Characteristics and Outcome of Hospitalized Adolescent Girls with Conduct Disorder MARK ZOCCOLILLO , M.D. ,

AND

KATHY ROGERS , R.N. , M.S .N .

Abstract. Fifty-five adolescent girls with conduct disorder from a psychiatric hospital were examined with a structured interview schedule and then reevaluated 2 to 4 years later. The majority also had depressive or anxiety disorder s. The criteria used for conduct disorder were less weighted toward violent crime and differed from the criteria in DSM-llI-R. Their outcome was poor; 6% had died a violent death , the majority had dropp ed out of school, one-third were pregnant before the age of 17, half were rearrested , and many suffered traumatic injuries. Diagnos es of depression or anxiety disorder s at the index admission were not associated with a better outcome. J . Am. Acad. Child Adolesc. Psychiatry. 1991, 30 , 6:973-981. Key Words: conduct disorder, females, outcome, mortality.

Even though conduct disorder is the second most common psychiatric disorder in adolescent girls (Kashani et al., 1987; McGee et al., 1990), there are very few studies of the outcome of conduct disorder in girls. A recent review has noted that most outcome studies of conduct disorder focused on boys or treated all children with conduct disorder together without examining girls separately (Robins, 1986). Recent studies of adult outcome of antisocial women have relied on retrospective data from adult interviews (Robins, 1986; Robins and Price , 1991; Zoccolillo et al., submitted manuscript) , or did not use clinical diagnoses of conduct disorder (Serbin, 1990; Werner , 1990), or only presented data on a small sample of women (Robins, 1966). These studies have found that women , compared with men , are less likely to engage in adult criminal offenses but have diffusely poor outcomes, including nonantisocia1psychiatric disorders, serious difficulties with interpersonal relationships, use of social services, and early pregnancy. One study has found increased mortality from unnatural causes in antisocial girls (Rydelius , 1988). Two other studies did not find increased mortality (Kuperman et aI., 1988; Robins, 1966). The purpose of this study is to describe the initial characteristics and outcome of a relatively large (55 subjects), prospectively studied sample of adolescent girls with reAccepted June 20, 1991 . Dr. Zoccolillo is Assistant Prof essor, Department of Psychiatry. University of Colorado Health Science Center, Denver, Colorado, and Kathy Rogers is Research Assistant, Department of Psychiatry and Neurology, Texas Tech University Health Sciences Center, Regional Academic Health Center, Amarillo, Texas. This work was supported in part by NIMH Small Grant No , l-R03 MH44608-0l , the Harrington/Amarillo Area Foundation, and the Southwest Institute for Addictive Diseases. The authors would like to thank the staff of Crossroads (the adolescent psychiatric unit of Northwest Texas Hospital), the administration and medical records staff of the Pavilion of Northwest Texas Hospital, and Jane King, Chief Juvenile Probation Officer. and the staff of the Randall County Juvenile Probation Office for their assistance in this study. Reprint requests to Dr. Zoccolillo, Suite 120, 1611 Federal Blvd. , Denver, CO 80219. 0890-8567 /9113006-0973$03 .00/0© 1991 by the American Academy of Child and Adolescent Psychiatry. J .Am.Acad . Child Adolesc.Psychiatry , 30 :6, November 1991

search diagnoses of conduct disorder from a psychiatric hospital. Outcomes examined include mortality, dropping out of high school , being fired from a job , pregnancy and childbearing, suicide attempts, institutionalization , and accidents. The effects of the number and type of conduct disorder symptom s and codiagnoses of depressive or anxiety disorders at the index admission on later outcome are also examined. The criteria for conduct disorder used in this study differ from those in DSM-Il/-R. They are less weighted to violence and criminality than those in DSM-III-R and may be more appropriate for conduct disorder in female subjects. Another purpose of this study is to test the validity of these criteria by outcome. Method

All girls ages 13 to 16 admitted to a locked adolescent short-term psychiatric unit during two time periods in 1987 and 1988 and a parent were asked to participate in an interview study (Table 1). At the time of the study , the psychiatric unit was the only one within a 2-hour driving distance and was a nonprofit facility affiliated with a general community hospital. The emergency room of that hospital was the only psychiatric emergency room and pediatric emergency room within a 2-hour driving distance. The approximate population within a 20-minute drive was 200,000. After being interviewed with a structured interview, a modification of the Diagnostic Interview Schedule (mS) (Robins et al. , 1981), only subjects who met the study diagnosis of conduct disorder and were not psychotic were retained in the study. Subjects could also have multiple other diagnoses, such as major depression or anxiety disorders. Information from both the parent and subject interview were used to decide if a patient met the study criteria for conduct disorder. The index data reported in this study is, however, only from the subject interviews. The study diagnosis of conduct disorder was two or more symptoms occurring before the age of 15, modified from criterion B (childhood symptoms ) of the DSM-III diagnosis of antisocial personality disorder . This definition of conduct disorder was chosen because Robins and Price (1991), Robins (1986), and Zocco1illo et al. (submitted manuscript) 973

