Internet Mental Health


Expanded Quality of Life Scale For Conduct Disorder

Internet Mental Health Quality of Life Scale

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • Children or adolescents with conduct disorder have, for 6 months or longer, the same behaviors as those with oppositional defiant disorder (i.e., defiance, disobedience, and disruptiveness).

  • In addition, they add delinquent behaviors (e.g., physical violence, property destruction, law-breaking, reckless thrill-seeking) and antisocial behaviors (e.g., disrespect of others, irresponsibility, and dishonesty).

  • Not due to a medical or substance use disorder.

  • Note: The symptoms of Conduct Disorder are almost identical to those of Adjustment Disorder. Thus is Conduct Disorder merely a form of chronic Adjustment Disorder?


    Onset in middle childhood to middle adolescence; onset after age 16 is rare. Most children grow out of this by adulthood; otherwise it usually becomes Antisocial Personality Disorder.


    Occupational-Economic Problems:

    • May lead to school expulsion, problems in work adjustment.

    • May prevent going to an ordinary school or living in a parental or foster home.

    • May be associated with lower-than-average intelligence (i.e., Learning Disorder).

    Critical, Quarrelsome (Antagonism):

    • Aggression to People and Animals:

      • Often bullies, threatens, or intimidates others.

      • Often initiates physical fights.

      • Has used a weapon that can cause serious physical harm to others.

      • Has been physically cruel to people.

      • Has been physically cruel to animals.

    • Suspicious, bears grudges, feels victimized.

    • Callous, unemotional lack of kindness and compassion.

    Impulsive, Disorderly (Disinhibition):

    • Destruction of Property:

      • Has deliberately engaged in fire setting to cause serious damage.

      • Other than fire setting, has deliberately destroyed others' property.

    • Deceitfulness or Theft:

      • Has broken into someone else's house, building, or car.

      • Often lies or "cons" others.

      • Has stolen items of nontrivial value without confronting a victim.

    • Serious Violations of Rules:

      • Has stolen while confronting a victim.

      • Has forced someone into sexual activity.

      • Often stays out at night despite parental prohibitions, beginning before age 13 years.

      • Has run away from home overnight.

      • Is often truant from school, beginning before age 13 years.

    • Lack of guilt; little concern for the rights or well-being of others.

    • Like Oppositional Defiant Disorder (ODD), have defiance, disobedience, and disruptiveness.

    • Unlike ODD, have delinquent behaviors (e.g., physical violence, property destruction, law-breaking, reckless thrill-seeking).

    • Unlike ODD, have antisocial behaviors (e.g., disrespect of others, irresponsibility, and dishonesty).

    • Early onset of sexual behavior, drinking, smoking, use of illegal substances, legal difficulties and reckless risk-taking.

    • Arrogant, manipulative.

    Easily Distracted (Cognitive Impairment):

    • Increased rates of Attention-Deficit/Hyperactivity Disorder.

    Distressed, Easily Upset (Negative Emotion):

    • Increased rate of Anxiety Disorders and Mood Disorders.

    • Increased risk of suicide attempts and completed suicide.


    • May lead to sexually transmitted diseases, unplanned pregnancy, and injury from fights or accidents.

Explanation Of Terms And Symbols

Internet Mental Health Quality of Life Scale

SAPAS Personality Screening Test

Individuals with this disorder would answer "Yes" to the red questions:

      In general, do you have difficulty making and keeping friends?
      Would you normally describe yourself as a loner?
      In general, do you trust other people? (No)
      Do you normally lose your temper easily?
      Are you normally an impulsive sort of person?
      Are you normally a worrier?
      In general, do you depend on others a lot?
      In general, are you a perfectionist?

Back to top

Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Conduct Disorder 312.8

This diagnosis is based on the following findings:
  • Criteria are not met for Antisocial Personality Disorder
  • In the past 12 months, often bullied, threatened, or intimidated others (still present)
  • In the past 12 months, often initiated physical fights (still present)
  • In the past 12 months, used a potentially lethal weapon in a fight (still present)
  • In the past 12 months, had been physically cruel to people (still present)
  • In the past 12 months, had been physically cruel to animals (still present)
  • In the past 12 months, had stolen while confronting a victim (still present)
  • In the past 12 months, sexually abused someone (still present)
  • In the past 12 months, deliberately engaged in potentially serious fire-setting (still present)
  • In the past 12 months, deliberately destroyed others' property (other than fire setting) (still present)
  • In the past 12 months, broke into someone else's house, building, or car (still present)
  • In the past 12 months, often lied (still present)
  • In the past 12 months, often stole (without confrontation of a victim) (still present)
  • Before age 13, often stayed out at night despite parental prohibitions (still present)
  • In the past 12 months, ran away from home (still present)
  • Before age 13, often was truant from school (still present)
  • In the past 6 months, these symptoms caused clinically significant distress or disability (still present)

Back to top

Conduct Disorders F91 - ICD10 Description, World Health Organization

Disorders characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. Such behavior should amount to major violations of age-appropriate social expectations; it should therefore be more severe than ordinary childish mischief or adolescent rebelliousness and should imply an enduring pattern of behavior (six months or longer). Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be preferred.
Examples of the behaviours on which the diagnosis is based include excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums, and disobedience. Any one of these behaviours, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.
Conduct Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with conduct disorder needs to meet all of the following criteria:

  • A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

    • Aggression to People and Animals

    • Often bullies, threatens, or intimidates others.

    • Often initiates physical fights.

    • Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).

    • Has been physically cruel to people.

    • Has been physically cruel to animals.

    • Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

    • Has forced someone into sexual activity.

    • Destruction of Property

    • Has deliberately engaged in fire setting with the intention of causing serious damage.

    • Has deliberately destroyed others' property (other than by fire setting).

    • Deceitfulness or Theft

    • Has broken into someone else's house, building, or car.

    • Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others).

    • Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

    • Serious Violations of Rules

    • Often stays out at night despite parental prohibitions, beginning before age 13 years.

    • Has run away from home overnight at least twice while living in parental or parental surrogate home, or once without returning for a lengthy period.

    • Is often truant from school, beginning before age 13 years.

