Cortisol levels and conduct disorder in adolescent mothers

OBJECTIVE: To examine the association between cortisol levels and conduct disorder (CD) in adolescent mothers. Past research has shown that low levels of cortisol were associated with CD, particularly with its aggressive symptoms. The authors tested the hypothesis that adolescent mothers with CD would show lower levels of salivary cortisol compared to mothers without CD at 4 and 9 months postpartum. METHOD: Midmorning salivary cortisol levels were measured in 228 adolescent mothers (age at delivery 16.9 +/- 1 years [mean +/- SD]) during a laboratory visit at 4 and 9 months postpartum. CD was diagnosed during pregnancy according to the CD subsection on the criteria for antisocial personality disorder (DSM-III-R). RESULTS: Results did not confirm the hypothesis. Lower cortisol levels were not significantly associated with a CD diagnosis, the number of CD symptoms, or aggressive symptoms. CONCLUSIONS: Despite valid measures and strong statistical power, this study failed to find an association between cortisol levels and CD in a sample of adolescent mothers. The results may have been influenced by the fact that participants were 4 and 9 months postpartum and by comparisons of mothers with CD to mothers living in stressful circumstances.     

Defense mechanisms in adolescent conduct disorder and adjustment reaction

The use of defense mechanisms by male and female adolescents with a diagnosis of conduct disorder was compared with the defense use of adolescents with a diagnosis of adjustment reaction. Because conduct disorder has been shown to be associated with a developmental lag in several areas of psychological functioning, we expected that these adolescents would show immaturity in the use of defenses. This expectation was confirmed. As compared with adjustment reaction, conduct disordered youths were more likely to use the immature defense of denial and less likely to use the mature defense of identification.     

Neuropsychological function in adolescent girls with conduct disorder

ObjectivesConduct disorder (CD) in adolescent girls is a significant problem, but few data exist on the neuropsychological function of girls with this disorder. We investigated whether girls with CD have poorer neuropsychological function than girls without any psychiatric disorder, whether these differences remained significant after adjusting for demographics, and whether psychiatric comorbidity, age at onset of CD symptoms, or aggressive CD behaviors were differentially associated with neuropsychological function within the CD group.MethodNinety-three girls, ages 15 to 17 years, from the community (52 CD; 41 without any disorder [normal controls]) received a neuropsychological battery examining motor/laterality, general intelligence, language, visuospatial, visual-motor, executive function, and academic achievement domains.ResultsGirls with CD had lower general intelligence and poorer performance on visuospatial, executive function, and academic achievement domains. After adjusting for demographic factors, scores in the CD group were worse for general intelligence and in the visuospatial and academic achievement domains. Comorbid substance use disorder was negatively correlated with motor/laterality; no other intra-CD group comparisons were statistically significant.ConclusionsGirls with CD had deficits in several domains of neuropsychological function. Possible explanations for the findings and clinical implications are discussed.     

Decreased cortisol levels in adolescent girls with conduct disorder

BACKGROUND: Female adolescent antisocial behavior is increasing, but little is known about the neuroendocrinologic aspects of this disorder. On the basis of reports of decreased cortisol levels in antisocial males, we investigated morning plasma cortisol levels in adolescent girls with conduct disorder (CD). METHODS: Three plasma samples for cortisol levels were taken every 20 minutes between 8 and 9 AM in 47 adolescent girls with CD (mean +/- SD age, 16.5 +/- 0.9 years) and 37 normal control girls (mean age, 16.0 +/- 0.8 years). All blood was drawn within 72 hours after the onset of menstrual flow. RESULTS: Girls with CD had significantly lower cortisol levels than girls in the normal control group at all 3 sampling times. This finding was not due to procedural factors, demographic characteristics, or the use of medications. The girls with CD who had no other psychiatric problems had lower cortisol levels than girls with other disorders or those in the normal control group. In the multiple regression analysis, having CD predicted 10% of the variance in cortisol levels. CONCLUSIONS: Morning plasma cortisol levels were significantly diminished in adolescent girls with CD. Decreased cortisol levels appear to be most strongly associated with antisocial girls who do not have other psychiatric disorders.     

