Antisocial Behavior in Girls with ADHD and Conduct Disorder

Introduction

Detention centers and residential treatment facilities are filled with male and female youth who have been in and out of the juvenile justice system for many years. Although the majority of the populations in these facilities are male, the number of female juvenile offenders is continually increasing. Many of the children in these facilities have a history of behavioral difficulties that may or may not have been diagnosed during much of their childhood.

Antisocial behaviors are acts that violate social rules and the basic rights of others. They include conduct intended to injure people or damage property, illegal behavior, and defiance of generally accepted rules and authority, such as truancy from school. These antisocial behaviors exist along a severity continuum (Clark et al., 2002). When childhood antisocial behaviors exceed certain defined thresholds — the diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) — the child is considered to have conduct disorder (CD) and possibly a comorbid condition. Together with attention deficit hyperactivity disorder (ADHD), these two disorders are classified as "disruptive behavior disorders" in the DSM-IV (Clark et al., 2002).

Antisocial behaviors represented in the DSM-IV diagnostic criteria for conduct disorder include aggression toward people and animals, destruction of property, deceitfulness, theft, and other serious social rule violations (Clark et al., 2002). A diagnosis of CD also requires a persistent behavior pattern in which three or more of a total of 15 behaviors occur over a 12-month period. The DSM-IV specifies childhood-onset and adolescent-onset types of CD and different degrees of severity of the disorder.

Female antisocial behavior and conduct disorder have often gone overlooked due to the abundance of research available for males. This paper examines existing research to discuss antisocial behavior in females with comorbid diagnoses of ADHD and conduct disorder, explaining the fundamentals of both conditions and the factors that led to the predominant association of males with these disorders.

Behaviors associated with attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD) are often implicated in incidents of juvenile offending. In many cases, these disorders occur simultaneously, making it extremely difficult for researchers to determine exactly how much each disorder contributes to delinquent behavior. Thirty to fifty percent of adolescents diagnosed with ADHD are also diagnosed with CD, though the two disorders are very different.

CD usually means that the juvenile violates the social norms and rights of others. According to statistics, this condition is generally considered a male disorder, occurring in approximately 9% of boys and 2% of girls under the age of 18. Conduct disorder typically appears before puberty in males and after puberty in females. Many of these children have normal IQs but are two or three years behind academically and have lower verbal skills and abstract reasoning abilities.

Children and adolescents with this disorder seem to be constantly in trouble — with parents, teachers, other children, or even the law. They display signs of low self-esteem, anger, frustration, irritability, hot tempers, and recklessness. CD often leads to adult antisocial personality disorder.

According to the DSM-IV, typical patterns of behavior in people with conduct disorder fall into four main categories: aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules. In most cases, aggression is necessary for a diagnosis of conduct disorder (Lexcen and Redding, 2000). Prevalence rates are 6% to 16% for males under age 18 and 2% to 9% for females. Boys outnumber girls in aggressive acts, but it is questionable whether DSM-IV criteria adequately assess the diagnosis of conduct disorder in girls or their level of aggression.

Recent studies reveal that approximately 90% of incarcerated juveniles were diagnosed with CD, which is characterized by persistent violation of age-appropriate societal norms or rules, or a disregard for the rights of other individuals. Many of these juveniles were also diagnosed with ADHD.

ADHD is characterized by symptoms of inattention, hyperactivity, or impulsivity. Children and adolescents with ADHD usually show signs of poor school performance, reduced participation in extracurricular activities, and negative social relationships. People with ADHD have limited problem-solving skills and difficulty paying attention. In adults, ADHD is associated with mental illness, incarceration, job failures, and marital problems.

Today, ADHD is the most common psychiatric disorder affecting children and adolescents. ADHD is often accompanied by at least one comorbidity — most commonly, CD (Weller et al., 1999, p. 60). Aggressive behaviors are often observed in juveniles with ADHD and CD. While many theories explain the fundamentals of aggression in these disorders, no single theory has accurately accounted for all the different types of aggressive behaviors associated with them.

However, a great deal of research has revealed that young people who display aggressive behavior alongside ADHD differ from those who have ADHD without aggression (Weller et al., 1999, p. 60). Aggressive behavior in children with ADHD is associated with greater psychological disturbance, antisocial familial factors, and subsequent development of antisocial personality and substance abuse. In children, ADHD without aggression is associated with greater cognitive deficits, cognitive problems at follow-up, and learning difficulties in siblings.