  • The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

  • If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Back to top

Diagnostic Features

The majority of children with oppositional defiant disorder grow out of it, but some progress into delinquency - i.e., conduct disorder. Children or adolescents with conduct disorder have the same behaviors as those with oppositional defiant disorder (i.e., defiance, disobedience, and disruptiveness). In addition, they add delinquent behaviors (e.g., physical violence, property destruction, law-breaking, reckless thrill-seeking) and antisocial behaviors (e.g., disrespect of others, irresponsibility, and dishonesty). At school, children or adolescents with conduct disorder are the bullies, thieves and vandals. Conduct disorder, to be diagnosed, must last 6 months or longer. Most children or adolescents with conduct disorder grow out of this disorder, but if this behavior persists past age 18 and intensifies, the diagnosis is changed to antisocial personality disorder. Thus oppositional defiant disorder, conduct disorder, and antisocial personality disorder are all part of the same dissocial spectrum. It appears that, by reason of nature/nurture, these individuals haven't learned compassion and cooperation; hence they disregard rules and the rights of others.


Conduct Disorder may be diagnosed in adults, however, symptoms of Conduct Disorder usually emerge in childhood or adolescence, and onset is rare after age 16.

Childhood-Onset Conduct Disorder: These children frequently display physical aggression towards others, have disturbed peer relationships, and may have had Oppositional Defiant Disorder during early childhood. Many children with this subtype also have concurrent Attention-Deficit/Hyperactivity Disorder (ADHD) or other neurodevelopmental difficulties. These children are more likely to have persistent Conduct Disorder into adulthood than are those with adolescent-onset type. These children are more likely than those with Adolescent-Onset Conduct Disorder to be callous and unemotional, thrill seeking, fearless, and insensitive to punishment. Those that are callous and unemotional are more likely to engage in aggression that is planned for personal gain.

Adolescent-Onset Conduct Disorder: These adolescents don't develop Conduct Disorder until after puberty, are less likely to display aggressive behaviors, and tend to have more normal peer relationships. These adolescents are less likely to have Conduct Disorder that persists into adulthood.


Males with Conduct Disorder often exhibit fighting, stealing, vandalism, and school discipline problems. Females are more likely to exhibit lying, truancy, running away, substance use, and prostitution. Females are less likely to exhibit physical aggression. Conduct Disorder behaviors may lead to school suspension or expulsion, problems in work adjustment, legal difficulties, sexually transmitted diseases, unplanned pregnancy, and physical injury from accidents or fights. Conduct Disorder is often associated with an early onset of sexual behavior, alcohol use, tobacco smoking, use of illegal drugs, and reckless and risk-taking acts.


For the majority of individuals, this disorder remits by adulthood. However, Childhood-Onset Conduct Disorder predicts a worse prognosis and an increased risk of criminal behavior, Conduct Disorder, and Substance-Related Disorders in adulthood. Individuals with Conduct Disorder are at risk for later Antisocial Personality Disorder, Mood Disorders, Anxiety Disorders, Post-traumatic Stress Disorder, Impulse-Control Disorders, Psychotic Disorders, Somatic Symptom Disorders, and Substance Use Disorders as adults.

Negative outcomes in adulthood also include criminal and violent offending, and incarceration. Childhood conduct problems further predict risk for numerous problems in adulthood: serious difficulties in education, work and finances, homelessness, abuse, dependence on tobacco, alcohol and drugs, and even poor physical health, including injuries, sexually transmitted infections, compromised immune function, dental and respiratory problems, as well as a variety of mental disorders and suicidal behavior.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.


The one-year (median) population prevalence is 4%. In Childhood-Onset Conduct Disorder, males predominate; however in Adolescent-Onset Conduct Disorder the male to female ratio is equal. Prevalence rates rise from childhood to adolescence and are higher among males than among females.


Conduct Disorder is asssociated with an increased risk of Substance Use Disorder (particularly in adolescent females), suicidal ideation, suicide attempts, and completed suicide. Personality traits that often co-occur with Conduct Disorder are: negative emotionality, poor self-control, poor frustration tolerance, irritability, temper outbursts, suspiciousness, insensitivity to punishment, thrill seeking, and recklessness.

Risk Factors

Family Risk Factors: These include parental rejection and neglect, inconsistent child-rearing practices, harsh discipline, physical or sexual abuse, lack of supervision, early institutional living, frequent changes of caregivers, large family size, parental criminality, and parental substance abuse.

Community Risk Factors: These include peer rejection, association with a delinquent peer group, and neighborhood exposure to violence.

Familial Pattern

The risk of having Conduct Disorder is increased in children with a biological or adoptive parents or a sibling with Conduct Disorder. Conduct Disorder is more common in children of biological parents with severe alcohol use disorder, depressive and bipolar disorders, or Schizophrenia or biological parents who have a history of ADHD or Conduct Disorder.

Effective Therapies

The common theme underlying effective therapies for Conduct Disorder is that they change the environment around the young person, with parent training emerging as the most effective. Medication is largely ineffective. Parent training is quite effective as a treatment for this disorder. At 5-6 year followup after parent training, two-thirds of the children no longer received the diagnosis of Conduct Disorder. It is essential that these individuals be given healthy, compassionate role models (e.g., Big Brothers, Scouts) and learn how to play by the rules and cooperate (e.g. structured sports programs). "Scared Straight" programs (showing delinquents what life in prison is like) may be effective.

Ineffective therapies

Physical punishment and incarceration is seldom effective; likewise medication is seldom effective against the core features of this disorder. Vitamins and dietary supplements are ineffective for this disorder.

Back to top



Rating Scales

Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These 5 major dimensions of human behavior seem to represent 5 major dimensions whereby our early ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, enthusiastic, and calm.

Which Dimensions of Human Behavior are Impaired in Conduct Disorder?

Agreeableness Antagonism       Sympathetic, Kind vs. Critical, Quarrelsome
Conscientiousness Disinhibition       Industrious, Orderly vs. Impulsive, Disorderly
Openness To Experience Impaired Intellect       Open-Minded, Creative vs. Easily Distracted
Sociability (Extraversion) Detachment       Enthusiastic, Assertive vs. Reserved, Quiet
Emotional Stability Negative Emotion       Calm, Emotionally Stable vs. Distressed, Easily Upset

The 5 Major Dimensions of Mental Illness

Our website uses the "Big 5 Factors" of personality as major dimensions of mental illness. Each of these 5 dimensions has a healthy side and an unhealthy side. The Big 5 Factors are: Agreeableness, Conscientiousness, Openness to Experience, Sociability (Extraversion), and Emotional Stability. Our website adds an additional factor, Physical Health. However, our discussion will primarily focus on the traditional "Big 5 Factors".