ZOCCOLILLO

have found it is associated with a poor adult outcome in both men and women, and these symptoms were derived from the original empirical work by Robins (1966) on antisocial personality disorder (Feighner et al., 1972; Williams and Spitzer, 1982). These symptoms are also used in the National Institute of Mental Health Epidemiologic Catchment Area study (Regier et al., 1984) of psychiatric disorder in the U.S. general population, and results from this study can be compared with national findings. The symptoms required and their frequency in the subjects meeting the criteria for conduct disorder are listed in Table 2. The patient's medical record from the index admission was reviewed and data obtained on length of stay, route of admission, pay status (insurance, Medicaid, indigent, or self-pay), admitting physician, one main or precipitating reason for admission, discharge diagnosis by the patient's physician, and treatment. In January and February of 1991, an attempt was made to interview all the subjects and a parent or other informant by telephone. The telephone interview covered job history, marital status, pregnancy and childbearing, education, criminality, suicide attempts, running away, institutionalization, and accidents. Subject and informant telephone interview data were merged into one record, with preference given to positive information. For example, if a subject reported no arrests since the index admission but a parent reported a definite arrest, then the parent's report was used. The subject data were used where the other informant was not certain if an event had occurred. The interviewers. The first author is a psychiatrist with experience with the DIS (Zoccolillo et al., 1986). The second author is a psychiatric nurse practitioner with experience with the precursor to the DIS, the Renard Psychiatric Diagnostic Interview (Robins et al., 1981). Halfway through the index study, she was also formally trained at Washington University in the DIS. Most of the index interviews were done by the second author. The follow-up telephone interviews were done by the first author. The index interview. The interview used was a highly modified form of the National Institute of Mental Health Diagnostic Interview Schedule (Robins et al., 1981). This interview was chosen for two reasons. First, a follow-up is planned in early adulthood, using the DIS. Using the same instrument at both times allows for comparison of the subject's recall over time of psychiatric symptoms. Second, the results can be compared directly with results from the Epidemiologic Catchment Area study (Regier et aI., 1984), because the instruments are similar. The interview was modified in several areas. The probe chart, which is used by lay interviewers to decide if a psychological symptom was medically explainable or caused by drugs or alcohol, was eliminated as the interviewers were clinically trained and appropriate questions substituted. The section on substance abuse in the DIS is weighted toward symptoms of dependence, tolerance and medical complications, symptoms likely to be infrequent in this population. The new section focused on age of onset, frequency of use, and social problems from use. Questions elsewhere in the interview covered medical complications. Bulimia was also 974

not covered in the DIS at the time of this study, and questions based on the DSM-III diagnosis of bulimia were added to the interview. Interviews with 20 subjects (including some subjects who were not in this study) were audio-taped and rated by the other interviewer and diagnoses determined by DSM-III criteria. Kappa, a statistical measure of agreement correcting for chance (Fleiss, 1981), was computed for agreement by the two interviewers on the DSM-III diagnoses (without exclusion criteria). There was acceptable agreement for major depression (1.0), conduct disorder (0.7), alcohol abuse (0.76), drug abuse (0.89), panic disorder (1.0), anorexia nervosa (0.64), and bulimia (0.64). Kappas were not acceptable for phobic and obsessive-compulsive disorder. The original questions in the DIS about phobias and obsessivecompulsive disorder asked simultaneously about the presence of the symptom and impairment. It was found that subjects often answered yes but on further questioning did not have the distress or impairment required for a diagnosis. Specific questions were added on impairment and kappas computed for another 20 subjects, with kappas of 0.71 for phobia and 1.0 for obsessive-compulsive disorder. Diagnoses were made by DSM-III criteria (except for conduct disorder), but exclusionary criteria were ignored. Diagnoses were coded as probable if it was uncertain if one criterion was met. For example, for major depression, a subject who met criterion A and three of criteria B but reported one additional criterion from Blasting 10 to 14 days, would be given a probable diagnosis. The frequency of diagnoses reported includes both definite and probable diagnoses. All the interviews were reviewed by the first author and lifetime diagnoses were assigned by him. For the first group of interviews (that were not reliable on assessing phobic or obssesive-compulsive disorder), there was sufficient information on the audio-tapes to decide on diagnoses of phobic and obsessive-compulsive disorders. A comparison between the frequencies of phobic and obsessive-compulsive disorders in the first set of subjects and the set with the modified interviews showed no differences in the frequencies of the disorder. Diagnoses assessed were alcohol abuse, drug abuse, major depression, panic disorder, phobic disorder, obsessive-compulsive disorder, bulimia, anorexia nervosa, and mania. There was no section of schizophrenia or other psychotic disorders, as these subjects were excluded from the study. Data management and statistical analysis were done using the computer program Systat (Wilkinson, 1990).

Results Table 1 shows the number of subjects at each stage of the study. The results are reported separately for the index interview and the follow-up interview.

