|Year : 2022 | Volume
| Issue : 1 | Page : 38-44
Determinants of poor outcome of conduct disorder among children and adolescents: A 1-year follow-up study
Raghavan Jayaprakash1, S Sharija2, Prabhakaran Anil3, K Rajamohanan4
1 Department of Paediatrics, Behavioral Paediatrics Unit, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
2 Department of Forensic Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
3 Department of Psychiatry, Medical College, Thiruvananthapuram, Kerala, India
4 Department of Paediatrics, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
|Date of Submission||23-Apr-2020|
|Date of Decision||24-Jun-2020|
|Date of Acceptance||02-Jul-2020|
|Date of Web Publication||17-Feb-2022|
Dr. Raghavan Jayaprakash
Behavioral Paediatrics Unit, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
Background: Conduct disorder (CD) is a heterogeneous disorder with variations in symptomatology and outcome. Slightly more than half of CD ceases to meet the criteria for CD during late childhood or adolescence. Many studies had examined the factors that determine the outcome of CD. However, limited follow-up studies are available in the Indian context. The present study aims to identify the factors that determine the poor outcome of CD. Materials and Methods: This was a clinic-based follow-up study. The study population consists of 300 consecutive children between 6 and 18 years of age who satisfied the International Classification of Disease-10 Diagnostic Criteria for Research guidelines for CD. Study setting was behavioral pediatrics unit under tertiary care pediatric department. Recruited children were intervened and followed up for 1 year. Initial and final scores of abnormal psychosocial situation, symptom severity, and functional level were assessed. A percentage of children who achieved clinically significant improvement were noticed. Determinants of poor outcome were identified by logistic regression. Results: Clinically significant improvement was observed among 64.51% of sample. Determinants of poor outcome were family history of single parent, alcoholism, domestic violence, and psychiatric illness and duration, initial severity, and type of symptoms and comorbidity. Conclusions: CD is amenable to intervention in the Indian setting. Early intervention will give good outcome. Among risk factors identified, four were socially modifiable factors.
Keywords: Comorbidity, conduct disorder, poor outcome, socially modifiable factors
|How to cite this article:|
Jayaprakash R, Sharija S, Anil P, Rajamohanan K. Determinants of poor outcome of conduct disorder among children and adolescents: A 1-year follow-up study. Indian J Soc Psychiatry 2022;38:38-44
|How to cite this URL:|
Jayaprakash R, Sharija S, Anil P, Rajamohanan K. Determinants of poor outcome of conduct disorder among children and adolescents: A 1-year follow-up study. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 18];38:38-44. Available from: https://www.indjsp.org/text.asp?2022/38/1/38/337871
| Introduction|| |
As per the International Classification of Diseases (ICD)-10, conduct disorders (CDs) are characterized by repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. CD is considered to be a socially relevant and serious childhood disorder, which is the primary precursor to chronic antisocial behavior during adulthood. Robins observed that between 30% and 50% of children with CD meet the criteria for antisocial personality disorder (APD) in adulthood, and virtually, all adult cases of APD are characterized by a childhood course of severe CD. APD is a serious social and mental health concern. Persistent antisocial behavior places a heavy burden on the society, the judiciary system, and the public health system. After reviewing the child–adolescent course and outcome studies, Lahey et al. observed that slightly more than half of children with CD cease to meet the criteria for CD sometime during late childhood or adolescence. Many researchers had studied the determinants of outcome of CD and identified both family-related,, and child-related,,,,, factors. It is very relevant to identify these sociocultural factors for early intervention. However, only limited follow-up studies are available in the Indian context. The present study aimed to identify the factors that determine poor outcomes of CD.
| Materials and Methods|| |
This was a 1-year, prospective, follow-up observational study.
Study population and setting
A total of consecutive 300 children between the ages of 6 and 18 years who attended the behavioral pediatrics unit outpatient department and satisfied the ICD-10 Diagnostic Criteria for Research (DCR) for CD formed the study population. Informed written consent was obtained from the parents and ascent from children at the beginning of the study.