The Following Pictures Are of The International Space Station

Agreeableness (Sympathetic, Kind)
Description: Agreeableness is synonymous with compassion and politeness; whereas Antagonism is synonymous with competition and aggression. Compassion reflects empathy, sympathy, and caring for others. Politeness reflects respect for others’ needs and desires and a tendency to refrain from aggression. The Agreeableness dimension measures the behaviors that are central to the concept of LOVE and JUSTICE.
Descriptors: Compassionate, polite, kind, sympathetic, appreciative, affectionate, soft-hearted, warm, generous, trusting, helpful, forgiving, pleasant, good-natured, friendly, cooperative, gentle, unselfish, praising, sensitive.
MRI Research*: Agreeableness was associated with increased volume in regions that process information about the intentions and mental states of other individuals.
"I am helpful and unselfish with others."
"I have a forgiving nature."
"I am generally trusting."
"I am considerate and kind to almost everyone."
"I like to cooperate with others."
"I don't find fault with others."
"I don't start quarrels with others."
"I am not cold and aloof."
"I am not rude to others."
"I feel other's emotions."
"I inquire about others' well-being."
"I sympathize with others' feelings."
"I take an interest in other people's lives."
"I like to do things for others."
"I respect authority."
"I hate to seem pushy."
"I avoid imposing my will on others."
"I rarely put people under pressure."
Antagonism (Critical, Quarrelsome)
* Callousness:
"It's no big deal if I hurt other people's feelings."
"Being rude and unfriendly is just a part of who I am."
"I often get into physical fights."
"I enjoy making people in control look stupid."
"I am not interested in other people's problems."
"I can't be bothered with other's needs."
"I am indifferent to the feelings of others."
"I don't have a soft side."
"I take no time for others."
* Deceitfulness:
"I don't hesitate to cheat if it gets me ahead."
"Lying comes easily to me."
"I use people to get what I want."
"People don't realize that I'm flattering them to get something."
* Manipulativeness:
"I use people to get what I want."
"It is easy for me to take advantage of others."
"I'm good at conning people."
"I am out for my own personal gain."
* Grandiosity:
"I'm better than almost everyone else."
"I often have to deal with people who are less important than me."
"To be honest, I'm just more important than other people."
"I deserve special treatment."
* Suspiciousness:
"It seems like I'm always getting a “raw deal” from others."
"I suspect that even my so-called 'friends' betray me a lot."
"Others would take advantage of me if they could."
"Plenty of people are out to get me."
"I'm always on my guard for someone trying to trick or harm me."
* Hostility:
"I am easily angered."
"I get irritated easily by all sorts of things."
"I am usually pretty hostile."
"I always make sure I get back at people who wrong me."
"I resent being told what to do, even by people in charge."
"I insult people."
"I seek conflict."
"I love a good fight."
("Agreeableness vs. Antagonism" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Conscientiousness (Industrious, Orderly)
Description: Conscientiousness is synonymous with being industrious and orderly; whereas Disinhibition is synonymous with being impulsive and disorderly. The Conscientiousness dimension measures the behaviors that are central to the concept of SELF-CONTROL.
Descriptors: Self-disciplined, achievement-oriented, industrious, competent, reliable, responsible, orderly, deliberate, decisive
MRI Research*: Conscientiousness was associated with increased volume in the lateral prefrontal cortex, a region involved in planning and the voluntary control of behavior.
"I do a thorough job. I want everything to be 'just right'. I want every detail taken care of."
"I am careful."
"I am a reliable hard-worker."
"I am organized. I follow a schedule and always know what I am doing."
"I like order. I keep things tidy."
"I see that rules are observed."
"I do things efficiently. I get things done quickly."
"I carry out my plans and finish what I start."
"I am not easily distracted."
Rigid Perfectionism (Excessive Conscientiousness)
"Even though it drives other people crazy, I insist on absolute perfection in everything I do."
"I simply won't put up with things being out of their proper places."
"People complain about my need to have everything all arranged."
"People tell me that I focus too much on minor details."
"I have a strict way of doing things."
"I postpone decisions."
Disinhibition (Impulsive, Disorderly)
* Irresponsibility:
"I've skipped town to avoid responsibilities."
"I just skip appointments or meetings if I'm not in the mood."
"I'm often pretty careless with my own and others' things."
"Others see me as irresponsible."
"I make promises that I don't really intend to keep."
"I often forget to pay my bills."
* Impulsivity:
"I usually do things on impulse without thinking about what might happen as a result."
"Even though I know better, I can't stop making rash decisions."
"I feel like I act totally on impulse."
"I'm not good at planning ahead."
* Distractibility:
"I can't focus on things for very long."
"I am easily distracted."
"I have trouble pursuing specific goals even for short periods of time."
"I can't achieve goals because other things capture my attention."
"I often make mistakes because I don't pay close attention."
"I waste my time ."
"I find it difficult to get down to work."
"I mess things up."
"I don't put my mind on the task at hand."
* Reckless Risk Taking:
"I like to take risks."
"I have no limits when it comes to doing dangerous things."
"People would describe me as reckless."
"I don't think about getting hurt when I'm doing things that might be dangerous."
* Hyperactivity:
"I move excessively (e.g., can't sit still; restless; always on the go)."
"I'm starting lots more projects than usual or doing more risky things than usual."
* Over-Talkativeness:
"I talk excessively (e.g., I butt into conversations; I complete people's sentences)."
"Often I talk constantly and cannot be interrupted."
* Elation:
"I feel much more happy, cheerful, or self-confident than usual."
"I'm sleeping a lot less than usual, but I still have a lot of energy."
("Conscientiousness vs. Disinhibition" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Open To Experience (Open-Minded, Creative)
Description: Open to Experience is synonymous with being open-minded and creative; whereas Closed to Experience is synonymous with being closed-minded and uncreative. The Openness to Experience dimension measures the behaviors that are central to the concept of WISDOM. Open-minded people ask "why?", are willing to challenge something that doesn't seem right, to listen to other people's opinions, and to be ever-ready to accept new truths, if the evidence is there. They are creative, flexible, and holistic in their thinking. They never stop questioning.
Descriptors: Wide interests, imaginative, intelligent, original, insightful, curious, sophisticated, artistic, clever, inventive, sharp-witted, wise
MRI Research*: Openness To Experience did not have any significant correlation with the volume of any brain structures. (This could suggest that "Openness To Experience", as defined here, is more a function of culture rather than of brain neurobiology.)