The Index Assessment Of the 15 girls not interviewed for the index interview, three were outright refusals by the parent, one girl had been admitted directly from a residential treatment center for crisis management for a few days only, one girl was too l.Am.Acad. Child Adolesc.Psychiatry, 30:6, November 1991

OUTCOME OF CONDUCT DISORDER IN ADOLESCENT GIRLS TABLE

I. The Sample

Girls ages 13-16 admitted during index study period (1987-1988) Number of girls interviewed Number of girls with conduct disorder Number of girls followed up (any data) (January-February , 1991) Number of girls with telephone interview data (subject and/or other informant) Number of girls interviewed Number of girls with informant interviews

T ABLE

76 61

55 53 50

35 47

uncooperative to be interviewed and was transferred to a state facility, two girls ran away before they could be interviewed, one girl was not interviewed because of low intelligence, and seven girls were not interviewed because they were hospitalized for a few days only (usually because of lack of funding) and the interviewer was not able to interview the subjects before dismissal. None of the girls admitted during the study period had a psychotic or manic disorder. The remainder of the paper reports only on the 55 girls with conduct disorder.

Characteristics of the Sample on the Initial Assessment Demographics. Forty-nine (89%) of the girls were white , three were black, and three were Hispanic. Twenty percent were 13, 24% were 14,31 % were 15, and 25% were 16 years of age. Seventy-one percent were covered by private medical insurance, 9% by Medicaid , 15% were indigent, and 5% were from families not covered by private insurance but not indigent (self-pay). Admission characteristics and physician diagnoses. Fortynine of the 55 subjects (84%) had no previous hospitalizations for psychiatric problems or substance abuse. Forty of the 55 (73%) had never seen a physician for psychiatric problems or a mental health professional before the index admission. Thirty-five percent were admitted directly from the emergency room, 13% came from pediatric or intensive care beds after medical treatment for suicide attempts, 51 % were direct admissions to the psychiatric hospital, and one subject was transferred from an inpatient substance abuse unit at another hospital. The one precipitating reason for admission was suicide attempts (38%), suicide threats (16%) , running away (20%), family conflict (9%) , worsening antisocial behavior (two subjects), worsening depression (two subjects) , alcohol intoxication (one subject), increased obsessional worrying, paranoid ideation, and anxiety and depression (one subject) , suspension from school (one subject), admitted to a substance abuse unit but found to have conduct disorder and transferred (one subject) , and associating with an adult male felon known to be extremely violent to women (one subject). Thirty-eight percent of the subjects were admitted by the first author and the remainder by three other physicians. Physicians' diagnoses were major depression (24%), dysthymia (15%), conduct disorder (24%), conduct disorder and major depression/dysthymia (9%), conduct disorder and l.Am .Acad. Child Adolesc .Psychiatry, 30:6, November 1991

2. Definition and Frequency of Conduct Disorder Criterion Symptoms (N = 55)

Chronic violations of rules at school Chronic lying School grades below expectations Two or more fights Repeated drunkenness or substance abuse Running away from home overnight More than one theft Chronic violations of rules at home Suspended or expelled from school Delinquency Promiscuity (three or more sex sexual partners or sex for money or drugs) Truancy (at least 5 days in a school year) Vandalism

73% 67% 60% 49% 42%

40% 36%

35% 31% 24% 22%

15% 13%

somatization disorder (7%) , adjustment disorder (7%), oppositional disorder (one subject), conduct disorder and substance abuse (5%) , major depression , rule out bipolar disorder, and severe obsessive-compulsive traits (one subject), major depression and somatization disorder (one subject), major depression and substance abuse (one subject), and dysthymic disorder, schizoid personality (one subject). The mean length of stay for the index admission was 26 days , with a range of two to 92 days . Thirteen subjects were treated with medication, 12 with antidepressants only, and one with multiple medications. Treatment for most subjects included family therapy, individual psychotherapy, and an individualized behavioral program with rewards and consequences for participation and work on specific goals.

Research Diagnoses Conduct disorder symptoms (Table 2). The mean number of self-reported conduct disorder symptoms was 5, with a range of 0 to 12 symptoms. Three subjects reported less than two symptoms, but a review of the parent interviews showed that all three girls had at least three criterion symptoms of conduct disorder. Eighty-seven percent of the sample reported three or more symptoms of conduct disorder; 60% reported five or more symptoms. Whereas 27 girls (49%) had been involved in at least two physical fights, an additional 10 had been in one fight. Of the girls who fought, the mean number of fights reported was six, with a range of one to 30. Ten girls reported being in 10 or more fights, and one additional subject could not quantify the number of fights beyond "a bunch." These fights were usually with other girls. Thirteen subjects (24%) had been arrested by the police or had contact with the juvenile justice system. Reasons for police or juvenile authority involvement were running away (five), stealing father's car (one), running away and fighting with mother (one) , being with friends who stole (two) , assaulting a police officer (one) , running away and stealing a truck (one), and, running away and theft (one). One additional subject had been arrested at age 13 after the death of a young child she was babysitting. No criminal charges were pursued, but a civil suit against the subject for causing the death of the child was settled out of court and the subject 975

ZOCCOLILLO AND ROGERS TABLE

3. Affective, Anxiety, and Eating Disorders (Definite and Probable) (N = 55)

Major depression Phobic disorder Obsessive-compulsive disorder Panic disorder Anorexia nervosa Bulimia None of the above One of the above Two of the above Three of the above Four of the above