Characteristics and outcome of hospitalized adolescent girls with conduct disorder.

Fifty-five adolescent girls with conduct disorder from a psychiatric hospital were examined with a structured interview schedule and then reevaluated 2 to 4 years later. The majority also had depressive or anxiety disorders. The criteria used for conduct disorder were less weighted toward violent crime and differed from the criteria in DSM-III-R. Their outcome was poor; 6% had died a violent death, the majority had dropped out of school, one-third were pregnant before the age of 17, half were rearrested, and many suffered traumatic injuries. Diagnoses of depression or anxiety disorders at the index admission were not associated with a better outcome.     

Clinical precursors of adolescent conduct disorder in children with attention-deficit/hyperactivity disorder

OBJECTIVE: To examine precursors of adolescent conduct disorder (CD) in children with attention-deficit/hyperactivity disorder (ADHD), investigating the significance of childhood oppositional defiant disorder (ODD) and ADHD. METHOD: A total of 151 children with ADHD recruited from child psychiatric and pediatric clinics were assessed through standardized diagnostic interviews at ages 6 to 13 years and in adolescence 5 years later. Using multiple regression analysis, we assessed baseline ODD diagnosis and ODD, CD, and ADHD symptom scores as clinical predictors of adolescent CD diagnosis and symptom scores. RESULTS: Childhood ODD (diagnosis and severity) was significantly associated with adolescent CD (diagnosis and severity), independent of childhood ADHD severity and childhood CD. Children with a diagnosis of ODD were almost three times more likely to develop CD in adolescence (odds ratio = 2.79, 95% CI 1.16-6.70, p = .02). Childhood ADHD severity predicted adolescent CD scores but not diagnosis of CD (although there was a trend toward association). The presence of at least one CD symptom in childhood predicted adolescent CD severity. CONCLUSIONS: ODD is a significant precursor of adolescent CD in children with ADHD independent of ADHD severity. Considering the negative prognosis of ADHD with comorbid CD, it is imperative that clinicians pay specific attention to the presence of childhood ODD behaviors.     

The OADP-CDS: a brief screener for adolescent conduct disorder

OBJECTIVES: To examine the ability of a very brief (6-item) self-report screener, the Oregon Adolescent Depression Project Conduct Disorder Screener (OADP-CDS), to identify adolescents with a lifetime diagnosis of conduct disorder and to examine its ability to predict antisocial personality disorder by age 24. Relevant scales from the Yough Self-Report and the Child Behavior Checklist were examined for comparison purposes. METHOD: A total of 1,709 high school students completed an initial questionnaire and diagnostic interview assessment (T1); 1,507 participants returned approximately 1 year later for a second assessment (T2). A third (T3) assessment was conducted with selected T2 participants (n = 940) after they had turned 24 years of age. RESULTS: The OADP-CDS had good internal consistency, test-retest stability, and screening properties. Differences in the screening ability of the OADP-CDS as a function of gender and social desirability were nonsignificant. The efficacy of the measure as a screener did not differ significantly from that of longer adolescent- and parent-report measures. Perhaps most importantly, the OADP-CDS was able to identify future cases of antisocial personality disorder in young adulthood. CONCLUSIONS: Results suggest that self-report screening for conduct disorder with older adolescents is possible and should be explored further.     

Adrenal androgen and gonadal hormone levels in adolescent girls with conduct disorder