Example: This video shows how we see what we want to see. What we pay attention to (or what we believe about the world) blinds us to reality. (Exit YouTube after first video.)
"I am original, and come up with new ideas."
"I am curious about many different things."
"I am quick to understand things."
"I can handle a lot of information."
"I like to solve complex problems."
"I have a rich vocabulary."
"I think quickly and formulate ideas clearly."
"I enjoy the beauty of nature."
"I believe in the importance of art."
"I love to reflect on things."
"I get deeply immersed in music."
"I see beauty in things that others might not notice."
"I need a creative outlet."
Closed To Experience (Closed-Minded, Uncreative)
"I prefer work that is routine."
"I have difficulty understanding abstract ideas."
"I avoid philosophical discussions."
"I avoid difficult reading material."
"I learn things slowly."
"I have few artistic interests."
"I seldom notice the emotional aspects of paintings and pictures."
"I do not like poetry."
"I seldom get lost in thought."
"I seldom daydream."
Cognitive Impairment
* Memory Impairment:
"I have difficulty learning new things, or remembering things that happened a few days ago."
"I often forget a conversation I had the day before."
"I often forget to take my medications, or to keep my appointments."
* Impaired Reasoning or Problem-Solving:
"My judgment, planning, or problem-solving isn't good."
"I lack creativity or curiosity."
* Eccentricity:
"I often have thoughts that make sense to me but that other people say are strange."
"Others seem to think I'm quite odd or unusual."
"My thoughts are strange and unpredictable."
"My thoughts often don’t make sense to others."
"Other people seem to think my behavior is weird."
"I have several habits that others find eccentric or strange."
"My thoughts often go off in odd or unusual directions."
* Unusual Beliefs and Experiences:
"I often have unusual experiences, such as sensing the presence of someone who isn't actually there."
"I've had some really weird experiences that are very difficult to explain."
"I have seen things that weren’t really there."
"I have some unusual abilities, like sometimes knowing exactly what someone is thinking."
"I sometimes have heard things that others couldn’t hear."
"Sometimes I can influence other people just by sending my thoughts to them."
"I often see unusual connections between things that most people miss."
* Perceptual Dysregulation:
"Things around me often feel unreal, or more real than usual."
"Sometimes I get this weird feeling that parts of my body feel like they're dead or not really me."
"It's weird, but sometimes ordinary objects seem to be a different shape than usual."
"Sometimes I feel 'controlled' by thoughts that belong to someone else."
"Sometimes I think someone else is removing thoughts from my head."
"I have periods in which I feel disconnected from the world or from myself."
"I can have trouble telling the difference between dreams and waking life."
"I often 'zone out' and then suddenly come to and realize that a lot of time has passed."
"Sometimes when I look at a familiar object, it's somehow like I'm seeing it for the first time."
"People often talk about me doing things I don't remember at all."
"I often can't control what I think about."
"I often see vivid dream-like images when I’m falling asleep or waking up."
("OPENNESS TO EXPERIENCE vs. BEING CLOSED TO EXPERIENCE" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Sociability (Enthusiastic, Assertive)
Description: Sociability is synonymous with being enthusiastic and assertive; whereas Detachment is synonymous with being reserved and quiet. Assertiveness encompasses traits relating to leadership, dominance, and drive. Enthusiasm encompasses both outgoing friendliness or sociability and the tendency to experience and express positive emotion. The Sociability (Extraversion) dimension measures the behaviors that are central to the concept of SOCIABILITY and LEADERSHIP.
Descriptors: Enthusiastic, assertive, sociable, outgoing, talkative, active, energetic, outspoken, dominant, forceful, show-off, spunky, adventurous, noisy, bossy.
MRI Research*: Sociability (extraversion) was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
"I'm talkative"
"I'm not reserved."
"I'm full of energy."
"I generate a lot of enthusiasm."
"I'm not quiet."
"I have an assertive personality."
"I'm not shy or inhibited."
"I am outgoing and sociable."
"I make friends easily."
"I warm up quickly to others."
"I show my feelings when I'm happy."
"I have a lot of fun."
"I laugh a lot."
"I take charge."
"I have a strong personality."
"I know how to captivate people."
"I see myself as a good leader."
"I can talk others into doing things."
"I am the first to act."
Attention Seeking (Excessive Sociability)
"I like to draw attention to myself."
"I crave attention."
"I do things to make sure people notice me."
"I do things so that people just have to admire me."
"My behavior is often bold and grabs peoples' attention."
Detachment (Reserved, Quiet)
* Social Withdrawal:
"I don’t like to get too close to people."
"I don't deal with people unless I have to."
"I'm not interested in making friends."
"I don’t like spending time with others."
"I say as little as possible when dealing with people."
"I keep to myself."
"I am hard to get to know."
"I reveal little about myself."
"I do not have an assertive personality."
"I lack the talent for influencing people."
"I wait for others to lead the way."
"I hold back my opinions."
* Intimacy Avoidance:
"I steer clear of romantic relationships."
"I prefer to keep romance out of my life."
"I prefer being alone to having a close romantic partner."
"I'm just not very interested in having sexual relationships."
"II break off relationships if they start to get close."
* Anhedonia (Lack of Pleasure):
"I often feel like nothing I do really matters."
"I almost never enjoy life."
"Nothing seems to make me feel good."
"Nothing seems to interest me very much."
"I almost never feel happy about my day-to-day activities."
"I rarely get enthusiastic about anything."
"I don't get as much pleasure out of things as others seem to."
* Restricted Affectivity:
"I don't show emotions strongly."
"I don't get emotional."
"I never show emotions to others."
"I don't have very long-lasting emotional reactions to things."
"People tell me it's difficult to know what I'm feeling."
"I am not a very enthusiastic person."
("Sociability vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Emotional Stability (Calm, Emotionally Stable)
Description: Emotional Stability is synonymous with being calm and emotionally stable; whereas Negative Emotion is synonymous with being distressed and easily upset. The Emotional Stability dimension measures the "safety vs. danger" behaviors that are central to the concept of COURAGE.
Descriptors: Stable, calm, relaxed, contented
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
Negative Emotion (Distressed, Easily Upset)
Description: Degree to which people experience persistent negative emotions (anxiety, anger, or depression) and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotional instability, anxiety, irritability, depression, rumination-compulsiveness, self-consciousness, vulnerability
MRI Research*: Negative Emotion was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
* Anxiousness:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
* Depression:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

