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Knowledge and attitudes about conduct disorder of professionals working with young people: The influence of occupation and direct and indirect experience

  • Chloe Pinchess ,

    Roles Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft

    chloepinchess@icloud.com

    Affiliations Centre for Forensic and Family Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom, Clayfields House, Nottinghamshire County Council, Nottingham, United Kingdom

  • Ruth Pauli,

    Roles Writing – review & editing

    Affiliation Centre for Human Brain Health, School of Psychology, University of Birmingham, Birmingham, United Kingdom

  • John Tully

    Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

    Affiliations Academic Unit of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom, Nottinghamshire Healthcare NHS Trust, Nottingham, United Kingdom

Abstract

Background

Knowledge and attitudes of professionals both pose a potential barrier to diagnosis and treatment of mental disorders. However, knowledge and attitudes about conduct disorder in professionals working with young people are poorly understood. Little is known about the impact of occupation, direct and indirect (training and education) experience, or the interrelationship between knowledge and attitudes.

Methods

We conducted an online survey of 58 participants, including Psychology Staff, Teaching Staff, Care Staff, and Other Non-Clinical Staff. A questionnaire comprising three subscales (causes, treatments, and characteristics) measured knowledge. A thermometer scale measured global attitudes. Open-ended response measures were used to measure four attitude components: stereotypic beliefs (about characteristics), symbolic beliefs (about the holder’s traditions), affect, and past behaviour. Primary analysis explored the impact of occupation, direct experience, and indirect experience on outcome measures. A secondary exploratory analysis was conducted to explore the relationship between knowledge and attitudes.

Results

Psychology Staff had significantly more favourable global attitudes (F = 0.49, p = 0.01) and symbolic beliefs (F = 0.57, p = 0.02) towards those with conduct disorder than Teaching Staff; there were no other significant group differences in attitudes. Psychology staff had more knowledge about conduct disorder than other groups, though the differences were not significant. Direct and indirect experience were associated with greater knowledge (direct: d = 0.97, p = 0.002; indirect d = 0.86, p = 0.004) and favourable global attitudes (direct: d = 1.12, p < 0.001; indirect: d = 0.68, p = 0.02). Secondary exploratory analyses revealed significant positive correlations between: all knowledge variables with global attitudes; total knowledge with past behaviour; and affect and knowledge of causes with past behaviour.

Conclusions

Psychology-based staff may have more favourable attitudes towards children with conduct disorder than teachers, primarily due to direct and indirect experience with the disorder. Our sample may have been too small to detect overall or within-group effects of knowledge or attitudes, however exploratory analyses showing a positive correlation between knowledge and attitudes suggest education may be critical in supporting teachers and other groups in their approaches to this challenging group of young people.

Background

Conduct disorder (CD) is a childhood behaviour disorder characterised by persistent disregard for others and a repetitive pattern of antisocial behaviour including theft, lies, and physical violence [1]. Also, following extensive debate in scientific literature about the importance of callous-unemotional (CU) traits, DSM-5 includes the specifier with or without ‘limited prosocial emotions’, such as lack of empathy, akin to CU traits [1]. Estimates suggest that 2–2.5% of individuals worldwide have CD [2], with consistency across geographical regions [3]. The diagnosis is approximately twice as common in males compared to females [2, 3].

Conduct disorder has considerable societal and personal consequences, primarily due to the strong associations between CD and violence [4] and life-course persistent offending [5]. It is associated with a substantial economic burden, with an estimated cost of £5,569 per child with CD over three years. Costs include care, mental health, and educational services [6], however between 19% and 64% of these total costs are accounted for by criminal justice services [7, 8]. Financial costs extend into adulthood, with around 50% of those with CD going on to develop antisocial personality disorder [9]. Furthermore, CD is associated with the development of other mental disorders in adolescence and later life, including anxiety disorders and depression [10], as well as particularly high rates of substance misuse [4, 11], which places significant strain on mental health services and reduces quality of life for the individual. Additionally, CD is associated with lower educational attainment [4], which is independently associated with higher levels of stress, negative health consequences, and poorer long-term job prospects [12].

Despite these serious implications, CD is suboptimally managed in healthcare settings. Various professionals work with children with CD, including teachers, psychologists, and care workers [13]. However, it often goes undiagnosed, perhaps due to a prejudice that CD is not a “legitimate” psychiatric disorder [14]. Also, clinical application of the evidence base for the management of CD remains limited. Although studies exploring the efficacy of both pharmacological and psychosocial interventions yield at best mixed findings, there is some evidence for effective treatments. For instance, meta-analyses demonstrate that psychosocial interventions such as multi-systemic therapy produce small effects on offending, psychopathology, and substance use in young people, showing most efficacy in youth under 15 years old [15, 16]. Also, antipsychotics and psychostimulants can reduce symptoms of aggression in CD, albeit possibly only in the short-term [17, 18]. Despite these therapeutic options, only a quarter of children with CD access specialist health services, possibly due to more practical support being sought rather than mental health assessment and treatment [19]. Furthermore, children with CD may be likely to drop out of treatment because it may not match the needs of the family [20].

One barrier to successful management of CD may be professionals’ lack of knowledge. This may be due to limited understanding about the benefits of treatments, meaning professionals may fail to make necessary referrals [21]. Knowledge of mental illness increases alongside experience, leading to reduced stigma and more favourable behaviours towards patients [22]. However, evidence for knowledge specifically about CD in staff working with youth populations is limited, with a particular lack of quantitative data. Some qualitative studies suggest that teachers have little knowledge of CD characteristics and management techniques [2325]. Other data suggest that psychiatrists have varied knowledge of the aetiologies of CD [26]. While no study to date has explored the impact of knowledge specifically on the management of CD, studies in young people with attention deficit hyperactivity disorder (ADHD) have demonstrated that teachers with greater knowledge more readily refer children for assessment due to a greater understanding of the challenges they face [21]. Similarly, research shows that teachers with greater experience have more favourable behaviours towards children with ADHD [27].