There are few data on the biological correlates of female antisocial behavior. This study compared adrenal androgen and gonadal hormone levels in adolescent girls with conduct disorder (CD) to girls without any psychiatric disorder (NC). We studied 87 girls, (47 CD; 36 NC), ages 15–17 years, obtaining three blood samples, drawn 20 min apart between 8 and 9 AM in the first 72 h of the onset of menstrual flow. Plasma was assayed for testosterone, estradiol, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone-sulfate (DHEA-S), sex hormone binding globulin (SHBG), and cortisol; area under the curve (AUC) for each of the three samples was used in the data analysis. We also calculated the Free Testosterone Index, Free Estrogen Index, Index of Hyperandrogenism and cortisol to DHEA ratio. In addition to receiving a full psychiatric interview, each girl completed a self-report questionnaire on general aggression. Main hormone analyses controlled for potentially confounding variables such as psychiatric comorbidity and race. Girls with CD had significantly lower cortisol to DHEA ratios, but did not differ from NC girls on any other hormone variable. Girls with symptoms of aggressive CD had significantly higher mean free testosterone indexes, lower SHBG levels, and lower cortisol to DHEA ratios than girls with non-aggressive CD. Girls with CD scored higher on the aggression questionnaire, but there was no association between general aggression and any hormone variable for the sample. Our data suggest that girls with CD, particularly aggressive CD, have lower cortisol to DHEA ratios, higher levels of free testosterone, and lower levels of SHBG. Clinical and research implications of these findings are discussed.     

Screening for conduct disorder in an adolescent male sample from Colombia

This study assessed the validity, reliability, and utility of a screening measure for detecting the signs or symptoms of Conduct Disorder in male adolescents from schools in Medellín, Colombia. A first study examined the differences between 70 male offender adolescents (aged 12-16 years) attending alternative education institutions, and 68 (sex, age, and socioeconomic status (SES)-matched) adolescent controls attending regular schools. A CD checklist (CD-CL) was constructed to be used by mothers (CD-CL-M) and for self-report by adolescents (CD-CL-SR). The validity of the screener for CD diagnosis was supported by significant differences between groups (ANOVA, p<.001). The CD-CL-SR had better sensitivity/specificity with a diagnostic cut-off point of 5 (sensitivity=95.3% and specificity=90.5%) than the CD-CL-M. A second study used the CD-CLSR with a random sample of 190 male adolescents (aged 12 to 16 years) from schools of low, middle and high SES. Reliability as assessed by Cronbach's alpha was 0.86. An epidemiological cut point of 5 classified 35.5% of the adolescents assessed as probable CD cases. A psychometric cut point at T score>59 (85th percentile) estimated 16.8% of the sample as probable CD cases. A psychometric cut point at T score>64 (90th percentile) revealed that 10.5% of the sample would be severe CD cases. Some significant differences (p<0.001) in proportions of CD adolescents were found between age and SES groups. It was concluded that such a high frequency of conduct problems in adolescence argues for the need for preventive programs in Colombian schools.     

An investigation of female adolescent twins with both major depression and conduct disorder

OBJECTIVE: Conduct disorder (CD) and major depression (MDD) frequently co-occur in adolescents, but little is known about the characteristics and functioning of youths, especially females, with both disorders. This study describes the functioning of female adolescents with histories of both CD and MDD. METHOD: Subjects were selected from an epidemiological sample of 17-year-old female twins based on having a lifetime DSM-III-R diagnosis of MDD and/or CD; control subjects had no history of either disorder. RESULTS: In nearly all domains examined, including measures of academic success (including academic achievement and school adjustment), personality, quality of peer relationships, and high-risk behavior (including substance dependence and early sexual experience), main effects of one or both disorders were found and related to impaired functioning. In addition, interaction effects were found in the areas of substance dependence symptoms (for all classes of substances), negative school-related events, and a personality-based predisposition not to experience positive emotions, indicating that those with both diagnoses were especially impaired. CONCLUSIONS: In some domains, histories of MDD and CD interact and relate to particularly severe problems. The implications of these findings for research and treatment, including the high likelihood of substance and school adjustment problems in these youths, are discussed.     

Lithium and conduct disorder

Lithium administration has been effective in treating severe aggression in children and adolescents with Conduct Disorder. An overview of the pertinent literature is presented. Side effects associated with lithium administration are discussed. Guidelines for lithium administration are given, including dosage regulation, monitoring of serum lithium, as well as of side effects and laboratory measures. When prescribed judiciously, under careful monitoring, lithium can be an important part of the comprehensive treatment program.     