Statement of the Problem

Earlier research suggested that these two syndromes stemmed from the same underlying condition, despite the fact that they had different symptoms — particularly since both diagnoses seemed to predict juvenile criminal offending. However, recent studies reveal that the two diagnoses represent two distinct disorders, with ADHD relating more closely to cognitive and academic problems and CD relating more closely to delinquency in childhood and adolescence.

According to Weller et al. (1999): "The reliability of measurable epidemiologic samples of aggression in children and adolescents is inadequate because aggressive behaviors of all types have extremely low base rates. Subcategories of aggression such as physical, nonphysical, and verbal aggression occur even less frequently, which results in even more problems in the reliability of measurements." Traditionally, males outnumber females in physically aggressive acts. However, girls are more likely to exhibit relational aggression — such as threats of ending friendships, exclusion of others from peer groups, and non-confrontational verbal devaluations — all of which are harder to assess than physical aggression.

Comorbidity issues are also important in assessing aggression because, in many cases, children with ADHD have comorbid oppositional defiant disorder or conduct disorder. Rating scales used to evaluate aggression in children and adolescents include the Iowa Conners Teacher Questionnaire, the Children's Aggression Scale, and the parent and teacher versions of the Child Behavior Checklist. However, these scales are often inaccurate in diagnosing females. As a result, there is a gender bias in terms of referring children for assessment or treatment, and girls are less likely to be referred because the scales are based on male-dominated research.

Due to the lack of available research on female adolescents with comorbid ADHD, it is difficult to accurately diagnose these disorders; in many cases, they remain undiagnosed and untreated (Weller et al., 1999, p. 60). Early detection of ADHD and associated comorbidities during a young girl's development would allow for appropriate treatment and counseling. However, many girls never receive the necessary care because they are never diagnosed.

Review of Existing Literature

Multisystemic Treatment (MST), which includes traditional treatment and interventions with offenders in school and community settings, has been shown to be a highly effective intervention for the delinquent behaviors associated with CD and comorbid disorders (Lexcen and Redding, 2000). Juvenile offending, regardless of diagnostic status, is best treated as a potentially chronic disorder requiring multiple, persistent interventions across numerous settings, rather than as an acute condition that resolves after a brief intervention. One of the most important aspects of helping female juveniles is developing a method to accurately diagnose their condition, and to do so it is important to fully understand how antisocial behavior manifests in females.

According to studies, CD appears more often in males than in females overall, with prevalence rates of 6% to 10% for males and 2% to 9% for females (APA, 1994). These rates vary depending on the age range and type of disorder. Some studies estimate the male-to-female ratio at between approximately 3:1 and 5:1. However, while more males are affected at all ages, the gap between males and females narrows at adolescence — and by mid-adolescence, females surpass males in the onset of conduct disorders (Offord, 1987).

Despite the obvious need for female-focused research on CD and comorbid ADHD, there is little research concentrating on females. Gender differences in the expression of CD become more pronounced at adolescence, as boys are more likely to exhibit aggressive behavior than girls. Still, girls at this age often engage in other types of antisocial behavior as a result of these disorders, including covert juvenile offenses and prostitution, and are also likely to display non-violent aggression.

While these differences are observable in the majority of adolescents, they appear to diminish among adolescents who are severely disturbed. Over the past several years, the number of highly aggressive girls has increased. Many of these girls have been victims of severe abuse and neglect. These factors create a very complex clinical picture and present significant risks to society.

Conclusion

More than half of all children with CD have comorbid ADHD (Lexcen and Redding, 2000). Nearly half also suffer from depression or an anxiety disorder. Children with CD and comorbid ADHD are more likely to commit crimes and are at higher risk for suicide. These children are also more likely to experiment with drugs.

These facts represent serious behavioral concerns. Most children with these problems are referred to a psychologist by the juvenile justice system — usually as a condition of probation, following the commission of a serious crime. However, many females are never diagnosed with CD or comorbid ADHD, as clinicians attempt to assess these conditions using research derived primarily from male populations.

As a result, these conditions often go untreated in females, and a large percentage continue to exhibit antisocial behavior into adulthood, with some developing antisocial personality disorders. This can lead to a lifetime of social adjustment difficulties, with frequent arrests and periods of incarceration. Research consistently shows that aggressive behavior during childhood predicts later social adjustment problems. While boys and girls may express their aggression and antisocial behaviors differently, the effects can be equally damaging.

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