Staff attitudes are another factor that may influence the management and outcomes of CD. Studies in adults with mental disorders demonstrate that negative staff attitudes towards patients results in avoidance of patients [28] and lower patient satisfaction [29]. In contrast, healthcare workers who have experience of working with those with mental illnesses display more positive attitudes and behaviours towards patients, including willingness to help [22]. A positive relationship between beliefs and behaviours towards children with ADHD has been demonstrated in teachers with experience teaching children with ADHD [27]. There is, however, very limited literature exploring staff attitudes specifically about CD. Some studies suggest that teachers view children with CD as disruptive and have concerns about the safety of other students during lessons [2325], indicating negative beliefs. Furthermore, teachers have reported feeling “disgust” and “fear” towards children with CD, implying negative overall affect [24]. In non-teaching professions, attitudes appear more varied. A mixed-methods study using a questionnaire and an interview suggested that nurses and psychologists may hold more positive attitudes towards children with CD than doctors [30]. Inferences from this work are limited, however, due to a lack of statistical appraisal of findings.

Attitudes can be broken down into several components, including the tripartite model, which focuses on affect, beliefs, and behaviour [31]. Affect includes feelings that are aroused after object exposure [31]; cognition refers to beliefs about the object [31], which can be stereotypic (about characteristics, such as “children with CD are disruptive”) or symbolic (about the holder’s traditions, such as “teaching children with CD is time consuming; [32]) while behaviour consists of actions towards the object or individual [31]. This model has been used to explore attitudes of professionals about ADHD. One study [33] used an adapted version of the Multidimensional Attitudes towards Inclusive Education Scale (MATIES; [32]) and found that psychologists have significantly more knowledge, favourable affect, favourable behaviour, and favourable attitudes than teachers and support assistants. Another study [27] adapted open-ended response measures from Haddock & Zanna [34] and demonstrated that experience elicits differences in knowledge and attitude components. Both the MATIES [32] and open-ended response measures have demonstrated validity when exploring attitude components [32, 35, 36]. To our knowledge, however, no study has used this model to explore attitudes towards CD.

Both knowledge and attitudes can also be impacted by direct and indirect experience with a disorder. Research demonstrates that direct experience of working in general mental health settings reduces negative attitudes towards patients because unrealistic preconceptions are challenged, such as the fear that psychiatric patients pose a threat and people with diagnoses are out of control [37]. Although evidence relating to CD is limited, qualitative work shows that direct experience of teaching children with disruptive behaviour disorders, including CD, contributes to greater confidence in teachers’ knowledge about the disorders and management techniques for these [23, 24]. Similarly, indirect experience with mental health disorders, such as educational training programmes about psychiatric patients, improves attitudes towards patients, because it provides a rationale for their behaviours [38]. One study shows that training through lectures and information leaflets about CD produced significant increases in knowledge and favourable attitudes about CD, compared to a group who received no training [39]. However, research on the impact of experience on knowledge and attitudes towards children with CD appears limited and thus may contribute to the insufficient support received by children with CD.

To address the lack of evidence about knowledge and attitudes towards CD in professionals working with CD, we administered an online questionnaire exploring knowledge, global attitudes, and the tripartite attitude components to four groups of professionals (Psychology Staff, Teaching Staff, Care Staff, and Other Non-Clinical Staff), with varied levels of experience and education or training on CD, who work with young people. Drawing on a limited previous literature, we hypothesised that (i) Psychology Staff would have significantly greater knowledge, favourable global attitudes, and favourable attitude components (tripartite model) than other staff groups; (ii) individuals with direct experience with young people with CD would have significantly greater knowledge, favourable global attitudes, and favourable attitude components than individuals without direct experience, across the entire sample (our design was not powered to perform within-group analyses); and (iii) individuals with indirect experience of CD (training/education) would have greater knowledge, favourable global attitudes, and favourable attitude components than individuals without indirect experience, across occupational groups. To explore the relationship between knowledge, including knowledge subscales (causes, treatments, and characteristics), and attitudes, we conducted secondary exploratory correlational analyses between these variables, across the entire sample.

Methods

Participants and procedure

To obtain 80% power, allowing for a detection of a large effect size of 0.8, with a significance threshold of p<0.05, at least 24 participants were required for one-way Analysis of Variance (ANOVA) tests and 52 participants for two-way independent sample t-tests, calculated by G*Power. Participants were required to provide informed consent and to be working with young people aged 10–17 in the UK. This age range was chosen to achieve a balance between maximising sample size and consistency across the clinical population in question, i.e. to include pre-adolescent and adolescent youth but not very young children.

Fifty-nine subjects were recruited from March to May 2021, through convenience and snowball sampling via social media. Advertisements for the study were posted and promoted on the researchers’ main and professional accounts on social media (Facebook, LinkedIn, and Twitter), as well as various research and dissertation groups on Facebook. Advertisement posts were also shared by numerous members of the public to reach a wider audience. The occupational groups included psychologists, therapists, and interventions facilitators (referred to henceforth as ‘Psychology Staff’; n = 18); teachers and teaching assistants (‘Teaching Staff’; n = 19); and nurses and care/support staff (‘Care Staff’; n = 15). There were also staff in non-clinical occupations, including sports coaches and managers (‘Other Non-Clinical Staff’; n = 6). One doctor, who did not fit into any of these four occupation groups, was excluded, resulting in an overall sample of 58 participants.

Written ethical approval was obtained from the University of Nottingham Faculty of Medical and Health Sciences Ethics Committee (reference FMHS 189–0221). All methods were performed according to UKRI’s policy and guidelines. Advertisements were posted on social media sites, including Twitter, Facebook, and LinkedIn. Participants gave written consent through an online consent form. Participants were presented with all materials via an online questionnaire. Upon completion, participants were given the opportunity to provide their email address if they wished to enter a prize draw. Authors had access to email addresses, though they were removed from data analysis following the prize draw. A random number generator chose four prize draw winners after the questionnaire closed, who were contacted via email.

Design

A cross-sectional design was used, with three independent variables: occupation, direct experience with CD, and indirect experience (education/training) with CD. The dependent variables were all quantitative scale variables based on scores from the questionnaire: total knowledge, global attitude, stereotypic beliefs, symbolic beliefs, affect towards CD, and past behaviour towards CD.