The "Big 5 Factors" of Personality as Shown In Dogs

The same "Big 5 Factors" of personality found in humans can be found in dogs. This makes sense because dogs, like humans, are a social species.

Agreeableness ("Friend")
Dog is friendly towards unfamiliar people.
Dog is friendly towards other dogs.
When off leash, dog comes immediately when called.
Dog willingly shares toys with other dogs.
Dog leaves food or objects alone when told to do so.
Antagonism ("Foe")
Dog is dominant over other dogs.
Dog is assertive with other dogs (e.g., if in a home with other dogs, when greeting).
Dog behaves aggressively towards unfamiliar people.
Dog shows aggression when nervous or fearful.
Dog aggressively guards coveted items (e.g., stolen item, treats, food bowl).
Dog is quick to sneak out through open doors, gates.

Conscientiousness ("Self-Controlled")
Dog works at tasks (e.g., getting treats out of a dispenser, shredding toys) until entirely finished.
Dog works hard all day herding or pulling a sleigh (if a "working dog" on the farm or in the snow).*
Dog is curious.
Disinhibition ("Disinhibited")
Dog is boisterous.
Dog seeks constant activity.
Dog is very excitable around other dogs.

Open To Experience ("Open-Minded")
Dog is able to focus on a task in a distracting situation (e.g., loud or busy places, around other dogs).
Closed To Experience ("Closed-Minded")
Dog is slow to respond to corrections.
Dog ignores commands.
Dog is slow to learn new tricks or tasks.

Sociability ("Approach")
Dog is attention seeking (e.g., nuzzling, pawing or jumping up on family members looking for attention and physical contact).*
Dog seeks companionship from people.
Dog is affectionate.
Detachment ("Avoidance")
Dog is aloof.
Dog gets bored in play quickly.
Dog is lethargic.

Emotional Stability ("Safety")
Dog tends to be calm.
Dog is relaxed when greeting people.
Dog is confident.
Dog adapts easily to new situations and environments.
Negative Emotion ("Danger")
Dog is anxious.
Dog is shy.
Dog behaves fearfully towards unfamiliar people.
Dog exhibits fearful behaviors when restrained.
Dog avoids other dogs.
Dog behaves fearfully towards other dogs.
Dog behaves submissively (e.g., rolls over, avoids eye contact, licks lips) when greeting other dogs.
Modified from Jones, A. C. (2009). Development and validation of a dog personality questionnaire. Ph.D. Thesis. University of Texas, Austin.

* New items added by Phillip W. Long MD

Notice the Personality Differences Between Dogs and Humans

Dogs and humans are strikingly similar on 4 of the "Big 5 Factors" of personality. However, dogs and humans are quite different on the "Conscientiousness" factor - because the canine brain isn't designed to organize work projects. That's why dogs don't build dog houses.

Two of the "Big 5 Factors" of dog personality are clearly a function of dogs being a social species that forms social hierarchies: (1) the "Agreeableness" factor describes "friend vs. foe" behaviors, and (2) the "Sociability" factor describes "approach vs. avoidance" behaviors.

The "Openness to Experience" describes the ability to learn from experience. The "Emotional Stability" factor describes "safety vs. danger" behaviors.

The Brain and the "Big-5 Factors" of Human and Dog Personality

It could be that the "Big-5 Factors" of personality represent some extremely basic brain functions. For example, when a young man approaches a young woman, she must: (1) decide whether he is friend or foe ["Agreeableness"], (2) decide if this represents safety or danger ["Emotional Stability"], (3) decide whether to approach or avoid him ["Sociability"], (4) decide whether to be self-controlled or disinhibited ["Conscientiousness"], and (5) learn from this experience ["Openness to Experience"].

Back to top

Treatment Guidelines

World Health Organization Behavioral Disorder Treatment Guidelines

Download Printable Version

(Summary Of) An update on interventions for conduct disorder - The Royal College of Psychiatrists, BJPsch Advances (2007)

Intervention principles

The common theme underlying interventions that work is that they change the environment around the young person, with parent training emerging as the most effective. Medication is largely ineffective.

Engage the family

Any family coming to a mental health service is likely to have some fear of being judged "bad" and possibly "mad". Families of children with conduct problems are more likely to be disadvantaged and disorganised, to have had arguments with official agencies such as schools and welfare officers, and to be suspicious of officialdom.

Rates of drop-out from treatment for such families are high - often up to 60%. Practical measures such as helping with travel, providing child care and holding sessions in the evening or at other times to suit the family are all likely to facilitate retention.

Forming a good alliance with the family is especially important: adding engagement strategies during the assessment, for example showing parents that the therapist clearly understood their viewpoint, leads to increased attendance at treatment sessions. Once engaged, the quality of the therapist's alliance with the family affects treatment success: in one meta-analysis it accounted for 15% of the variance in outcome.

Select which treatment to use and who should deliver it

If possible, interventions should specifically address each context, as it cannot be assumed that successful treatment in one area will generalise to another. For example, improvements in the home arising from a successful parent training programme will not necessarily lead to less antisocial behavior at school.

If classroom behavior is a problem and a school visit shows that the teacher is not using effective methods, advice to the teacher and other school staff can be very effective. If the child has pervasive problems including fights with peers, individual work on anger management and social skills should be added.

Medication is controversial and generally best avoided; possible indications are discussed below. Generally speaking, in light of the strong evidence for its effectiveness, the first line of treatment should be parent training.

The National Health Service (NHS) has insufficient resources to treat all antisocial behavior in childhood, so the mental health professional must decide whether other agencies can be involved. A number of voluntary-sector bodies now provide parent training, and schools may be able to set up suitable behavioural programmes.

Develop strengths

Identifying the strengths of both the child and the family is crucial. This helps engagement, and increases the chances of effective treatment. Encouraging their abilities helps the child spend more time behaving constructively rather than destructively - more time spent playing football is less time spent hanging round the streets looking for trouble.

Encouraging prosocial activities - for example to complete a good drawing or to play a musical instrument well - may lead to increased achievements, heightened self-esteem and greater hope for the future.

Treat comorbid conditions

A child's antisocial behavior often affects others so strongly that comorbid conditions can easily be missed. Yet in clinical referrals, comorbidity is the rule rather than the exception.

Common accompaniments are depression and attention-deficit hyperactivity disorder (ADHD); a number have post-traumatic stress disorder (PTSD), for example having been beaten by their father or witnessing his physical violence against their mother.

Promote social and scholastic learning

Treatment involves more than the reduction of antisocial behavior - stopping tantrums and aggressive outbursts, while helpful, will not lead to good functioning if the child lacks the skills to make friends or to negotiate - positive behaviours need to be taught too.

Specific intellectual disabilities such as reading retardation, which is particularly common in these children, need to be addressed, as do more general difficulties such as planning homework.

Use guidelines

The American Academy of Child and Adolescent Psychiatry (1997) has drawn up sensible practice parameters for the assessment and treatment of conduct disorder, and the UK National Institute for Health and Clinical Excellence (2006) has published an appraisal of the clinical efficacy and cost-effectiveness of parent training programmes.

Treat the child in their natural environment

Most of the interventions described below are intended for out-patient or community settings. Psychiatric hospitalisation is very rarely necessary: there is no evidence that in-patient admissions lead to gains that are maintained after the child goes home.