Factor structure and individual patterns of DSM-IV conduct disorder criteria in adolescent psychiatric inpatients

We investigated the factor structure of the DSM-IV conduct disorder (CD) diagnostic criteria and typical individual patterns of CD subscales in an adolescent inpatient population using detailed hospital records of a Norwegian nationwide sample of 1087 adolescent psychiatric inpatients scored for the 15 DSM-IV CD criteria. Varimax rotated principal components and full-information factor analyses of 12 CD criteria were carried out separately for boys and girls employing two methods. Standardized values on three subscales of CD criteria were subjected to Ward's method of hierarchical cluster analyses followed by k-means relocation employing a double cross-replication design. Similar factor structures emerged regardless of factoring method and gender. With the exception of Criteria 8 ("Fire setting") and 14 ("Run away from home") the factor loadings for both genders were in accordance with Loeber's tripartite model, with Aggression, Delinquency, and Rule Breaking factors largely corresponding to Loeber's overt, covert and authority conflict pathways. A five-cluster solution proved highly replicable and interpretable. One cluster gathered adolescents without CD, and the remaining four described groups with different conceptually meaningful constellations of CD criteria, which were not equally prevalent in each gender. Delinquency appeared in all symptomatic clusters. The cluster analytic results highlighted typical forms of expressions of conduct problems, and the fact that these forms may not be equally prevalent in girls and boys even while the underlying structure of conduct problems may be similar across genders. Future research should address the prediction of specific outcomes from CD criteria subscales or constellations.     

Factor structure and individual patterns of DSM-IV conduct disorder criteria in adolescent psychiatric inpatients

We investigated the factor structure of the DSM-IV conduct disorder (CD) diagnostic criteria and typical individual patterns of CD subscales in an adolescent inpatient population using detailed hospital records of a Norwegian nationwide sample of 1087 adolescent psychiatric inpatients scored for the 15 DSM-IV CD criteria. Varimax rotated principal components and full-information factor analyses of 12 CD criteria were carried out separately for boys and girls employing two methods. Standardized values on three subscales of CD criteria were subjected to Ward's method of hierarchical cluster analyses followed by k-means relocation employing a double cross-replication design. Similar factor structures emerged regardless of factoring method and gender. With the exception of Criteria 8 (“Fire setting”) and 14 (“Run away from home”) the factor loadings for both genders were in accordance with Loeber's tripartite model, with Aggression, Delinquency, and Rule Breaking factors largely corresponding to Loeber's overt, covert and authority conflict pathways. A five-cluster solution proved highly replicable and interpretable. One cluster gathered adolescents without CD, and the remaining four described groups with different conceptually meaningful constellations of CD criteria, which were not equally prevalent in each gender. Delinquency appeared in all symptomatic clusters. The cluster analytic results highlighted typical forms of expressions of conduct problems, and the fact that these forms may not be equally prevalent in girls and boys even while the underlying structure of conduct problems may be similar across genders. Future research should address the prediction of specific outcomes from CD criteria subscales or constellations.     

Randomized controlled pilot study of quetiapine in the treatment of adolescent conduct disorder

OBJECTIVE: The aim of this study was to examine whether quetiapine is superior to placebo in the treatment of adolescents with conduct disorder. METHODS: This was a 7-week, randomized, double-blind, placebo-controlled pilot study with two parallel arms. Nine youths were randomly assigned to receive quetiapine, and 10 youths were randomly assigned to receive placebo. Patients were assessed weekly throughout the trial. Quetiapine was dosed twice daily, and medications could be titrated flexibly through the end of study week 5. The dose was fixed for the final 2 weeks of the study. The primary outcome measures were the clinician-assessed Clinical Global Impressions-Severity (CGI-S) and-Improvement (CGI-I) scales. Secondary outcome measures included parent-assessed quality of life, the overt aggression scale (OAS), and the conduct problems subscale of the Conners' Parent Rating Scale (CPRS-CP). RESULTS: The final mean dose of quetiapine was 294 +/- 78 mg/day (range 200-600 mg/day). Quetiapine was superior to placebo on all clinician-assessed measures and on the parent-assessed quality of life rating scale. No differences were found on the parent-completed OAS and CPRS-CP. Quetiapine was well tolerated. One patient randomized to quetiapine developed akathisia, requiring medication discontinuation. No other extrapyramidal side effects occurred in patients receiving active drug. CONCLUSIONS: This methodologically controlled pilot study provides data that quetiapine may have efficacy in the treatment of adolescents with conduct disorder. Because of the preliminary nature of the study, further research with larger samples is needed to confirm these findings.     