T AB LE

31% 45% 16% 4% 7% 5% 42% 29% 13% 11% 5%

was not allowed to babysit again by her parents. One other subject had run away to California to be a prostitute, had been beaten and raped, and put in a juvenile detention facility for her protection until an emergency shelter could be . found. Affective, anxiety, and eating disorder diagnoses. Lifetime prevalence rates are presented in Table 3. The percentage of subjects with one or more of these diagnose s is also presented. Substance abuse. Eighty-nine percent had used drugs or alcohol. A wide range of drugs was used: alcohol 89%; amphetamine or cocaine 25%; hallucinogens 18%; marijuana 55%; inhalants, phencyclidine, sedative hypnotics 3% to 5%; and other drugs 13%. Sixty-five percent had problems from alcohol or drug use , and 24% met DSM-III criteria for drug or alcohol abuse . No subject had medical complications (other than passing out from overintoxication) or withdrawal symptoms needing medical attention from substance abuse.

Relationships between Conduct Disorder Symptoms, Substance Abuse, and Affective/Anxiety Diagnoses Age relationships. The mean age of onset of diagnoses and selected symptoms are presented in Table 4. The age of onset of conduct disorder for subjects with a codiagnosis of major depression was 9; for subjects with phobia, 8; and for subjects with obsess ive-compul sive disorder, 7.8. . Number of self-reported conduct disorder symptoms in subjects with and without emotional disorders . The number of conduct disorder symptoms by self-report was examined in subjects with conduct disorder with and without cooccurring diagnoses of major depression or any anxiety/depressive disorder . The mean number of symptoms of conduct disorder was 4 (range , 0-7) in subjects who also had a diagnosis of major depression and 5.5 (range, 1-12) in subjects who did not have a diagnosi s of major depression , a significant difference (p < 0.05). The mean number of symptoms of conduct disorder was 4.9 (range, 0-11) in subjects with any emotional disorder (major depression , phobia, panic, or obsessive-compulsive) and 5.2 (range, 112) in subjects without an emotional disorder, an insignificant difference. Three subjects reported zero or one symptom of conduct disorder but had entered the study based on a parental report of two or more symptoms of conduct disorder.

976

4. Age of Onset (Years)

First symptom of conduct disorder Phobic disorder Obsessive-compulsive disorder First use of alcohol or drugs Major depression

8.2 9.8 11.3 12.4

13.5

Follow-up Table 1 presents details on the number of subjects followed-up. Of the two subjects' families who could not be found, one had an unlisted number and the other had no telephone. Letters to both families were not answered . Of the remaining 53 girls, one mother refused to participate or allow her daughter to participate, stating her daughter was "well." One subject and her family could not be found but had been admitted by the first author to the hospital after a suicide attempt 26 months after the index admission , and considerable information was available from the admission note. One subject died 2 months after the index admission , and her mother could not be found for interview; only details of the cause of death are available. Thirty-one mothers, nine fathers, and seven other informants (including aunts, grandparents, and adult friends ) were interviewed. The reasons for not interviewing the 15 subjects on whom other informant interviews were available were as follows: no telephone or telephone number not known (eight), refused to be interviewed (three), in a residential treatment center (one) , hiding from the law (one) , and death (two) . Excluding the subjects who died , the length of followup was between 48 and 21 months; all but one had a followup of 24 months or more . Two-thirds had a follow-up period of 3 years or more. The ages at follow-up were 15 to 20; 24 were between the ages of 15 and 17, and 25 between the ages of 18 to 20. Forty-nine were white, two were black, and two were Hispanic. A summary of the outcome of these girls is presented in Table 5. The events in the table are occurrences since the index admission , except for accidents and pregnancies . Accidents were not covered in the index interview; to cover a period spanning adolescence, accidents since age 11 were covered in the outcome interview . The index interview only covered childbirth but not interrupted pregnancies, and it was decided to cover all pregnancies as part of the outcome interview. Because pregnancies before age 17 are considered medical "high-risk" pregnancies and are also not socially desirable, this outcome was also examined. Mortality. Circumstances of the deaths of the three fatalities are presented below . All three fatalities were white, and two came from families with private medical insurance. Case no. 067. At the index interview , the patient had seven symptoms of conduct disorder and a DSM -Ill diagnosis of both alcohol and drug abuse . After her discharge, she was placed in a residential treatment center but convinced her parents to discharge her against the advice of the center. She was readmitted to the psychiatric hospital and then transferred to a substance abuse program in a state hospital for 4 months. Three weeks after discharge , she l.Am.Acad. Chi/dAdolesc . Psychiatry, 30:6, November 1991

OUTCOME OF CONDUCT DISORDER IN ADOLESCENT GIRLS TABLE

5. Outcome

Dead (53)a 3 (6%) Education (49) Still in high school 13 (26%) Graduated 7 (14%) 20 (41%) Dropped out permanently 5 (10%) Dropped out but returned Expelled and did not return 4 (8%) Obtained general equivalency degree (of those dropped out or expelled) (20) 5 (25%) Suspended or expelled from school since 12 (24%) index interview Arrested or juvenile probation contact (50) 25 (50%) Psychiatric hospitalization (50) 19 (38%) Placement in children's home or long-term treatment facility (51) 16 (35%) Suicide attempts (50) II (22%) Runaways (50) 24 (48%) Fired, of those who held a job (39) 8 (21%) Motor vehicle accidents since age 11 (50) 26 (52%) Requiring medical care 14 (28%) Ever pregnant (50) 25 (50%) Pregnant before age 17 16 (32%) a Number in parentheses indicates number on whom information is available.