Materials

An online questionnaire was presented on Online Surveys (www.onlinesurveys.ac.uk), including the information sheet, consent form, questionnaire, prize draw details, and debriefing sheet. The following demographic information was collected: gender, age, where they work with young people, whether the setting is forensic or non-forensic, their main job role, whether their work is full-time/part-time/bank, and years of employment in this role. Education and training were accounted for through asking whether they had completed any university units or training on CD. Experience with CD was measured through asking whether they have worked with a child believed to have CD. The questionnaire contained the sections outlined below, adapted from an ADHD study [27] because, to our knowledge, a questionnaire exploring knowledge and all attitude components in CD does not exist. The original ADHD questionnaire that this study adapted [27] used a shortened version of the Knowledge about Attention Deficit Disorder Questionnaire [40] to optimise rates of inclusion. Both ADHD scales previously demonstrated internal consistency when exploring subscales of knowledge [27, 40].

Knowledge.

The knowledge measure was adapted from Anderson et al. [27]. New questions were developed, drawing from literature on relevant items, using the original format of 33 questions (see S1 Appendix for the tool, its format, and references). There were three 11-item subscales exploring knowledge of (i) causes, (ii) treatments, and (iii) characteristics. The order of questions for each subscale and true answers remained the same as the original measure by Anderson et al. [27]. Statements included “only biological factors cause conduct disorder”; “antipsychotic drugs can be used to manage symptoms of conduct disorder”; and “language impairments are common amongst children with conduct disorder”. Participants were asked to respond with ‘true’, ‘false’ or ‘don’t know’ for each item. Correct answers were summed to form total scores from 0 (low knowledge) to 33 (high knowledge). Subscale scores were devised by summing correct answers from each subscale.

Global attitude.

A vertical, 11-point, attitude thermometer scale determined overall attitudes towards children with CD. Thermometer scales have concurrent validity in samples of adults when exploring attitudes towards stigmatised groups [35, 41]. Attitudes were rated from 1 (extremely unfavourable) to 100 (extremely favourable).

Attitude components.

Attitude components were selected using the Tripartite Model of Attitudes. Separate attitude components (stereotypic beliefs, symbolic beliefs, affect, and past behaviour) were explored using four open-ended questions. The four items were: “please describe what you think the characteristics a child with conduct disorder would have” (stereotypic beliefs), “please say how you think children with conduct disorder affect or may affect your work with them” (symbolic beliefs), “please describe how you feel when thinking about working with children with conduct disorder” (affect), and “please describe how you think you have acted when working with a child with conduct disorder” (past behaviour). Participants wrote up to 12 words or phrases answering each component statement, relevant to CD. Participants transformed their own responses into quantitative data themselves by rating each word or phrase on a 5-point scale ranging from ‘very negative’ (-2) to ‘very positive’ (+2). Each participant’s four individual scores for each of the four components were formed by calculating a means score of their ratings given to their responses to each statement. This method of interpreting open-ended questions is a valid and reliable technique of eliciting attitudinal responses exploring various components [34, 36, 42]. Cognitive and affective open-ended measures average at 0.75 split-half reliability [34]. Discriminant validity between cognitive and affective component responses has also been established [34].

Statistical analyses

All analyses were performed using IBM SPSS Statistics version 27. One-way ANOVAs were performed with occupation as an independent variable for each of: total knowledge, global attitude, stereotypic beliefs, symbolic beliefs, affect, and past behaviour. Separate t-tests were conducted for the direct experience variable and the training/education variable with the aforementioned dependent variables.

Exploratory secondary analyses investigated the relationship between knowledge variables (including the knowledge subscales) and attitude variables. Pearson’s correlation coefficient tests were performed, followed by three partial correlation tests, controlling for occupation, experience with CD, and training/education separately.

Some data was missing from attitude component questions, so participants’ responses were only included for the components they answered to ensure maximum data inclusion. Calculations were carried out on the following number of remaining participants: stereotypic beliefs (n = 50, missing 8 [13.79%]), symbolic beliefs (n = 47, missing 11 [18.97%]), affect (n = 48, missing 10 [17.24%]), and past behaviour (n = 36, missing 22 [37.93%]).

Results

Demographic variables

Forty-nine females and nine males participated (see Table 1). The mean age was 32.5 (SD +/- 11.0). Psychology Staff included psychologists, therapists, and interventions facilitators working in environments including schools, secure homes, and the community. Teaching Staff included teachers and teaching assistants working mostly in primary or secondary schools, with one working in a Special Educational Needs school. Care Staff included nurses and care/support staff working in environments including child and adolescent mental health inpatient wards, secure children’s homes, and the community. Finally, the Non-Clinical Staff group included three sports coaches/teachers in dance schools and youth centres, mentors at youth centres, and a manager in a young offender institution. It is important to highlight that the sample size is relatively small. It is also predominantly female, however this may be representative of the number of females working with CD in the general population [43].

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Table 1. Demographics and details of direct and indirect experience of participant groups.

https://doi.org/10.1371/journal.pone.0292271.t001

Internal consistency of the knowledge of conduct disorder scale

Internal consistency, measured by Cronbach’s alpha, was 0.90 for the overall knowledge scale, 0.79 for the causes subscale, 0.73 for the treatment subscale, and 0.75 for the characteristics subscale.

Effect of occupation on knowledge and attitudes

Table 2 shows mean scores for occupation. There were no significant differences between occupation groups in their total knowledge (F(3, 22.47) = 1.62, η2 = 0.08, p = 0.21). See Fig 1 for knowledge scores grouped by occupation. There were, however, significant differences between occupation groups in global attitudes towards CD (F(3, 54) = 4.36, η2 = 0.20, p = 0.01). See Fig 2 for global attitude scores grouped by occupation. Post-hoc between-group analyses revealed that Psychology Staff had significantly more favourable global attitudes than Teaching Staff (F = 0.49, p = 0.01). No other group differences were significant. There were also significant differences between occupation groups in symbolic beliefs (F(3, 43) = 3.24, η2 = 0.18, p = 0.03). Post-hoc between-group analyses revealed that Psychology Staff had significantly more favourable symbolic beliefs than Teaching Staff (F = 0.57, p = 0.02). No other group differences were significant.

