due to child-based cognitive behavioral treatment (CBT) led to a reduction in parental depression, anxiety and stress. Eighty-one boys (age 6-12years) with a diagnosis of ODD/CD were randomized either to a cognitive behavioral intervention group or an educational play group (acting as control group). Mediation analyses were conducted using path analysis. The stronger reduction in child ODD symptoms in the CBT group compared to the control group led to a decrease in parental depression and stress, as indicated by significant indirect effects (ab=0.07 and ab=0.08, p<0.05). The proposed model for mechanisms of change was, therefore, confirmed for two of the three outcome parameters. Parental psychopathology and stress can be modified by child-centered CBT. The preceding reduction in ODD symptoms acts as a mediator for at least some of the changes in parental depression and stress. However, due to some limitations of the study, other possible explanations for the results found cannot be completely ruled out and are, therefore, discussed

Bifactor Models Show a Superior Model Fit: Examination of the Factorial Validity of Parent-Reported and Self-Reported Symptoms of Attention-Deficit/Hyperactivity Disorders in Children and Adolescents

Background: Various studies have demonstrated that bifactor models yield better solutions than models with correlated factors. However, the kind of bifactor model that is most appropriate is yet to be examined. The current study is the first to test bifactor models across the full age range (11-18 years) of adolescents using self-reports, and the first to test bifactor models with German subjects and German questionnaires. Sampling and Methods: The study sample included children and adolescents aged between 6 and 18 years recruited from a German clinical sample (n = 1,081) and a German community sample (n = 642). To examine the factorial validity, we compared unidimensional, correlated factors and higher-order and bifactor models and further tested a modified incomplete bifactor model for measurement in-variance. Results: Bifactor models displayed superior model fit statistics compared to correlated factor models or second order models. However, a more parsimonious incomplete bifactor model with only 2 specific factors (inattention and impulsivity) showed a good model fit and a better factor structure than the other bifactor models. Scalar measurement invariance was given in most group comparisons. Conclusion: An incomplete bifactor model would suggest that the specific inattention and impulsivity factors represent entities separable from the general attention-deficit/hyperactivity disorder construct and might, therefore, give way to a new approach to subtyping of children beyond and above attention-deficit/hyperactivity disorder. (C) 2016 S. Karger AG, Base

An evaluation of the pharmacokinetics of methylphenidate for the treatment of attention-deficit/hyperactivity disorder

Introduction: Methylphenidate (MPH) plays a principal role in the multimodal treatment of attention-deficit/hyperactivity disorder (ADHD). Controlled studies have demonstrated an effective reduction in the core symptoms of the disorder following MPH therapy, although long-term studies also demonstrate that the therapeutic benefits dissipate in the absence of combined psychosocial interventions. Areas covered: This review article focuses on the pharmacological characteristics of MPH, examining its effects on brain metabolism and the neurotransmitter system. Neuropsychological and clinical effects of different immediate and extended release MPH formulations are discussed to aid clinicians in choosing the appropriate formulation. The drug's addictive potency and abuse potential is also discussed. Data came from a literature search of relevant studies performed using the PubMed database up to June 2013. Expert opinion: MPH is effective in the treatment of the core symptoms of ADHD. Considerable clinical expertise is required to identify an individually well-adapted dosage which will produce the optimal clinical effects with potential side effects minimized. Due to low adherence to medication, especially in adolescents, motivation to treatment and attentive clinical monitoring is mandatory, as is the consideration of risks of abuse or the presence of a comorbid addictive disorder

Evidence for the Trait-Impulsivity Etiological Model in a Clinical Sample: Bifactor Structure and Its Relation to Impairment and Environmental Risk

The trait-impulsivity etiological model assumes that a general factor (trait-impulsivity) underlies attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and other externalizing disorders. We investigated the plausibility of this assumption by testing the factor structure of ADHD and ODD in a bifactor framework for a clinical sample of 1420 children between 6 and 18 years of age (M = 9.99, SD = 3.34; 85% male). Further, the trait-impulsivity etiological model assumes that ODD emerges only if environmental risk factors are present. Our results support the validity of the trait-impulsivity etiological model, as they confirm that ADHD and ODD share a strong general factor of disruptive behavior (DB) in this clinical sample. Furthermore, unlike the subdimensions of ADHD, we found that the specific ODD factor explained as much true score variance as the general DB factor. This suggests that a common scale of ADHD and ODD may prove to be as important as a separate ODD subscale to assess externalizing problems in school-age children. However, all other subscales of ADHD may not explain sufficient true score variance once the impact of the general DB factor has been taken into consideration. In accordance with the trait-impulsivity model, we also showed that all factors, but predominantly the general factor and specific inattention factor, predicted parent-rated impairment, and that predominantly ODD and impulsivity are predicted by environmental risk factors