TABLE

Case no. 003 Convicted of forgery by passing, age 17, 4 years adjudicated

probation. 012 Arrested asjuvenile fordrugs andminor outofcontrol, placed

on probation. 015 Arrested and convicted of public intoxication age 16, put on

probation 016 Placed inresidential treatment byjuvenile probation fortruancy

023 034

039 040 041 042

043 048

began using drugs and alcohol again and was thrown out of the house by her parents. Three weeks later at a party a 24-year-old man borrowed a motorcycle and took the subject for a ride. He drove at high speed into the back of a car. The subject was killed instantly, and the man was severely injured. Alcohol and marijuana were found in his blood stream. She was 16 at the time of her death. Case no. 080. At the index interview, the subject had four symptoms of conduct disorder and met DSM-III criteria for phobic disorder, obsessive-compulsive disorder, anorexia nervosa, major depression, and drug and alcohol abuse. Shortly after the index interview, the patient and her family moved to another part of Texas, where she entered the Job Corps. Two months after the index admission, she was strangled to death. According to the investigating officer, she had met her murderer for the first time 1 or 2 days before her death. She willingly accepted a ride by him on the day of her death. He was convicted and sentenced to 75 years in prison. He did not confess his crime, and the motive remains unknown. She was 16 at the time of her death. Case no. 082. The patient had five symptoms of conduct disorder at the index interview and no other diagnoses. After her discharge, she was placed in a residential treatment center. She ran away and was not found for 6 weeks. She returned home for 4 months but continued to be defiant, to run away, and to be truant from school. She went to live with an aunt for 8 months, with the same pattern of behavior. She was then placed at a runaway shelter, where she ran away twice. On the second runaway, she left with another girl and spent two nights in motels known to be associated with prostitution and with a man known to be a pimp. Thirtysix hours before her death, this man was picked up by the l.Am.Acad. Child Ado!esc. Psychiatry, 30:6, November 1991

6. Criminality

and running away. Ran away from residential treatment to another state. Has told father she will not return to Texas or give out her address until she turns 18 and is no longer on probation. Failed to pay traffic ticket. Arrested and fined $100.00 Several arrests forrunaways. Onlastarrest, kicked thepolice officer who fell anddislocated his shoulder. Convicted of assault on a police officer, placed on probation. Convicted of shoplifting, age 18, given 6 months deferred probation. Arrested for not paying traffic tickets. Convicted of driving while intoxicated, age 19, put on probation. Stopped for unpaid traffic tickets, then cursed several police officers. Spent weekend in jail, now paying off multiple fines. Convicted of narcotics violation, age 16, on probation for 6 months. Convicted of minor in possession of alcohol, age 16, fined

$40.00 049 Put in jail overnight for public intoxication at age 18, court

case pending. 050 Arrested as juvenile for trespassing in vacant home and run-

aways, puton informal probation. 051 Stole mother's boyfriend's carwith another girl,then wrecked

061

064

083 086

it. Convicted of auto theft andrunaways, puton probation and sent to court-ordered residential treatment. Probation for truancy and runaways. Husband and subject (age 17) arrested for shooting out bedroom window of subject's ex-boyfriend with a shotgun. Subject charged with evading arrest and carrying a concealed weapon (butcher knife). Husband charged with possession of a prohibited weapon. Court case pending. Arrested for driving while intoxicated, age 17, court case pending. Arrested for truancy and assaulting mother, placed on voluntary probation.

police because he was with the two girls but later released. The next night, he stole a car and drove it with the two girls into a train at high speed at a railway crossing, going around the barrier arms and past the flashing lights. All died. The subject and the man both had high blood alcohol concentrations. She was 15 at the time of her death. Marriage. Twelve had been married, and nine were still married. One subject was divorced, one was separated, and one subject was widowed (her husband had died in a late night car accident involving alcohol and may have been driving). Education. Of those who had dropped out or been expelled (and not returned), over half had not completed the tenth grade, and one subject had only completed through the sixth grade. All of the 15-year-olds were still in school 977