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Table 2. Effect of occupation on knowledge and attitudes.

https://doi.org/10.1371/journal.pone.0292271.t002

Effect of direct experience on knowledge and attitudes

Table 3 shows mean scores for individuals with and without direct experience working with young people with CD across all occupational groups. Individuals with direct experience displayed significantly higher knowledge (t(34.80) = 3.41, d = 0.97, p = 0.002) compared to individuals without experience. Global attitudes of individuals with direct experience were significantly more favourable than those without experience (t(56) = 4.21, d = 1.12, p < 0.001). However, no significant differences were found for stereotypic beliefs (t(48) = 0.74, d = 0.21, p = 0.47), symbolic beliefs (t(45) = 1.74, d = 0.51, p = 0.09), affect (t(46) = 1.89, d = 0.55, p = 0.07), or past behaviour (t(34) = .34, d = 0.12, p = 0.73). There were insufficient numbers in each occupational group to conduct within-group analyses of the effect of direct experience.

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Table 3. Differences in attitudes in individuals with and without direct experience and indirect experience (training/education).

https://doi.org/10.1371/journal.pone.0292271.t003

Effect of indirect experience (training and education) on knowledge and attitudes

Table 3 also shows mean scores for individuals with and without training/education across all occupational groups. Individuals who had received training/education showed significantly higher knowledge (t(56) = 2.99, d = 0.86, p = 0.004) compared to individuals who had not. Global attitudes were significantly more favourable in those who had received training/education compared to those who had not (t(56) = 2.35, d = 0.68, p = 0.02). There were no significant group differences in stereotypic beliefs (t(48) = 0.40, d = 0.13, p = 0.69), symbolic beliefs (t(45) = 1.81, d = 0.59, p = 0.08), affect (t(46) = 1.52, d = 0.50, p = 0.13), or past behaviour (t(34) = 0.19, d = 0.07, p = 0.85). There were insufficient numbers in each occupational group to conduct within-group analyses of the effect of training/education.

Relationships between knowledge and attitude measures

Table 4 shows the bivariate correlations for the relationship between knowledge and attitudes across all occupational groups. The following factors had significant, positive relationships: global attitudes with total knowledge and all knowledge subscales, affect with knowledge of causes and knowledge of characteristics, and past behaviour with knowledge of causes, knowledge of characteristics, and total knowledge.

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Table 4. Bivariate correlations between knowledge and attitude measures.

https://doi.org/10.1371/journal.pone.0292271.t004

The partial correlations are presented in Tables 5 and 6. In summary, when controlling separately for both direct and indirect (training/education) experience, global attitude was no longer significantly correlated with knowledge and the knowledge subscales. Also, the relationships between both affect and past behaviour with knowledge of characteristics was no longer significant. However, the relationships between both affect and past behaviour with knowledge of causes, and past behaviour with total knowledge, remained significant.

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Table 5. Partial correlations between knowledge and attitude measures after controlling for direct experience with CD.

https://doi.org/10.1371/journal.pone.0292271.t005

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Table 6. Partial correlations between knowledge and attitude measures after controlling for indirect experience (training/education).

https://doi.org/10.1371/journal.pone.0292271.t006

Discussion

We examined knowledge and attitudes about CD in professionals working with young people with the condition. There were three key findings. Firstly, Psychology Staff had significantly more favourable global attitudes and symbolic beliefs than Teaching Staff (though not other staff groups, therefore only partly supporting our hypothesis). Secondly, also partially supporting our hypothesis, those with direct experience working with young people with CD had significantly greater total knowledge and global attitudes than those without, though no significant differences were found in any attitude components. Thirdly, those with indirect experience (training or education) about CD had significantly greater objective knowledge and global attitudes than those without, though there were no significant differences in any attitude subcomponents.

Effect of occupation on knowledge and attitudes

Unexpectedly, there were no significant differences in knowledge between occupation groups. Previous studies have demonstrated that teachers lack knowledge about CD [2325]. It is notable that Psychology Staff did have higher mean scores for knowledge than all other groups in our sample, and it is possible that a larger sample size may have elicited significant differences between groups. However, the relatively low scores across all professional groups (62.7% for Psychology Staff, 47% for Teaching Staff, 53.9% for Care Staff, and 56.7% for Other Non-Clinical Staff) suggests that there may be a lack of specific training in CD for staff working in child and adolescent services, including psychologists.

The finding that global attitudes were significantly more favourable in Psychology Staff than Teaching Staff is in keeping with limited previous research focusing on attitudes towards children with CD, which demonstrates that psychologists, nurses, and therapists held more positive attitudes than doctors [30], and teachers appear to hold mostly negative views [23, 24]. It is also broadly in keeping with research in ADHD, demonstrating that psychologists had more positive attitudes than teachers [33]. One potential explanation is more favourable pre-existing attitudes, with those interested in a career in psychology tending to be more understanding of complex emotional and behavioural problems. This, however, is not supported by existing research and without data on baseline attitudes, our study cannot clarify this further. An additional, or alternative, contributory factor is differing occupation-based experiences and responsibilities. Teachers promote learning skills in a safe environment, with a responsibility for maintaining the best classroom environment across groups of students, and must contend with typical CD behaviours as disruptive towards learning and other students. When signs of behavioural disturbance or mental health issues emerge, they refer children elsewhere for assessments [13]. In contrast, psychology staff are responsible for assessing CD and providing psychosocial interventions at an individual level [9, 44]. Such therapeutic encounters may allow for an emerging understanding and empathy about the condition, in a way that fraught experiences in a classroom environment may not. Similar findings have been observed in patients with schizophrenia. For instance, one study showed that public health nurses were more socially accepting of patients than psychiatric nurses due to potentially seeing patients live in socially responsible conditions; however, they demonstrated both more positive affect and higher social acceptance than non-care workers, potentially because these staff had more contact and greater educational opportunities [45]. Although we found no significant differences between Teaching Staff and other groups, the overall (‘global’) attitude of Teaching Staff was the lowest of the four groups, which suggests that teachers may have particular difficulties in understanding or adapting to the disorder and may be faced with particular challenges. This is an important consideration in developing support structures for teachers, particularly in challenging environments. Teachers may need more support when teaching children with CD, which could be informed by psychologists.

