Profile of male adolescents with conduct disorder on intellectual efficacy, cognitive flexibility, cognitive coping, impulsivity and alexithymia: A comparison with high-risk controls

Background and Objectives: To specify which of the documented cognitive and emotional deficits characterize adolescents with conduct disorder (CD) compared with high-risk controls. Methods: High-risk adolescent males with and without CD were compared on intellectual efficiency, cognitive flexibility, impulsivity, alexithymia, and cognitive coping strategies. Substance use was controlled for in analyses. Results: Both groups showed normal intellectual efficiency and cognitive flexibility, as well as heightened alexithymia and behavioral impulsivity. Youths with CD evidenced more self-defeating and black-and-white thinking under stress, and more acting-out under negative affect, than those without CD. Conclusions: Deficits specific to CD resided in facets of emotional functioning and cognitive coping that might be targeted by a coping skills intervention. Received: 16 March 2011 Revised: 5 April 2012 Accepted: 31 May 2012 216 S. PIHET, M. SUTER, O. HALFON AND P. STEPHAN Background and objectives Conduct disorder (CD) is one of the most common mental disorders in juvenile offenders1, and may thus be an important target for the application of Juvenile Court Acts, for example the Swiss and German ones, which put a strong emphasis on education and treatment in response to juvenile delinquency. In this perspective, skills training programs represent cost-effective interventions that could be implemented in facilities accommodating juvenile offenders. However, the currently available evidence-based programs, which mostly focus on social skills, are scarce and have demonstrated limited efficacy2,3. The emotional or cognitive deficits that have been shown to be associated with offending or CD4,5 could be good candidates for alternative or additional skills training programs. Yet to date most studies identifying them compared extreme groups, i.e. CD diagnosed adolescents or incarcerated juvenile offenders with pupils of the regular school curriculum, without controlling for important confounding factors such as comorbid mental disorders, and particularly substance use disorders. Some of the differences we will review might thus be overestimated. One century of research has repeatedly established the existence of a negative relationship between IQ and offending or CD, but only in the past decades has extensive examination suggested it to hold only for verbal IQ6. Given the typically low level of academic achievement of delinquent youths, this finding could be partly explained by their lack of exposure to the kind of information assessed by verbal IQ tests7. Measures of intelligence unrelated to education (e.g. non verbal intelligence), or culture-free tests, might thus fit better this population. More so as research using them found no differences between youths with and without CD8,9. Findings from extensive scientific research focusing on executive functions, suggest that two types of dysfunctions are strongly involved in delinquency. Firstly, deficits in cognitive flexibility10, in particular the ability to shift cognitive set according to changing contingencies, have been described using the Wisconsin Card Sorting Test11: adolescents with CD seem to perform more poorly than community controls5,12, although some found them to perform equally well13. Secondly, deficits in inhibition are well documented14-16, in particular in some aspects of behavioral inhibition, such as the ability to refrain from responding before the stimulus is fully processed, as measured by the behavioral task of Immediate and Delayed Memory, IMT/DMT17: this type of impulsive behavioral response was observed more frequently in adolescents with disruptive behavior18,19 or with CD20,21, compared with community adolescents. Impairments in emotional regulation also appear to play an important role in delinquent behavior. Apart from the executive function research approach mentioned above, impulsivity has also been extensively investigated in offenders as a personality trait22,23, using questionnaire measures. Higher levels of trait impulsivity were consistently observed in adolescent offenders6,24 or with CD25 compared to adolescents from the general population. Nevertheless, using more differentiated measures of trait impulsivity such as the UPPS scale26, externalizing problems were found to be associated with only some of the four investigated dimensions27. Another important concept related to emotional regulation, though more scarcely investigated, is alexithymia, meaning the inability to recognize and describe feelings, and an externally oriented way of thinking28. Higher levels of alexithymia have been documented in male adolescent offenders, compared to community adolescents29,30. However, these results remain to be replicated in adolescents with CD. PROFILE OF MALE ADOLESCENTS WITH CONDUCT DISORDER 217 Constructive thinking is yet another pro mising concept, covering the use of functional cognitive coping styles in stressful situations31: adolescent girls with CD reported to use less constructive and more destructive coping strategies than their counterparts from the general population32. However, this result has not yet been replicated in boys. Although the literature reviewed has shed light on features of cognitive and emotional functioning that might characterize adolescent offenders and, in some cases, adolescents with CD, they share a number of methodological shortcomings. Firstly, most of the studies have used control groups consisting of community adolescents, recognized as presenting, among other potentially confounding factors, a much lower prevalence of psychiatric disorders (particularly substance use disorders)1,33. The latter were often not controlled for in analyses, and might be responsible for part or all of the observed differences between the two groups. Secondly, cognitive and emotional deficits have predominantly been studied separately, despite a growing body of evidence underlining their interdependence34,35. The present study thus aimed at assessing simultaneously the reviewed cognitive and emotional deficits, comparing male adolescents with CD to high-risk adolescents presenting similar rates of other psychiatric disorders, and controlling for problematic substance use in all analyses. We expected some of the documented differences not to be replicated in this more stringent design.