The Factor Structure of ADHD - Different Models, Analyses and Informants in a Bifactor Framework

The methodological approach of exploratory structural equation modelling (ESEM) has only been applied once to the construct of Attention-deficit/ hyperactivity disorder (ADHD). We decided to compare bifactor models based on confirmatory factor analyses (Bi-CFA) and exploratory equation modeling (Bi-ESEM) only, as there is a growing support of a bifactor structure of ADHD. To examine the factorial validity of the construct we compared three possible bifactor models. One model with two specific factors (inattention and hyperactivity/impulsivity), another model with three specific factors (inattention, hyperactivity and impulsivity) and an alternative, incomplete model with one general ADHD and two specific factors (inattention and impulsivity). We used parent( N = 1386; Age: M = 11.70, SD = 3.18; Sex: 74.5 % male) and teacher-ratings (N = 110; Age: M= 11.27, SD = 3.04; Sex: 77.5 % male) from clinically referred children between the age of 6 and 18. The results indicate that both methods lead to equally good model fit and for both informants the reliable variance of the specific factor hyperactivity is almost completely explained by the general factor. However, in the teacher condition cross-loadings seem to be of particular importance. Across both methods and informants covariation among ADHD symptom items can be in most part attributed to a general ADHD factor as well as to three (inattention, hyperactivity and impulsivity) or two (inattention and impulsivity) weakly defined specific factors. Further research regarding associations between the specific factors of ADHD and other disorders (e.g. conduct disorder) should be conducted

Psychometric properties of a modified version of the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) in a clinical sample of children with aggressive behavior

PurposeTo evaluate the psychometric properties of a German modification of the Weiss Functional Impairment Rating ScaleParent Report for children with aggressive and oppositional behavior problems (WFIRS-P for ODD/CD).MethodsData were collected from a clinical sample of children (6-12 years; 96% boys) with oppositional defiant disorder (ODD) and conduct disorder (CD) (N=219). The WFIRS-P conceptual framework was evaluated using confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach's alpha) and omega statistics. Validity was assessed through correlations between WFIRS-P for ODD/CD domain scores and parent-rated scales on symptoms of ODD, CD, attention-deficit/hyperactivity disorder (ADHD), a broad range of other behavioral and emotional problems, and scales on health-related quality of life and family burden.ResultsCFA of the WFIRS-P for ODD/CD revealed that a bifactor model, with a general factor accounting for common variance ((H)=0.23-0.48) and independent specific group factors accounting for additional variance in item scores ((S)=0.37-0.60), best fits the data. Thus, CFA confirmed the theoretical assumption of a general construct of impairment (total scale) and additional specific impairments (subscales, e.g., family, social activities). Cronbach's alpha coefficient exceeded 0.70 for all subscales. Omega statistics showed that both the general construct and specific factors accounted for item variance. As expected, correlations with symptoms scales for ODD/CD and ADHD were low to moderate.ConclusionsThe use of the parent-rated WFIRS for ODD/CD in identifying ODD- and CD-related impairment in children is psychometrically supported. The scale can be employed to assess functional impairment in children with aggressive behavior problems

Effects of a smartphone app-augmented treatment for children with oppositional defiant disorder/conduct disorder and peer-related aggressive behavior - a pilot study

Background: Social competence training interventions, especially child-focused ones, have proven to be effective in the treatment of children with conduct disorder. Therapy homework assignments implemented between the therapy sessions are essential for practicing strategies developed during treatment sessions and transferring them to everyday life. However, clinical experience shows that patients' adherence regarding these assignments is often low, thus diminishing the treatment success. One obstacle in this regard is a lack of motivation. The use of smartphone apps in the context of child and adolescent psychotherapy is relatively new, and may provide novel ways to improve the transfer of coping strategies to daily life between treatment sessions. However, only a small number of high-quality studies have analyzed the systematic use of smartphone apps in therapy. The present study will therefore evaluate patients' homework assignment adherence when using a smartphone app as compared to a paper-and-pencil method. Method: The study will be conducted as a randomized controlled trial to evaluate the impact of a smartphone app on the adherence to therapy homework assignments (n = 35) in the treatment of children with aggressive behavior aged 6-12 years compared to paper-and-pencil homework assignments (n = 35). . Discussion: This trial is intended as a pilot study and aims to provide a basis for a subsequent multicenter trial. However, the results may already lead to recommendations for the development and use of mental health-related smartphone apps for children and adolescents with aggressive behavior problems