Specific interventions for children 3-12 years of age

Parent management training

Programmes have been designed to improve parents' behavior management skills and the quality of the parent-child relationship. Most target skills such as those listed in Box 1, but interventions may also address distal factors likely to inhibit change, for example parental drug or alcohol misuse, maternal depression and violence between parents. Treatment can be delivered in individual parent-child sessions or in a parenting group. Individual approaches offer the advantages of live observation of the parent-child dyad and therapist coaching and feedback regarding progress.

Box 1

Parent management training

Key targets of parenting skills include:

  • promoting play

  • developing a positive parent-child relationship

  • using praise and rewards to increase desirable social behavior

  • giving clear directions and rules

  • using consistent and calmly executed consequences for unwanted behavior

  • reorganising the child's day to prevent problems

Box 2

The four common targets of cognitive-behavioural and social skills therapies

  • To reduce children's aggressive behavior such as shouting, pushing, and arguing

  • To increase prosocial interactions such as entering a group, starting a conversation, participating in group activities, sharing, cooperating, asking questions politely, listening and negotiating

  • To correct the cognitive deficiencies, distortions and inaccurate self-evaluation exhibited by many of these children

  • To ameliorate emotional dysregulation and self-control problems so as to reduce Emotional Instability, impulsivity and explosiveness, enabling the child to be more reflective and able to consider how best to respond in provoking situations

Cognitive-behavioural therapies were originally used mainly with school-age children and with adults, but more recently they have been successfully adapted for pre-school children. These interventions may be delivered in individual or group therapy.

Although groups offer several advantages (e.g. opportunities to practise peer interactions), they may have iatrogenic effects (Dishion et al, 1999). These appear to be particularly common in larger groups and those with inadequate therapist supervision, where children learn deviant behavior from their peers and encourage each other to act antisocially.

Box 3

The four common targets of classroom techniques

  • Promoting positive behaviours such as compliance and following established classroom rules and procedures

  • Preventing problem behaviours such as talking at inappropriate times and fighting

  • Teaching social and emotional skills such as conflict resolution and problem-solving

  • Preventing the escalation of angry behavior and acting out

Some of the targets listed in Box 3 can be met by training teachers in methods similar to those taught to parents, as described above. However, other techniques are classroom specific.

For example, establishing and teaching rules and procedures involves setting rules such as "use a quiet voice", "listen when others are speaking", "keep your hands and feet to yourself" and "use respectful words". Note that these rules are all expressed positively, describing what the child should do, rather than what they should not.

Striepling-Goldstein (1997) offers six "rules for making rules":

  1. make few rules (between three and six)

  2. negotiate them with the children

  3. state them behaviourally and positively

  4. make a contract with the children to adhere to them

  5. post them on the classroom wall

  6. send a copy to parents.

Crucial to all this is a systematic and consistent response to children following or not following the rules. Rewards can be social (teacher praise, peer recognition, notes home to parents), material (stickers, certificates, tokens to exchange for food, etc.) or privileges (e.g. extra breaktime, games, parties, computer time).

Mild punishments include reprimands, response-costs procedures (losing privileges or points) and time out (being sent to the corner of the room or to another boring place).

Interventions to promote academic engagement and learning

These include self-management and self-reinforcement training programmes that help children, for example, to spend more time on a task or to complete written work more quickly and accurately. An older review of 16 studies found moderate to large effects for such programmes (Nelson et al, 1991), and subsequent trials uphold this finding.

A number of programmes build on the idea that antisocial children who are failing at school often have parents who do not get involved in their academic schoolwork, and indeed may not value it highly. They do not read with their children, encourage homework or attend school meetings.

Approaches include removing barriers to home-school cooperation by training parents to view teachers positively (often their own memories of school will be negative and discouraging) and, equally, training teachers to be constructive in solving children's difficulties and helping parents engage in academic activities with their children.

Although there are good descriptions of such programmes (e.g. Christenson & Buerkle 1999), rigorous evaluations are lacking.

Interventions for teenagers

In adolescence, conduct disorder frequently becomes more serious and can involve criminal offending.

Family-based interventions

The best known intervention for serious antisocial behavior in teenagers is functional family therapy, brought into being in 1969 by James Alexander and colleagues (Alexander et al, 2000). It is designed to be practicable and relatively inexpensive.

Between eight and twelve 1-hour sessions are given in the family home, to overcome attendance problems common in this client group; for more intractable cases, 12-16 sessions are offered, usually over 3 months. The target age range is 11-18 years.

There are four phases to treatment. The first two involve engagement and motivation. Here the therapist works to enhance the perception that change is possible and to minimise negative perceptions of therapy (e.g. poor programme image, access difficulties, insensitive referral).

The aim is first to keep the family in treatment, and only then to move on to finding what precisely they want.

Box 4

The four phases of functional family therapy

  1. Engagement

  2. Motivation

  3. Behavioural change

  4. Generalisation

One of the techniques used is reframing, whereby positive attributes are enhanced. For example, a youth who frequently offends without getting caught is labelled (the word used in the therapy) as bright. Emotional motivation can be used in reframing: a mother who continually nags may be labelled as caring, upset and hurt.

Families are encouraged to see themselves as doing the best they can under the circumstances. Problem-solving and behavioural change are not introduced until motivation has been enhanced, negativity decreased and a positive alliance established.

Explicit attempts are made to reduce negative spirals in family interactions, by interrupting and diverting the flow of negative, blaming speech.

Reframing does not play down the impact of the negative behavior, but each family member should feel at the end of these two initial stages that:

  • they are not inherently bad: it is the way they have done things that has not worked

  • even though they have made mistakes, the therapist took their side as much as everybody else's

  • even though they experience the problems differently, each family member must contribute to the solution

  • even though they may have a lot to change, the therapist will work hard to protect them and everyone else in the family

  • they want to come back to the next session because it finally seems that things might get better.

The third phase targets behavioural change. There are two main elements to this: communication training and parent training. The success of this phase is dependent on success in the first two phases, and it is therefore not introduced until good engagement and motivation have been established.

(In this, functional family therapy differs from programmes in which a fixed number of sessions are allocated to each topic, irrespective of the family's rate of progress.)

Behavioural change is approached flexibly according to the family's needs. Thus, if the parents are continually arguing and this is affecting their teenager, the "marital subsystem" will be addressed (Box 5).

Box 5

Techniques for dealing with a dysfunctional marital subsystem

  • Using the first person voice rather than the second, e.g. instead of "You are a lazy slob" saying "I find it upsets me when you leave your socks on the floor"

  • Being direct, e.g. instead of complaining to a partner "He never...", saying directly to the youth "You never..."