Differences between occupational groups were also observed in symbolic beliefs, which represent staff values about how individuals with CD impact their working process (for example, for teachers, beliefs about how teaching a class may be impacted if one student has CD). Individuals may deduce beliefs from experiences at work because experiences play a critical role in belief formation [46]. Therefore, differences between occupations may simply arise because the item specifically focuses on values towards their occupation, supporting the view that occupation-based experiences may impact global attitudes. Conversely, the lack of differences between occupation groups in their stereotypic beliefs, affect, and past behaviour may be because these items focused less on their occupation and more on their evaluation towards the individual with CD, perhaps explaining the lack of significant difference between occupation groups. This is supported by previous research demonstrating that teachers report many concerns when teaching children with CD [23, 24], but psychologists and therapists do not believe children with CD are especially challenging to work with [30].

Effect of direct and indirect experience on knowledge and attitudes

Direct experience was associated with greater knowledge, across the entire sample. Our findings support previous studies, demonstrating that increased experience with CD [23, 24] and ADHD [27, 47] led to improvements in knowledge of each disorder. Knowledge can be shaped through observation, reflection, conceptualisation, and adaptation from experiences, a process called experiential learning [48]. Therefore, individuals who have direct experience have likely undergone this process and may have improved their knowledge in this way. Furthermore, negative preconceptions are usually challenged through gaining direct experience with mental health disorders [37]. This should be considered in training programmes for all professionals likely to come into contact with CD. Direct encounters through work experience and placements may be a valuable means of optimising learning in these important professional groups.

As predicted, knowledge was also higher in individuals with training/education than those without. Previous research supports that training/education about CD improves knowledge about CD [2325, 39]. Specifically, one study suggests that training individuals about various factors (including risk factors, symptoms, and treatment) contributed to an overall increase in knowledge of CD [39]. This reinforces the idea that targeting specific aspects is essential when exploring knowledge of CD. However, this research on CD training only explored a combination of a lecture, two videos, and an information leaflet. Printed materials [49] and lectures [50] have been shown to have minimal effects on clinical knowledge, whereas interactive groups [50] and courses with practical components [5153] are more effective. Therefore, controlling for types of training methods would provide greater insight into the impact it has on knowledge. This may also have further implications for knowledge about CD, when techniques such as video call lectures are increasingly used following the COVID-19 pandemic.

Also as predicted, global attitudes were more favourable in individuals with direct experience of CD and training/education compared to individuals without experience and training/education, respectively. This may result from empathic responses to individuals with CD, where professionals may explain behaviours as a result of a diagnosis of CD [54]. Furthermore, those who seek out training in CD may have pre-existing favourable attitudes to CD. Supporting this, previous findings suggest a relationship between having more empathy and a greater understanding of mental health issues [54]. The relative contribution of these factors should be explored in future research, controlling for pre-existing attitudes.

Contrary to our hypothesis, neither training/education nor experience working with children with CD had an effect on specific the attitude components within the tripartite model. Theorists suggest that beliefs are particularly resistant to change, more-so than factual knowledge [55, 56], perhaps explaining why there were no differences in symbolic or stereotypic beliefs. This has also been observed in ADHD research [27]. Therefore, their experience may not be sufficient enough to change beliefs.

Exploratory analysis: Relationships between knowledge and attitudes

Our secondary exploratory analysis revealed that all aspects of knowledge were positively correlated with global attitudes. This is in keeping with past findings that demonstrate that individuals with greater knowledge have more positive attitudes about CD [39] and other disorders, such as ADHD [27, 33, 57]. The directionality of this relationship warrants exploration in future research studies.

Interestingly, knowledge about causes of CD was also positively correlated with affect and past behaviour as well as global attitudes. This suggests that a greater understanding of the aetiology of CD may have beneficial effects on approaches to individuals with the condition. Recent research has increasingly pointed to a considerable genetic and neurobiological contribution to CD [5860], particularly for CD with CU traits [61]. Knowledge of these factors, however, may hypothetically influence professionals in two ways. On one hand, understanding these biological contributions may make them more sympathetic toward individuals with CD, given their predilection to developing the disorder and its sequelae. On the other hand, it may cause professionals to be guarded about CD, and develop a therapeutic hopelessness about outcomes for the disorder, seeing affected individuals as beyond the influence of usual psychosocial interventions. This has parallels in the field of ‘Neurolaw’, whereby presentation of neurobiological evidence of potential causation to juries and judges has been shown to be both an aggravating and a mitigating factor in sentencing [62, 63]. In our study, it would appear that the former is the case; greater knowledge about causes leads to a more sympathetic attitude towards the condition. This has positive implications for young people suffering with CD and their families and puts an onus on clinical services to help educate staff and the general public.

The relationship between all knowledge scales and global attitudes, however, was no longer significant after controlling for occupation, experience with CD, and training/education. Previous research demonstrates that a relationship between knowledge and attitudes towards ADHD exists for teachers with experience, but not for those without [27]. Our sample was insufficiently powered to carry our subgroup analyses of the interrelationship, however future work would benefit from further exploration of this.

Strengths and limitations

This is the first study to examine the impact of occupation and direct and indirect experience on knowledge and attitudes towards children with CD. We identified a sample of relevant professionals and used an adapted version of validated and reliable measures, providing the first evidence for internal consistency of this adapted version. Our study, however, had several limitations. Firstly, smaller effects may have been missed and the scope of subgroup analyses was limited. Despite this study being promoted and widely circulated online, uptake and completion was limited to a relatively small sample of 58. There are several possible reasons for this, two of which warrant particular mention. Firstly, it may be that many staff working with CD are unaware or unclear about of the concept of CD, because it is rarely diagnosed [14], and so the advert would not have captured their attention. This highlights the importance of psychoeducation about CD for staff within educational and healthcare settings for young people. Secondly, CD is a contentious issue. Some argue that CD does not exist and the diagnosis is harmful, whereas others believe a diagnosis can help highlight treatment needs [64]. Even within groups of staff who are aware of the CD concept, some individuals who work with youths with CD may be reluctant to validate the concept by engaging in research using this terminology. Frank and open discussions about the quality of evidence for CD and the potential ethical and practical implications of use of this diagnosis are important for researchers in this field to embrace.