Children with bipolar disorder, schizophrenia, and neurological illnesses including head injury, seizure disorder, cerebral palsy, and mental retardation were excluded from the study population.
Parent Interview Schedule (PIS) was used to assess the abnormal psychosocial situation of the family, Revised Behavioral Problem Checklist (RBPC) was used to assess the symptom quantity of CD, and Children's Global Assessment Scale (C-GAS) was used to assess the functional level of the children.
The study was started only after the approval from the institutional ethics committee. The initial rating of abnormal psychosocial situation including family psychopathology was done using PIS. The initial rating of behavioral symptoms was done using the validated RBPC. The initial rating of children's global assessment function was done using C-GAS. Intelligent quotient assessment was done for those children with comorbid specific learning disability (SLD). All the initial scoring was done by the researcher. Following baseline rating, standard intervention for CD was administered. It included initial weekly individual sessions of parent management training including principles of behavior therapy to the parents for 12 weeks. In parent management training, the parents were taught social learning techniques to change their behavior and that of children. Parents were given training to understand the principles of behavior therapy. The principles of behavior therapy involve understanding the antecedents, behavior, consequences of the target behavior, and altering the behavior by changing the consequence. They were also trained in giving attention diversion, time out, and behavior shaping by giving positive reinforcement and giving feedback to child on needy situations. They were also suggested to control their emotional outburst and act out behavior. Thus, parent management training was administered according to the issues of the child and family. Similarly, initial weekly individual sessions of cognitive problem solving skill training were given simultaneously to all the children for 12 weeks. The study population ranged from primary school-going children to adolescents. Hence, therapy to the children was administered in a developmentally appropriate manner. For small children, play therapy method was used. For adolescents, their issues were discussed in a developmentally appropriate manner. Each session for parent and children was of 30 min duration. The sessions to the children and parents were given separately. As far as possible, both parents were included in the sessions. Pharmacotherapy was advised to children based on the symptoms of violence and comorbidity, such as hyperkinetic disorder or depression. Drugs commonly prescribed were risperidone, fluoxetine, and atomoxetine. For children with very severe violence, risperidone was prescribed. Similarly, depression was treated with fluoxetine and severe hyperkinetic disorder with atomoxetine. Comorbid conditions were managed accordingly with remedial teaching, cognitive behavioral therapy, and pharmacotherapy.
After the weekly sessions for 12 weeks, they were reviewed and given monthly sessions for a total period of 1 year. The total number of visits done by each children and their parent during the study and follow-up were 21 (12 + 9 = 21). There was dropout of seven children. Follow-up of three children lost during the second visit and two children each in the third and fourth visits. All of them were coming from faraway places. The children who lost follow-up were not included in the final analysis.
Final follow-up rating of symptoms, family psychopathology, and functional level of each child were done at the end of 12th month after inclusion into the study population. Final evaluation and diagnostic re-assessment were done at the end of 12th month using the ICD-10 DCR guidelines for CD.
Outcome measure was defined as the percentage of reduction in RBPC. Children who attained clinically significant improvement were calculated. Clinically significant improvement was defined as those children having 50% or more reduction from the initial RBPC score (RBPC1). Others were considered as partial or no improvers depending on the percentage of reduction in RBPC.
Comparison between preintervention and postintervention scores of RBPC, PIS, and C-GAS was done using Wilcoxon signed-rank test. Factors that determine the poor outcome of CD among children and adolescents were identified by doing univariate analysis followed by binary logistic regression. Receiver operating characteristic (ROC) curve was plotted for the predicted probability derived by the logistic model.
| Results|| |
There is convincing degree of male domination in all the age groups [Table 1].
|Table 1: Baseline data of the study population including age and sex distribution and clinical profile of conduct disorder (n=300)|
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Psychosocial problems noticed were family history of psychiatric illness (8.4%), alcoholism (15%), domestic violence (5.3%), and alcoholism and domestic violence together (22.4%). Among the study population, 82% of the parents were living together and 10.4% of the mother and children were abandoned by their fathers.
Childhood onset is the predominant group (76.7%) among the ICD-onset type [Table 1].