  • Being brief instead of making long speeches

  • Being specific about the behavior that is desired

  • Offering alternatives to the spouse

  • Active listening

Standard parent training techniques are used, including praise, rewards (called "contracting" in functional family therapy: e.g. "If you come home by 6 o'clock each night, I'll take you to the cinema on Saturday"), limit-setting, consequences and response-cost (e.g. losing TV time for swearing).

The fourth and final phase of functional family therapy is generalisation. Here the goals are to encourage family members to generalise the improvements made in a few specific situations to similar situations; to help the teenager and family to negotiate with community agencies such as school; and to help them get the resources they need.

Sometimes this requires the therapist to be a case manager for the family, a role that necessitates knowledge of the community agencies and how the system works.


The effectiveness of functional family therapy is well established, and of the 10 replication studies discussed by Alexander et al (2000) over half were independent of the developers; a further four are under way in Sweden. The trials published to date all have been positive, with typical recidivism rates 20-30% lower than in control groups.

Multiple-component interventions

I will discuss the example of multisystemic therapy here, as it is one of the best developed treatments of this kind. Developed by Henggeler and colleagues in the USA (Huey et al, 2000), multisystemic therapy rests on nine treatment principles (Box 6).

The way the therapy is delivered is closely controlled. The weekly monitoring of progress enables barriers to improvement to be addressed immediately and hypotheses regarding what is going on in the family and systems around the teenager to be revised in the light of progress.

Clinicians take on only four to six cases at a time, since the work is intensive; there is close attention to quality control by weekly supervision along prescribed lines, and the parents and teenagers fill in weekly questionnaires on whether they have been receiving therapy as planned.

Therapy is given for 3 months and then stopped.

Box 6

The principles of multisystemic therapy

  1. An assessment is made to determine the fit between the young person's problems and the wider environment, identifying strengths and difficulties; difficulties are understood as reactions to a specific context, not necessarily as intrinsic deficits

  2. During sessions the therapist emphasises the positive and uses systemic strengths (e.g. an aptitude for sports, getting on well with grandmother, the presence of prosocial peers in grandmother's neighbourhood) as levers for change. Each session should acknowledge and work on these strengths

  3. Interventions are designed to promote responsible behavior and reduce irresponsible behavior

  4. Interventions are focused in the present and are action oriented, with specific, well-defined goals. The emphasis is on what can be done in the here and now, rather than on the need to understand the family and the youth's past

  5. Interventions target sequences of behavior in multiple systems that maintain problems

  6. Interventions are developmentally appropriate. They should fit the life stage and personal level of the family members

  7. Interventions require daily or weekly effort by family members. This enables frequent practice of new skills, frequent positive feedback for efforts made; non-adherence to treatment agreements rapidly becomes apparent

  8. The effectiveness of interventions is evaluated continuously from multiple perspectives, with the multisystemic therapy team assuming responsibility for overcoming barriers to successful outcomes.

  9. Interventions are designed to promote treatment generalisation by empowering parents to address their offspring's needs across multiple contexts


The first outcome studies by the therapy's developers were positive. A meta-analysis of papers published to the end of 2002 by authors that include one of the developers, Charles Borduin, found that in seven studies comparing multisystemic therapy with treatment as usual or an alternative, the mean overall effect size across several domains was moderate; the studies involved a total of 708 youths and 35 therapists (Curtis et al, 2004).

Outcome domains included offending (arrests, days in prison, self-reported criminality, self-reported drug use), where the mean effect size was moderate; peer relations, where it was small; family relations (large); and individual youth and parent psychopathology symptoms (moderate).

However, noticeably larger effect sizes were reported when the therapists were the developers' own graduate students than when they were local community therapists supervised by the developers, when the effect size mean was small.

Long-term follow-up (14 years later, when the mean age of the original teenagers was 29) of 176 individuals allocated to multisystemic therapy or usual individual therapy found recidivism rates of 50% and 81% respectively.

The next test of any therapy is its effectiveness when carried out by teams who have no financial or employment ties with its developers (although they may pay the developers for materials and supervision), with an independent evaluation team (Littell, 2005).

The only independent evaluation was also the only one to use proper intention-to-treat analyses (rather than excluding treatment refusers, etc.), and it found, with a large sample (n = 409) in Canada, that multisystemic therapy gave no significant improvement over treatment as usual on any outcome, either immediately or at 3-year follow-up (Leschied & Cunningham, 2002).

A smaller (n = 75) independent study in Norway (Ogden & Hagen, 2006) was more positive, reporting effect sizes that were small for self-reported delinquency, moderate for parent-rated and large for teacher-rated (although 40% of data were missing here).

Harsh and outdoor interventions

Harsh, military-style shock incarceration, so-called boot camps, are still popular for young offenders in the USA, where they were promoted by the Office of Juvenile Justice and Delinquency Prevention in 1992, when three pilot programmes were set up.

However, several reviews have concluded that they are ineffective (Tyler et al, 2001; Benda, 2005; Cullen et al, 2005; Stinchcomb, 2005), as did an RCT by the California Youth Authority in which long-term arrest data found no difference between boot camp and standard custody and parole (Bottcher & Ezell, 2005).

In contrast, a meta-analysis of 28 studies of wilderness programmes found a small overall effect size, with recidivism rates of 29% v. 37% for controls (Wilson & Lipsey, 2000). Programmes involving intense physical activity and a distinct therapeutic component were the most effective.

Another approach, used for example in the Scared Straight programme, is to attempt to deter delinquent behavior by frightening individuals with visits to prisons. However, a meta-analysis of nine controlled trials found that this intervention was on average more harmful than doing nothing, as it led to worse outcomes (Petrosino et al, 2003).


No pharmacological intervention is currently approved specifically for conduct disorder. Nevertheless, medication is used relatively frequently and increasingly for this behavior in the USA (Steiner et al, 2003; Turgay, 2004).

Primary care physicians are often required to manage such medication, and concerns have been raised because many lack adequate training in developmental psychopathology and do not have time to carry out thorough assessment and monitoring (Vitiello, 2001).

In the UK, medication would not generally be supported as good practice because, as discussed below, well-replicated trials of effectiveness are limited, particularly for children without comorbid ADHD.

The best-studied pharmacological interventions for children and adolescents with conduct problems are psychostimulants (methylphenidate and dexamfetamine), used for ADHD comorbid with conduct disorder. In these circumstances, there is evidence that reduction in hyperactivity and impulsivity also result in reduced conduct problems (Connor et al, 2002; Gerardin et al, 2002).

There is insufficient reliable evidence to decide whether stimulants reduce aggression in the absence of ADHD; one study (Klein et al, 1997) found that improvements in the symptoms of conduct disorder were independent of reduction in the symptoms of ADHD, but this needs replication.