Secondly, there were significant within-group differences in training/education within occupation and direct experience groups. This meant that exploring the effect of occupation on knowledge and attitudes may have been less meaningful than more homogenous subgroup samples would have allowed.

Thirdly, individuals with direct experience were more likely to work in a forensic setting, perhaps since the prevalence of CD is greater in forensic settings [65]. This limits the generalisability of our findings to non-forensic settings, such as schools. Furthermore, the sample was predominantly female, and the females in the sample had more training/education than males. This may well be representative of the make-up of professionals working with CD in the general population [43]. However, sex has been shown to impact attitudes, whereby females hold more positive views than males towards individuals who have committed sexual offences [66] and students with disorders including CD and anxiety [67].

Conclusions

Our study contributes to the evidence base suggesting psychology staff have more favourable attitudes to conduct disorder than teachers, though the reasons for this remain unclear. Both direct and indirect experience were associated with greater knowledge and more favourable attitudes, perhaps because experience challenges negative preconceptions about CD. Future research will benefit from a longitudinal approach exploring the directionality of the relationship between knowledge and attitudes and larger sample sizes to more fully elucidate potential differences between occupational groups. Teachers in particular may require extra support in dealing with youths with this challenging condition.

Supporting information

S1 Appendix. List of items on objective knowledge of conduct disorder scale, corresponding citations, and scoring instructions.

The items that correspond to each of the subscales (characteristics, treatments, and causes) can be seen. Also, it states which items are true or false. Finally, Table 7 in S1 Appendix demonstrates the items and their corresponding citations, followed by a list of references.

https://doi.org/10.1371/journal.pone.0292271.s001

(DOCX)

Acknowledgments

We express gratitude to all staff who took time to participate in this study.