Predominant comorbidities observed were hyperkinetic disorder (66.7%), mixed disorders of emotion and conduct (17.3%), SLD (14%), and somatoform disorder (5%).
All children in the study population received psychosocial interventions and 26.7% of the study population received drugs as per the standard protocol following in the center. The follow-up rate was 97.7% and the dropout rate was 2.3%.
There was statistically significant difference between pre (T1) and post (T2) intervention and follow up of symptom quantity (RBPC score), abnormal psychosocial situation (PIS scale score) , and functional status (C GAS score) in the whole study population [Table 2].
|Table 2: Symptom quantity (Revised Behavioral Problem Checklist 2), abnormal psychosocial situation (Parent Interview Schedule 2), and functional level of children (Children's Global Assessment Scale 2) among the study group after 1 year follow-up (T2) and its comparison with preintervention (T1) scores (n=293, no follow-up=7)|
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Clinically, significant improvement was present in the 64.51% of the follow-up group (valid percentage); total partial improvers were 26.62%; no improvement was seen in 6.14% and worsening in 2.73% of the follow-up group [Graph 1].
Univariate analysis of the variables showed family- and child-related factors which were significantly related to the poor outcome of CD. Family-related factors were parental status, family history of alcoholism, domestic violence, and physical child abuse. Child-related factors were behavioral symptoms of physical fights, using of weapon, physical cruelty to people, destroying properties, fire setting, committing crime, history of hyperkinetic disorder in child, childhood onset of CD, severity of CD, ICD subtype, comorbid hyperkinetic disorder and mixed disorder of emotion and conduct, ≥3 years' duration of CD, ≥12 number of symptoms, and initial high RBPC score (≥82).
These factors were put into binary logistic regression analysis.
Among the factors that showed significant relation in univariate analysis, only nine factors showed highly significant relation with the poor outcome. There were family- and child-related factors. Family-related factors were parental status, family history of psychiatric illness, alcoholism, and domestic violence. The child-related factors were use of weapon by the children, ≥3 years duration of CD, initial high RBPC Score (≥82), and comorbid hyperkinetic disorder and depression. The statistics showed that 56% of variation in the outcome was explained by the independent variables put in the equation.
Sensitivity of the model was 84.6% and specificity was 95.8%. Overall predictability was 91.8% [Table 3].
|Table 3: Binary logistic regression analysis and variables in the equation|
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ROC curve plotted for the predicted probability derived by the binary logistic regression. Area under curve was 0.959, i.e., accuracy of the model was 0.959, and it is statistically significant.
| Discussion|| |
The determinants of poor outcome of CD identified in the present study were family history of psychiatric illness, domestic violence, alcoholism, family abandonment by father, long duration of CD, initial severity of symptom, severe type of symptom of using weapon, and comorbidity, namely hyperkinetic disorder and mixed disorders of emotion and conduct. The discussion is arranged as follows.
Main group of children in the study population belongs to the age group of 9–11 years (30%) [Table 1]. Similar pattern of CD was observed in other Indian study also. Pediatric background could be the reason for more representation of lower primary children in the present study. There was male domination (4:1) in the whole study population. A study in the Indian background also reported similar male dominance.
In the present study, 10.4% of the population of children was living with mothers alone, because they were abandoned by their respective fathers, without any official divorce or financial assistance. The contextual risk factor for conduct problems includes parental divorce and single parent status. Even though, in the present study, the prevalence of divorce rate was less (1.3%), single parent status generated by abandonment rate was high (10.4%), which is more disastrous to children and their mother than official divorce with financial assistance. The adversity of this unstable family relationship is harmful to developing child.
Apart from this, the main psychosocial problem noticed in the present study was alcoholism, domestic violence, and psychiatric morbidity. This type of family environment with aggression and interparental conflict is a sociocultural contextual risk for CD. The criminal behavior and alcoholism are consistently documented among the parents of conduct-disordered children. Antisocial parents are known to produce family adversities. It will disrupt the quality of parenting and may increase the likelihood of harsh disciplinary methods or lead to arguments between parents about disciplining of the child. Studies show that parental psychopathology and family breakdown occur at higher than expected rates in conduct-disordered samples.