ZOCCOLILLO AND ROGERS

without interruption of their education , as were seven of nine 16-year-olds. Only 29% of the 17- to 20-year-olds had graduated or continued in school without interruption. Criminality. Six of the 25 subjects had only been in trouble with the law for running away . The reasons for legal contact of the others are presented in Table 6. Even though several subjects had court cases pending, none was incarcerated at the time of follow-up . Pregnancy, abortions, and children. Fifteen had been pregnant once, seven twice, two three times, and one four times. Of those who become pregnant, one-fifth had an abortion, and seven had a miscarriage or stillborn baby . Fourteen of the 25 had one or more live deliveries. Ten had had one child, and four had two children. Four mothers had given up one or more children for adoption. Twelve had one or more of their own children living with them. Two first became mothers at age 16, six at age 17, one at age 18, and three at age 19. Of the 12 who had children living with them, six had been married . Of those six, one was separated from her husband . Accidents. In addition to the 14 subjects who had been in motor vehicle accidents requiring medical treatment, three of the subjects in accidents not requiring medical care had "totalled" their car, and all three had been driving. Fifteen of 49 (31%) had been in nonmotor vehicle accidents requiring medical care. For eight subjects, the accidents were due to sports injuries, trivial accidental cuts requiring stitches, or details were not given. For seven subjects, the accidents were more serious or the results of antisocial behavior: one subject had her tongue torn during a fight with two other girls and required stitches, one girl had her head rammed into a metal bar during a fight with another girl and required stitches, one girl was beaten and severely bruised by her father as punishment for antisocial behavior, one girl almost drowned on a church picnic, one girl was beaten and raped while working as a prostitute then had a ruptured ectopic pregnancy, one girl was treated for a rape, and one girl had multiple emergency room visits for hand injuries from punching walls. Composite outcome. How many subjects had a normal outcome? Normal is defined as graduating from high school without interruption (or continuing in school if younger than age 18), not becoming pregnant before age 17, no contacts with the legal system, not being fired from a job, and not being placed in a children's home or residential treatment facility. Only six subjects out of 51 (12%) had such an outcome. One of those six was only 16, had married at age 15, and had repeated the ninth grade because of persistent truancy. A summary measure of multiple problems was made by summing four problem areas: fired from a job, high school education interrupted, pregnant before age 17, and arrests or legal contact since the index admission. Excluding the subjects who died, 14% had no problem areas, 33% had one problem, 35% two problems, and 18% three problems. The effect of comorbid depression and anxiety disorders on outcome. The outcome of criminality, interruption of schooling, pregnancy before age 17, and being fired from a job was examined in subjects with and without lifetime 978

codiagnoses (at the index interview) of major depression or anxiety disorders (panic , phobia, or obsessive-compulsive disorders). Two categories were examined: major depression with or without other anxiety disorders, and subjects with any anxiety disorder or major depression. A difference of 15 percentage points was considered meaningful (but not necessarily statistically significant). Educational disruption, criminality, and being fired from a job were not meaningfully different in subjects with and without major depression: 56% versus 61%, 50% versus 50%, and 29% versus 16%. Pregnancy before age 17 was less common in subjects with depression: 19% versus 41 %, a difference that was not statistically significant. To examine this further, the frequency of ever being pregnant was examined in subjects with and without major depression: 37.5% versus 56%, a statistically insignificant difference. Of the six subjects with major depression who had children, two had first become pregnant at age 15, one at age 16, two at age 17, and one at age 18. When subjects with depression or anxiety disorder were compared with subjects with no emotional disorders, there were no meaningful differences on education disruption (59% versus 60%) , criminality (50% versus 50 %), pregnancy before age 17 (32% versus 35%), and being fired (23% versus 18%). Initial conduct symptoms and later outcome. The correlations between the number of criterion symptoms at the index interview or age of onset of the first conduct disorder symptom and the summary measure of poor outcome were low (0.132 and - 0.132) and statistically not significant. There was also no meaningful pattern between the number of index symptoms of conduct disorder and any of the individual outcomes of education disruption, criminality, pregnancy before age 17, or having been fired from a job. Individual symptoms of conduct disorder were also crosstabulated with the four poor outcomes. Only differences of 15% or greater were considered to be potenially meaningful. Of 48 comparisons (12 conduct symptoms by four poor outcomes), only 19 showed a difference of 15% or greater between subjects with and without the conduct disorder symptom, and only three comparisons approached statistical significance (p < 0.1) , using Yates' corrected chi-square. The three comparisons were fights by interrupted education (74% versus 46%, p = 0.09), promiscuity by educational interruption (89% versus 50%, p = 0.08), and promiscuity by pregnant before age 17 (67% versus 22%, p = 0.03). Individual symptoms were not good predictors of outcome. Effect of pay status. Indigent or Medicaid subjects were just as likely as insured or self-pay subjects to have a cooccurring diagnosis of major depression (23% versus 33%) or any emotional disorder (54% versus 60%) . The mean number of conduct symptoms was somewhat greater in indigent or Medicaid subjects (4.8 versus 5.8) but not significantly so. Outcome was significantly worse for indigent or Medicaid patients only for interrupted education: 91 % versus 50% (p < 0.05). The respective comparisons for pregnant before age 17 is 40% versus 32% ; for criminality, 60% versus 47%; and fired from a job, 29% versus 19%. On the sumJ. Am. Acad. Child Adolesc . Psychiatry, 30:6, November 1991

OUTCOME OF CONDUCT DISORDER IN ADOLESCENT GIRLS

mary rating of all four outcomes, the comparisons for indigent/Medicaid versus insured/self-pay were none (0% versus 18%), one problem (27% versus 34%), two problems (45% versus 32%) , and three problems (27% versus 16%).