References

  1. 1. American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. Arlington. 2013.
  2. 2. Polanczyk G V., Salum GA, Sugaya LS, Caye A, Rohde LA. Annual Research Review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry [Internet]. 2015 Mar;56(3):345–65. Available from: https://onlinelibrary.wiley.com/doi/10.1111/jcpp.12381
  3. 3. Erskine HE, Ferrari AJ, Nelson P, Polanczyk G V., Flaxman AD, Vos T, et al. Research Review: Epidemiological modelling of attention-deficit/hyperactivity disorder and conduct disorder for the Global Burden of Disease Study 2010. J Child Psychol Psychiatry [Internet]. 2013 Dec;54(12):1263–74. Available from: http://doi.wiley.com/10.1111/jcpp.12144
  4. 4. Erskine HE, Norman RE, Ferrari AJ, Chan GCK, Copeland WE, Whiteford HA, et al. Long-Term Outcomes of Attention-Deficit/Hyperactivity Disorder and Conduct Disorder: A Systematic Review and Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):841–50.
  5. 5. Moffitt TE. Male antisocial behaviour in adolescence and beyond. Nat Hum Behav [Internet]. 2018 Mar 21;2(3):177–86. Available from: http://www.nature.com/articles/s41562-018-0309-4 pmid:30271880
  6. 6. Snell T, Knapp M, Healey A, Guglani S, Evans-Lacko S, Fernandez JL, et al. Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data. J Child Psychol Psychiatry [Internet]. 2013 Sep;54(9):977–85. Available from: https://onlinelibrary.wiley.com/doi/10.1111/jcpp.12055 pmid:23442096
  7. 7. Foster EM, Jones DE. The High Costs of Aggression: Public Expenditures Resulting From Conduct Disorder. Am J Public Health [Internet]. 2005 Oct;95(10):1767–72. Available from: http://ajph.aphapublications.org/doi/10.2105/AJPH.2004.061424 pmid:16131639
  8. 8. Scott S, Knapp M, Henderson J, Maughan B. Financial cost of social exclusion: follow up study of antisocial children into. BMJ [Internet]. 2001 Jul 28;323(7306):191–191. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.323.7306.191
  9. 9. National Institute for Health and Clinical Excellence. Antisocial behaviour and conduct disorders in children and young people: Recognition, intervention and management. Nice Clinical Guideline. 2017.
  10. 10. Copeland WE, Shanahan L, Erkanli A, Costello EJ, Angold A. Indirect Comorbidity in Childhood and Adolescence. Front Psychiatry [Internet]. 2013;4. Available from: http://journal.frontiersin.org/article/10.3389/fpsyt.2013.00144/abstract
  11. 11. Connor DF, Ford JD, Albert DB, Doerfler LA. Conduct Disorder Subtype and Comorbidity. Ann Clin Psychiatry [Internet]. 2007 Jul;19(3):161–8. Available from: http://www.portico.org/Portico/article?article=pf1m9kdb8p pmid:17729017
  12. 12. Muennig P. Education and Health. In: International Encyclopedia of Education [Internet]. Elsevier; 2010. p. 169–77. Available from: https://linkinghub.elsevier.com/retrieve/pii/B9780080448947013026
  13. 13. Bell PS. A Teacher’s Guide to Understanding the Disruptive Behaviour Disorders: Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder. AuthorHouse; 2013.
  14. 14. Coghill D. Editorial: Do clinical services need to take conduct disorder more seriously? Journal of Child Psychology and Psychiatry and Allied Disciplines. 2013. pmid:23957373
  15. 15. Sinclair I, Parry E, Biehal N, Fresen J, Kay C, Scott S, et al. Multi-dimensional Treatment Foster Care in England: differential effects by level of initial antisocial behaviour. Eur Child Adolesc Psychiatry [Internet]. 2016 Aug 10;25(8):843–52. Available from: http://link.springer.com/10.1007/s00787-015-0799-9 pmid:26662809
  16. 16. van der Stouwe T, Asscher JJ, Stams GJJM, Deković M, van der Laan PH. The effectiveness of Multisystemic Therapy (MST): A meta-analysis. Clin Psychol Rev [Internet]. 2014 Aug;34(6):468–81. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0272735814000981 pmid:25047448
  17. 17. Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev [Internet]. 2017 Aug 9; Available from: http://doi.wiley.com/10.1002/14651858.CD008559.pub3 pmid:28791693
  18. 18. Pringsheim T, Hirsch L, Gardner D, Gorman DA. The Pharmacological Management of Oppositional Behaviour, Conduct Problems, and Aggression in Children and Adolescents with Attention-Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder: A Systematic Review and Meta-Analysi. Can J Psychiatry [Internet]. 2015 Feb;60(2):42–51. Available from: http://journals.sagepub.com/doi/10.1177/070674371506000202
  19. 19. Vostanis P, Meltzer H, Goodman R, Ford T. Service utilisation by children with conduct disorders. Eur Child Adolesc Psychiatry [Internet]. 2003 Oct 1;12(5):231–8. Available from: http://link.springer.com/10.1007/s00787-003-0330-6
  20. 20. Luk ESL, Staiger PK, Mathai J, Wong L, Birleson P, Adler R. Children with persistent conduct problems who dropout of treatment. Eur Child Adolesc Psychiatry [Internet]. 2001 Mar 21;10(1):28–36. Available from: http://link.springer.com/10.1007/s007870170044 pmid:11315533
  21. 21. Ohan JL, Cormier N, Hepp SL, Visser TAW, Strain MC. Does knowledge about attention-deficit/hyperactivity disorder impact teachers’ reported behaviors and perceptions? Sch Psychol Q [Internet]. 2008 Sep;23(3):436–49. Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/1045-3830.23.3.436
  22. 22. Sherring S. The impact of lived experience on health care workers’ knowledge, attitudes and behaviour regarding mental illness. Br J Ment Heal Nurs [Internet]. 2021 Jan 2;10(1):1–7. Available from: http://www.magonlinelibrary.com/doi/10.12968/bjmh.2019.0039
  23. 23. Jones DB. Phenomenological study: What are pre -kindergarten teachers’ lived experiences with children identified with conduct disorder, oppositional defiance disorder, and attention -deficit hyperactivity disorder in the southeastern United States? [Internet]. The University of Alabama at Birmingham; 2008. Available from: https://search.proquest.com/docview/89243606?pq-origsite=gscholar&fromopenview=true
  24. 24. Bell PS. Jamaican teachers’ attitudes toward children with oppositional defiant disorder, conduct disorder, and attention deficit hyperactivity disorder. Capella University; 2006.
  25. 25. Drugli MB, Clifford G, Larsson B. Teachers’ Experience and Management of Young Children Treated Because of Home Conduct Problems: A qualitative study. Scand J Educ Res [Internet]. 2008 Jun;52(3):279–91. Available from: http://www.tandfonline.com/doi/abs/10.1080/00313830802025082
  26. 26. Staniford JA, Lister M. An Interpretative Phenomenological Analysis exploring how psychiatrists conceptualise conduct disorder and experience making the diagnosis. Clin Child Psychol Psychiatry [Internet]. 2020 Jan 20;26(1):243–56. Available from: pmid:33081498
  27. 27. Anderson DL, Watt SE, Noble W, Shanley DC. Knowledge of attention deficit hyperactivity disorder (ADHD) and attitudes toward teaching children with ADHD: The role of teaching experience. Psychol Sch. 2012;
  28. 28. Peckover S, Chidlaw RG. Too frightened to care? Accounts by district nurses working with clients who misuse substances. Health Soc Care Community [Internet]. 2007 Jan 12;15(3):238–45. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2524.2006.00683.x pmid:17444987
  29. 29. Brener L, Hippel W Von, Kippax S, Preacher KJ. The Role of Physician and Nurse Attitudes in the Health Care of Injecting Drug Users. Subst Use Misuse [Internet]. 2010 May 4;45(7–8):1007–18. Available from: http://www.tandfonline.com/doi/full/10.3109/10826081003659543 pmid:20441447