[Table 1] shows that majority of CD (76.7%) came under childhood-onset type. A study by Jayaprakash et al. also observed these phenomena.
Clinical grading shows that majority of CD (63.3%) are of moderate degree of severity with problems in the family, school, and peer group [Table 1].
Main group in the study was CD confined to family subtype (31.7%). Delinquent behaviors were seen among socialized type which agrees with the literature (ICD-10).
Regarding comorbidity, high prevalence of comorbidity of attention-deficit/hyperactivity disorder was reported by many authors also. The comorbidity of depression and somatoform disorder is also documented in the literature.
Comparison of the T1 scores (RBPC1, PIS1, and C-GAS1) with T2 score (RBPC2, PIS2, and C-GAS2) showed a statistically significant difference between the scores [Table 2], i.e., there was significant improvement in the quantity of symptoms (reduction in RBPC), abnormal psychosocial situation (reduction in PIS), and functional status (increase in C-GAS) after 1 year intervention and follow-up in the whole study population.
This clinical improvement in the present study stresses the need for early recognition and treatment of antisocial behavior problems, which is documented in the literature.
Clinically significant improvement (50% or more reduction in RBPC) was observed among 64.51% of the study population [Graph 1], i.e., 64.51% of the population in the present study (valid percentage after excluding the 7 no follow-up group) achieved clinically significant improvement with 1 year clinical intervention and follow-up. The clinically significant outcome in the present study was more than the outcome by other classic studies, which gives only slightly more than 50% of the study population., Sociocultural factors could be the reasons for better outcome. Pharmacotherapy might have also played an important role for better outcome. Children with clinically significant improvement in the study population had become better with 1 year clinical intervention and follow up and their symptoms had lowered; so that they were no more satisfied the ICD 10, DCR diagnostic guideline for CD. It is shown in the literature.
Apart from this clinically significant improvement, 26.62% of the study population had partial improvement ranging from 49% to 1% in terms of the percentage of reduction in RBPC [Graph 1].
The determinants of poor outcome of CD among children and adolescents were found out by multivariable analysis by including the significantly related factors into the logistic regression model [Table 3]. From the logistic model, nine factors were found which determined the poor outcome of CD among children and adolescents in the present study. Among this, four factors were family related and five factors were child related. It has been shown that no single factor predicts a high proportion of variance in outcome.
Family-related factors that determined the poor outcome of CD were parents living separately, alcoholism in the family, domestic violence, and family history of psychiatric illness. The importance of parental conflict and living separately is well documented in the literature.,, Similarly, the importance of alcoholism, domestic violence,, and family history of psychiatric illness is also well described in the literature.
Child-related factors that determined poor outcome of CD were initial severity of symptom, duration of CD, severe symptom of using weapons that cause severe harm to others, and comorbid hyperkinetic disorders and mixed disorders of conduct and emotion. Importance of initial severity of symptom is already documented by many pioneer researchers in the area.,, Similarly, significance of long duration of CD is also documented. Importance of severe type of symptom is already described in the literature. Poor prognostic effect of comorbid hyperkinetic disorder is well researched by many authors.,, The importance of mixed disorders of emotion and conduct is also documented in the literature.
Among the nine determinants of poor outcome of CD, three family-related factors namely parents living separately or single parent family, alcoholism, and domestic violence were socially modifiable factors. Similarly, among the child-related factors, duration of CD was socially modifiable.
Importance of early identification and prevention of its progress to APD is well described in the literature. In an adolescent school mental health model, 36.4% of the attending population were CDs. Diamantopoulou et al. suggested that prevention of the initial onset of conduct problems is the key step to prevent antisocial behavior. For early identification and intervention, we can focus in to the schools.
Limitation of the study
It was purposive sampling. The sample was taken as per convenience. Another limitation is wide variability in the age of study population and thus variability in techniques used.
To conclude, CD is a socially amenable condition. The finding of the present study has therapeutic, research, and social implications in the Indian context in the area of CD among children and adolescents.
We would like to acknowledge Dr. T. S. S. Rao and Dr. K. N. Janaki for their valuable suggestions and inspiration during the course of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]