Discussion Before discussing the implications of these findings , it is important to consider two limitations of this study . The first is the lack of a comparison group . National statistics on mortality, pregnancy, and high school dropout are available for comparison, and some comparisons are made below . The second limitation is whether this sample is so unique that no general conclusions can be made. U.S. census data from the Statistical Abstract of the United States (U.S. Bureau of the Census, 1990) and Blum (1987) provide some comparable data on mortality, high school dropout , and pregnancy rates. Where appropriate, 95% confidence intervals on the sample findings using the Geigy Scientific Tables (Lentner, 1982, Tables 89 and 90) have been computed; if the intervals do not contain the population figure, then it is unlikely that sampling error is responsible for the difference (Gardner and Altman , 1990). The mortality rate can only be compared indirectly to national statistics. The death rate in 1987 for white women aged 15-24 from violent death (accidents, homicide , and suicide) was 0 .034% (U.S . Bureau of the Census, 1990, Table 122), compared with the study figure of 6%. Another population statistic available is expected deaths over the next year per 1,000 live subjects (U.S. Bureau of the Census , 1990, Table 106). For white women , the expected number of deaths from all causes between each successive year from ages 13 through 19 vary from 0.023% to 0.053%. Because the mortality rates are not cumulative, direct comparisons cannot be made to the sample rate. Nonetheless, the mortality rate in the study sample is considerably greater than population data would suggest is the norm for adolescent white women. The pregnancy rate in Texas in 1980 for girls aged 15 to 17 was 7.36% (Blum, 1987). A comparable rate in the study sample is the pregnancy rate of girls in the 12 months before the interview . Of 26 girls aged 15 to 17, nine or 35% (95% confidence interval 17.2% to 55 .7%) had been pregnant in the previous 12 months . The proportion of white women in the U.S . in 1988 who were high school dropout s (defined as persons not in regular school and who have not completed the 12th grade or received a general equivalency degree) was 7.1 % of 16- to 17-year-old white girls and 14.2 % of 18- to 21-year-olds (U.S. Bureau of the Census , 1990, Table 248) . The study figure for 16- to 17-year-olds is nine of 23, or 39% (95% confidence interval 19.7% to 61.5 %), and for 18- to 20year-oIds, it is 10 of 24, or 42% (95% confidence interval 22.1% to 63.4%) . Comparison with national figures indicates that the outcome of these girls is much worse than expected and that these differences are unlikely to be due to sampling error. Could these outcomes be due to unique characteristics of this sample? Only replications in other samples can determine how generalizable these findings are. What can be l .Am.Acad. Child Adolesc.Psychiatry,30:6, November 1991

said is that the social setting from which these girls came does not explain these findings and that they are not a highly referred and selected population. Social setting does not explain these findings because most of the girls were white , most came from families able to affort private health care , and most came from neighborhoods that would not be considered disadvantaged. The schools they attended were not schools with high drop-out rates; the drop-out rate for area schools in 1989 to 1990, all sexes and races, seventh through 12th grade, was 3.3% (personal communication, Amarillo Independent School District). Even though hospitalized , this was not a highly referred sample or a sample of previous treatment failures. Most had no previous hospitalizations or mental health treatment of any kind. Because this was the only psychiatric hospital in the region at the time of the study, there was no selective referral bias; the girls admitted are representative of those in the area thought by their family or the community to need treatment. The findings from this study are probably generalizable to the general population of girls in psychiatric hospitals with diagnoses of conduct disorder. Another important issue to consider is whether this sample, with a wide variety of pathological behaviors, including high levels of internalizing disorders , would meet more narrow criteria for conduct disorder that emphasized illegal or aggressive behavior. One way to examine this is to examine how many subjects had involvement with the criminal justice system at any time during the study period or marked aggression (10 or more physical fights , excluding fights with siblings). Thirty-seven of 55 subjects met this criterion , or two-thirds of the sample . Even by this narrow definition, this group would be diagnosed as having conduct disorder. What are some implications of these findings? First, conduct disorder in girls is a significant health and social problem. Its neglect by researchers is not justified by either its prevalence (the second most common disorder in adolescent girls) or poor outcome. Future studies on conduct disorder should not focus solely on boys, and studies of conduct disorder in girls should examine different areas of functioning to give the full picture . If, for example, this study had focused solely on felony criminal convictions, the poor overall outcome would have been missed. This study has focused on the natural history and symptoms of conduct disorder in girls but does not address factors that lead to the development , continuation, or amelioration of conduct disorder. Future studies will need to address such issues as family psychopathology, social support, and different types of treatment on the development and outcome of conduct disorder in girls . Second , consideration should be given to adopting the criteria used in this study as diagnostic criteria for conduct disorder in future editions of the Diagnostic and Statistical Manual of the American Psychiatric Association because these criteria will be less likely to miss conduct disorder in girls. Some of the most common symptoms of conduct disorder in this sample (school problems, discipline problems at home, early substance abuse, and promiscuity) are not even criterion symptoms in DSM-III-R. The DSM-III979

