Clinical Assessment of Child and Adolescent Personality and ...

400CHAPTER 17 Assessment of Attention Deficit HyperactivityComorbiditiesThe most common problem co-occurringwith conduct problems is ADHD. In ameta-analytic study of community studies,Waschbusch (2002) reported that 36% ofboys and 57% of girls with conduct problemshad comorbid ADHD. When studyingpre-adolescent children and childrenreferred to clinics, the rate is even higherand often ranges from 75 to 90% (Abikoff& Klein, 1992; Hinshaw, 1987). Thisdegree of overlap has led to a debate as towhether or not ADHD and conduct problemsshould even be considered separatepsychological domains (see Rutter, 1983).We feel that the research indicates thatthese domains are at least partially independent(Frick, 1994; Hinshaw, 1987).Research does suggest that the developmentof ADHD usually precedes the developmentof conduct problems (Waschbusch,2002) and it often signals the presence of amore severe and more chronic form of conductproblems in children (Frick & Loney,1999). Also, there is growing evidence thatconduct problems improve when childrenwith ADHD have been treated with stimulantmedication (Hinshaw, 1991). Therefore,clinical assessments of children withconduct problems should routinely assessfor the presence of ADHD.Children with conduct problems alsofrequently have a comorbid anxiety disorder,and this seems to be especially thecase for girls (Loeber & Keenan, 1994).Children with conduct disorders alsoshow a high rate of depression (Harrington,Fudge, Rutter, Pickles, & Hill,1991). Importantly, there is evidence thatchildren with both conduct problems anddepression show a high rate of suicidalideation (Capaldi, 1992). The combinationof suicidal ideation, depression, andpoor impulse control that often is presentin children with conduct problemshas been associated with increased risk forsuicide (Shaffer, Garland, Gould, Fisher,& Trautman, 1988). Finally, childrenwith CD are at higher risk for substanceabuse, especially those children with bothADHD and CD (Lynskey & Fergusson,1995; Thompson, Riggs, Mikulich, &Crowley, 1996).Research also indicates that approximately20–25% of children with CD areunderachieving in school relative to a levelpredicted by their age and intellectualabilities (Frick et al., 1991). The reasonfor this association is not clear, possiblybecause the mechanisms involved maydiffer depending on the age of the samplestudied (Hinshaw, 1992). For example, inelementary school-age samples, much ofthe overlap between CD and academicunderachievement seems to be due tothe presence of ADHD (Frick et al.,1991). However, learning difficultiesseem to predict adolescent-onset conductproblems independent of other factors(Hinshaw, 1992). Despite the lack of adefinitive explanation for the correlationbetween learning and conduct problems,the simple fact that they co-occur so consistentlywarrants the assessment of learningproblems when assessing children andadolescents with conduct problems.Correlates with PotentialCausal RolesMost researchers agree that conduct problemsare the result of a complex interactionof multiple causal factors (Frick, 2006).Identifying the important causal agentsand how they interact to cause conductproblems is still an area in need of moreresearch. Past research has uncovered severalfactors that are associated with conductdisorders and that likely play a role in theirdevelopment. These factors can be summarizedin five categories: biological factors,cognitive correlates, family context,social ecology, and peers. The research onthe biological correlates of conduct problemsin children, while crucial for developingcausal theories, is not reviewed here