Prospective effects of attention-deficit/hyperactivity disorder, conduct disorder, and sex on adolescent substance use and abuse

CONTEXT: Attention-deficit/hyperactivity disorder (ADHD), an early manifestation of externalizing behavior, may identify children at high risk for later substance abuse. However, the ADHD-substance abuse relationship often disappears when co-occurring conduct disorder (CD) is considered. OBJECTIVE: To determine whether there is a prospective relationship between ADHD and the initiation of substance use and disorders, and whether this relationship depends on the ADHD subtype (hyperactive/impulsive or inattentive), CD, or sex. DESIGN, SETTING, AND PARTICIPANTS: Dimensional and categorical measures of ADHD and CD were examined via logistic regression analyses in relation to subsequent initiation of tobacco, alcohol, and illicit drug use by 14 years of age and onset of substance use disorders by 18 years of age in a population-based sample of 11-year-old twins (760 female and 752 male twins) from the Minnesota Twin Family Study. MAIN OUTCOME MEASURES: Structured interviews were administered to adolescents and their mothers regarding substance use and to generate diagnoses. RESULTS: For boys and girls, hyperactivity/impulsivity predicted initiation of all types of substance use, nicotine dependence, and cannabis abuse/dependence (for all, P < .05), even when controlling for CD at 2 time points. By contrast, relationships between inattention and substance outcomes disappeared when hyperactivity/impulsivity and CD were controlled for, with the possible exception of nicotine dependence. A categorical diagnosis of ADHD significantly predicted tobacco and illicit drug use only (adjusted odds ratios, 2.01 and 2.82, respectively). A diagnosis of CD between 11 and 14 years of age was a powerful predictor of substance disorders by 18 years of age (all odds ratios, > 4.27). CONCLUSIONS: Hyperactivity/impulsivity predicts later substance problems, even after growth in later-emerging CD is considered, whereas inattention alone poses less risk. Even a single symptom of ADHD or CD is associated with increased risk. Failure in previous research to consistently observe relationships between ADHD and substance use and abuse outcomes could be due to reliance on less-sensitive categorical diagnoses.     

Childhood behavioral profiles leading to adolescent conduct disorder: risk trajectories for boys and girls

OBJECTIVE: To examine the link between childhood behavioral dimensions and adolescent conduct disorder (CD) among a large sample of boys and girls monitored longitudinally. METHOD: Teachers rated the behaviors of 1,569 children every year between kindergarten and grade 6. On the basis of these seven yearly ratings, groups of children who followed distinct trajectories on three behavioral dimensions--hyperactivity, fearfulness, and helpfulness--were identified with a semiparametric statistical analysis. Children were then categorized into one of eight behavioral profiles, representing different combinations of the trajectories. Logistic regressions were used to estimate the relation between the profiles and CD in adolescence (mean = 15.7 years). RESULTS: Boys had a significant risk for CD if they were hyperactive (odds ratio [OR] = 4.27; 95% confidence interval [CI], 1.8-10.16); hyperactive and unhelpful (OR = 2.83; CI, 1.07-7.46); or hyperactive, fearless, and unhelpful (OR = 3.93; CI, 1.27-12.17). Girls had a significant risk for CD only if they were both hyperactive and unhelpful (OR = 4.61; CI, 1.31-16.24). More boys than girls exhibited profiles of risk and met criteria for CD in adolescence. CONCLUSIONS: Sex-specific childhood behavioral profiles that represented risk for CD in adolescence were identified.There were sex differences in the prevalence of the childhood profiles representing risk for CD.