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R symptoms of vandalism and fire setting are very uncommon, as are three other symptoms (as reflected in arrests and questions about fights): breaking into someone's else's property, using a weapon in more than one fight, and stealing with confrontation. One other symptom, forcing someone into sexual activity, must be decidedly rare for female subjects. It is likely that the DSM-III-R criteria will grossly underdiagnose female subjects with conduct disorder. One possible concern about the criteria used in the study, as compared with the DSM-III-R criteria, is that they may identify too many girls with transient behavioral problems. The results from this study show that is not the case in those girls who are psychiatrically hospitalized. Robins (1986) and Robins and Price (1991) have examined the psychiatric outcome of men and women with histories of conduct disorder, using similar criteria in a general population sample, and also found poor outcomes. This suggests that these criteria identify subjects in general population samples who later have a poor outcome. Third, the findings in this study are similar to previous findings by Robins (1986) and Robins and Price (1991): conduct disorder predicts a poor outcome regardless of the presence of other psychiatric disorders. Even though the girls with conduct disorder and major depression had an average one and a half less conduct symptoms at the index interview, their outcome, including arrests, did not differ from subjects without a diagnosis of major depression. An additional confirmation that these are girls who have conduct disorder and not conduct symptoms secondary to another disorder is that the age of onset of the conduct disorder precedes the other disorders; in the case of major depression by 5 years. A practical implication of this finding is that clinicians diagnosing and treating adolescent girls meeting the criteria of conduct disorder who also have other diagnoses (such as major depression) should diagnose and treat the subject as having two separate disorders. Although the emotional disorder may be the salient diagnosis and more treatable, it is the conduct disorder that will significantly determine the long-term prognosis. Could the high rates of depression and anxiety disorders seen in this sample be a general feature of conduct disorder or is it due to the setting of a psychiatric hospital? A review (Zoccolillo, in press) of general population studies of the cooccurrence of conduct or antisocial personality disorder with depressive and anxiety disorders concluded that depressive and anxiety disorders occur very commnly in antisocial female subjects and appear to be part of the antisocial syndrome. The comorbidity seen in this sample is therefore probably a result of the disorder itself and not sample bias. A fourth important finding is that very few symptoms of conduct disorder are needed to have a poor prognosis. It is the author's impression that many clinicians will not diagnose conduct disorder in the absence of many behavioral problems or obvious criminality. This study suggests a lower threshold of symptoms will help the clinician better identify girls at risk for a poor outcome. Finally, the poor outcome of these girls, all of whom entered treatment (and a third of whom entered long-term care), is in keeping with the findings of other studies (Kaz980

din, 1985; McCord, 1978; Shamsie, 1981). Current treatment for conduct disorder is ineffective. The lack of effective treatment coupled with a poor prognosis, including death, poses a dilemma to clinicians and to those responsible for paying for treatment. On the one hand, it is tempting for clinicians and third-party payers to abandon this group, as traditional treatments (such as inpatient or residential treatment) are ineffective. On the other hand, the poor prognosis and lethal behaviors of these girls is a powerful incentive for heroic measures (such as long-term hospitalization) that can bankrupt the family, with little long-term benefit. A more reasonable course is to recognize both the seriousness of the disorder and the lack of effective treatment and for clinicians and third-party payers to agree on some balance between abandoning this group and prohibitively expensive and ineffective care.

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J, Am. Acad. Child Adolesc. Psychiatry, 29:611-619. Regier, D. A., Myers, J. K., Kramer, M. et al. (1984), The NIMH Epidemiologic Catchment Area program. Arch. Gen. Psychiatry, 41:934-941. Robins, L. N. (1966), Deviant Children Grown Up. Baltimore: Williams & Wilkins. - - (1986), The consequences of conduct disorder in girls. In: Development of Antisocial and Prosocial Behavior, eds. D. Olweus, 1. Block & M. Radke-Yarrow, Orlando: Academic Press, pp. 385414. - - Helzer, J. E., Croughan, J. & Ratliff, K. S. (1981), The NIMH Diagnostic Interview Schedule: its history, characteristics, and validity. Arch. Gen. Psychiatry, 38:381-389. - - - - Price, R. K. (1991), Adult disorders predicted by childhood conduct problems: results from the NIMH Epidemiologic Catchment Area project. Psychiatry, 54:113-132. Rydelius, P.-A. (1988), The development of antisocial behaviour and sudden violent death. Acta Psychiatr. Scand., 77:398-403. Serbin, L. A. (1990), Childhood aggression and withdrawal as predictors for women: reproductive patterns and parenting skills as "outcome." Proceedings of the Workshop on Gender Issues in the Development ofAntisocial Behavior, Cambridge, MA, June 11-12, 1990. Shamsie, S. (1981), Antisocial adolescents: our treatments do not work-where do we go from here? Can. J, Psychiatry, 26:357364. U.S. Bureau of the Census. (1990), Statistical Abstract of the United

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