Other pharmacological approaches for antisocial behavior have tended to target reactive aggression and overarousal, primarily in highly aggressive adolescents in psychiatric hospitals. Medications used for these conditions include mood stabilisers (e.g. lithium and carbamazepine) and drugs purported to target affect dysregulation (e.g. buspirone and clonidine).

Some studies have reported that lithium reduced aggression and hostility in children and adolescents in psychiatric hospitals (Campbell et al, 1995; Malone et al, 2000), but others have failed to show effectiveness in out-patient samples (e.g. Klein, 1991) and with treatment of shorter duration (2 weeks or less; Rifkin et al, 1997).

In a double-blind placebo-controlled study (Cueva et al, 1996) carbamazepine failed to outperform placebo. A placebo-controlled randomised trial of stimulants plus placebo v. stimulants plus clonidine found that the latter combination was more effective in children with aggression and hyperactivity (Hazell & Stuart, 2003).

However, it should be noted that polypharmacy carries increased risk of side-effects (Impicciatore et al, 2001).

In the past few years, the use of antipsychotics such as risperidone and clonidine in out-patient settings has been increasing. However, there is only modest evidence for their effectiveness in conduct disorder in children of average IQ without ADHD.

The review by Pappadopulos et al (2006) found that antipsychotics were more effective where ADHD or intellectual disability was present. Findling et al (2000), in a small (n = 10 per group) double-blind placebo-controlled study, found significant short-term reductions in aggression.

The Risperidone Disruptive Behavior Study Group used a placebo-controlled double-blind design to study the effects of risperidone in 110 children of below-average IQ with conduct problems. Results suggest that risperidone gives significant improvements in behavior over placebo (Aman et al, 2002; Snyder et al, 2002), but it remains unclear whether the same findings would apply to children of average or above-average IQ.

Even the newer (atypical) antipsychotics, although not especially sedating, have substantial side-effects (e.g. risperidone typically leads to considerable weight gain), and the risk of movement disorders with long-term use is unknown.

So when might the use of antipsychotics be contemplated? My own clinical experience with children and adolescents suggests that they can dramatically reduce aggression in some cases, especially where there is poor emotional regulation characterised by prolonged rages.

Prescribing antipsychotics for relatively short periods (say up to 4 months) in lower doses (say no more than 1-1.5 mg risperidone per day) can help families cope. During this time it is crucial to introduce more effective psychological management. Nevertheless, these drugs are not recommended in anything other than unusual circumstances.


Psychological therapies are the mainstay of treatment for conduct problems. However, despite the strong evidence base, in both the USA and the UK only a minority of affected children receive any treatment, and even fewer receive evidence-based interventions.

Furthermore, the effectiveness of these interventions as practised in community settings tends to lag behind documented efficacy in controlled trials (e.g. Curtis et al, 2004). As can already be seen in recent efforts with many of the interventions described here, the next generation of evidence-based treatments for conduct problems should pay much greater attention to dissemination, including strategies for ongoing training and supervision of practitioners to ensure treatment fidelity.

The ultimate goal, of course, is to ensure that children and adolescents with these disorders have access to high-quality, evidence-based care.

  • Conduct Disorder Treatment Guidelines
  • Treatment

    • Conduct Disorder Treatment - Google

    • Five- to six-year outcome and its prediction for children with ODD/CD treated with parent training. The effects of parent training (teaching better parenting skills) have been extensively evaluated. This study assessed the effectiveness of parent training 5-6 years later. While all the children qualified for a diagnosis of ODD/CD before treatment, 5-6 years later, two-thirds no longer received such a diagnosis, the same proportion as found at the 1-year follow-up.
    • Progression from conduct disorder to antisocial personality disorder following treatment for adolescent substance abuse. This was a prospective longitudinal study of 137 substance-abusing adolescents (53 female and 84 male), whose average age was 15.9 years and who met the DSM-III-R criteria for conduct disorder. Consecutively admitted patients were recruited from two adolescent inpatient alcohol and drug treatment facilities. Participants were interviewed again 4 years after treatment. Four years after treatment, 61% of the study group met the DSM-III-R criteria for antisocial personality disorder. Results of a logistic regression analysis indicated that onset of deviant behavior at or before age 10, a greater diversity of deviant behavior, and more extensive pre-treatment drug use best predicted progression to antisocial personality disorder. At 4-year follow-up, the subjects with an antisocial personality disorder diagnosis exhibited more involvement with alcohol and drugs and poorer functioning across important life domains than the subjects without antisocial personality disorder.

Back to top

Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning the day in the morning, then assessing these plans in the evening has been shown to increase health and happiness. There is an additional benefit from doing a weekly review of your life satisfaction.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.

International Space Station (For Meditation)

Planning My Day (5-Minute Meditation Video)

Planning My Day (Picture)

Reviewing My Day Or Week (5-Minute Meditation Video)

Life Satisfaction Scale (Video)

Healthy Social Behaviors Scale (Video)

Mental Health Scale (Video)

Why We All Need to Practice Emotional First Aid

The Philosophy Of Stoicism (5 minute video)

Stoicism 101 (52 minute video)

The Roman emperor and Stoic philosopher Marcus Aurelius ruled from 161 to 180 A.D.

An Example Of Mindfulness Meditation (10 minute video)

In the 5th century BCE, Buddha spent 6 years of his life mastering mindfulness meditation. He then decided to look beyond meditation. Buddha concluded that simply emptying the mind of thought is calming, but otherwise it accomplishes little - since "You return to the same world". Instead, Buddha taught that we should change our world by seeking enlightenment through practicing compassion, and living a calm, peaceful, happy life.

7-Minute Workout Is All You Need To Get Back Into Physical Shape

Click Here For More Self-Help

Back to top

  • The best summary on bad research is given by Laura Arnold in this Tedx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Criteria For High Quality Research Studies

  • It is imperative that medical researchers conduct high quality research studies, otherwise the US Food and Drug Administration (FDA) refuses to licence their new drug or therapy. In 2009, the cost of successfully licensing one new drug or therapy under the FDA scheme was estimated to be US$1,000 million. Thus psychiatric research which leads to FDA approval of a new drug or therapy has to be of the highest quality; however the majority of psychological research studies on new therapies fail to reach these high standards for research. This could explain why two-thirds of psychological research studies can't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes

  • Cochrane Collaboration - the best evidence-based, standardized reviews available

Research Topics

Conduct Disorder - Latest Research (2016-2017)

Back to top

Internet Mental Health © 1995-2017 Phillip W. Long, M.D.