  30. 30. Woolley E, Muncey T. Demons or Diamonds: A Study to Ascertain Health Professionals’ Attitudes Toward Children With Conduct Disorder. J Child Adolesc Psychiatr Nurs [Internet]. 2004 Oct;17(4):151–60. Available from: http://doi.wiley.com/10.1111/j.1744-6171.2004.tb00012.x pmid:15742796
  31. 31. Rosenberg MJ, Hovland CI. Cognitive, affective, and behavioral components of attitudes. In: Attitude organization and change: An analysis of consistency among attitude components. Yale University; 1960. p. 1–14.
  32. 32. Mahat M. The development of a psychometrically-sound instrument to measure teachers’ multidimensional attitudes toward inclusive education. Int J Spec Educ. 2008;23(1):82–92.
  33. 33. Toye MK, Wilson C, Wardle GA. Education professionals’ attitudes towards the inclusion of children with ADHD: the role of knowledge and stigma. J Res Spec Educ Needs [Internet]. 2019 Jul 4;19(3):184–96. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/1471-3802.12441
  34. 34. Haddock G, Zanna MP. On the use of open-ended measures to assess attitudinal components. Br J Soc Psychol [Internet]. 1998 Jun;37(2):129–49. Available from: http://doi.wiley.com/10.1111/j.2044-8309.1998.tb01161.x
  35. 35. Haddock G, Zanna M. Evaluation thermometer measure for assessing attitudes toward gay men. In: Davis CM, Yarber WL, Bauserman R, Schreer GE, Davis SL, editors. Handbook of sexuality-related measures [Internet]. 2nd ed. Sage; 1998. p. 381–2. Available from: http://orca.cf.ac.uk/id/eprint/35135
  36. 36. Esses VM, Maio GR. Expanding the Assessment of Attitude Components and Structure: The Benefits of Open-ended Measures. Eur Rev Soc Psychol [Internet]. 2002 Jan;12(1):71–101. Available from: http://www.tandfonline.com/doi/abs/10.1080/14792772143000021
  37. 37. Kennedy V, Belgamwar RB. Impact of work experience placements on school students’ attitude towards mental illness. Psychiatr Bull [Internet]. 2014 Aug 2;38(4):159–63. Available from: https://www.cambridge.org/core/product/identifier/S2053486800002228/type/journal_article pmid:25237537
  38. 38. Tapola V, Wahlström J, Lappalainen R. Effects of training on attitudes of psychiatric personnel towards patients who self-injure. Nurs Open [Internet]. 2016 Jul;3(3):140–51. Available from: https://onlinelibrary.wiley.com/doi/10.1002/nop2.45 pmid:27708824
  39. 39. Kavitha S, Jayanthi P, Hemavathy J, Kanchana S, Celina D. Effectiveness of a Training Package on Knowledge and Attitude Regarding Conduct Disorder in Children among School Teachers in South India. ICCRJNR [Internet]. 2016;1(2):13–9. Available from: https://www.iccrjnr.com/downloads/ICCRJNR010202.pdf
  40. 40. West J, Taylor M, Houghton S, Hudyma S. A Comparison of Teachers’ and Parents’ Knowledge and Beliefs About Attention-Deficit/Hyperactivity Disorder(ADHD). Sch Psychol Int [Internet]. 2005 May 29;26(2):192–208. Available from: http://journals.sagepub.com/doi/10.1177/0143034305052913
  41. 41. Stangor C, Sullivan LA, Ford TE. Affective and Cognitive Determinants of Prejudice. Soc Cogn [Internet]. 1991 Dec;9(4):359–80. Available from: http://guilfordjournals.com/doi/10.1521/soco.1991.9.4.359
  42. 42. Eagly AH, Mladinic A, Otto S. Cognitive and Affective Bases of Attitudes toward Social Groups and Social Policies. J Exp Soc Psychol [Internet]. 1994 Mar;30(2):113–37. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0022103184710067
  43. 43. Department for Education. Education and Training Statistics for the United Kingdom 2019 [Internet]. 2019. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/993344/UKETS_2019_Main_text.pdf
  44. 44. Pilling S, Gould N, Whittington C, Taylor C, Scott S. Recognition, intervention, and management of antisocial behaviour and conduct disorders in children and young people: summary of NICE-SCIE guidance. BMJ [Internet]. 2013 Mar 27;346(mar27 1):f1298–f1298. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.f1298 pmid:23535256
  45. 45. Ishige N, Hayashi N. Occupation and social experience: Factors influencing attitude towards people with schizophrenia. Psychiatry Clin Neurosci [Internet]. 2005 Feb;59(1):89–95. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1819.2005.01337.x pmid:15679546
  46. 46. Bogousslavsky J, Inglin M. Beliefs and the Brain. Eur Neurol [Internet]. 2007;58(3):129–32. Available from: https://www.karger.com/Article/FullText/104711 pmid:17622716
  47. 47. Kos JM, Richdale AL, Jackson MS. Knowledge about Attention-Deficit/Hyperactivity Disorder: A comparison of in-service and preservice teachers. Psychol Sch [Internet]. 2004 May;41(5):517–26. Available from: https://onlinelibrary.wiley.com/doi/10.1002/pits.10178
  48. 48. Kolb DA. The Process of Experiential Learning. In: Experimental Learning: Experience as the Source of Leearning and Development. Prentice Hall; 1984. p. 20–38.
  49. 49. Giguère A, Zomahoun HTV, Carmichael PH, Uwizeye CB, Légaré F, Grimshaw JM, et al. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev [Internet]. 2020 Jul 31;2020(8). Available from: http://doi.wiley.com/10.1002/14651858.CD004398.pub4
  50. 50. O’Brien MA, Freemantle N, Oxman AD, Wolfe F, Davis D, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. In: O’Brien MA, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2001. Available from: https://doi.wiley.com/10.1002/14651858.CD003030
  51. 51. Mazmanian PE, Davis DA, Galbraith R. Continuing Medical Education Effect on Clinical Outcomes. Chest [Internet]. 2009 Mar;135(3):49S–55S. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0012369209601744
  52. 52. Oyler J, Vinci L, Arora V, Johnson J. Teaching Internal Medicine Residents Quality Improvement Techniques using the ABIM’s Practice Improvement Modules. J Gen Intern Med [Internet]. 2008 Jul 1;23(7):927–30. Available from: http://link.springer.com/10.1007/s11606-008-0549-5 pmid:18449612
  53. 53. Tomolo AM, Lawrence RH, Aron DC. A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum. Qual Saf Heal Care [Internet]. 2009 Jun 1;18(3):217 LP– 224. Available from: http://qualitysafety.bmj.com/content/18/3/217.abstract
  54. 54. Furnham A, Sjokvist P. Empathy and Mental Health Literacy. HLRP Heal Lit Res Pract [Internet]. 2017 Apr;1(2). Available from: http://journals.healio.com/doi/10.3928/24748307-20170328-01 pmid:31294250
  55. 55. Halligan PW, Pechey R. Exploring the Folk Understanding of Belief: Identifying Key Dimensions Endorsed in the General Population. J Cogn Cult [Internet]. 2012 Jan 1;12(1–2):81–99. Available from: https://brill.com/abstract/journals/jocc/12/1-2/article-p81_6.xml
  56. 56. Lao J, Young J. Resistance to Belief Change. New York: Routledge; 2019.
  57. 57. Ghanizadeh A, Bahredar MJ, Moeini SR. Knowledge and attitudes towards attention deficit hyperactivity disorder among elementary school teachers. Patient Educ Couns [Internet]. 2006 Oct;63(1–2):84–8. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0738399105002661 pmid:16504452
  58. 58. Alegria AA, Radua J, Rubia K. Meta-Analysis of fMRI Studies of Disruptive Behavior Disorders. Am J Psychiatry [Internet]. 2016 Nov;173(11):1119–30. Available from: http://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2016.15081089 pmid:27523497
  59. 59. Zhou J, Yao N, Fairchild G, Zhang Y, Wang X. Altered Hemodynamic Activity in Conduct Disorder: A Resting-State fMRI Investigation. Zhan W, editor. PLoS One [Internet]. 2015 Mar 27;10(3):e0122750. Available from: https://dx.plos.org/10.1371/journal.pone.0122750 pmid:25816069
  60. 60. Jaffee SR, Caspi A, Moffitt TE, Dodge KA, Rutter M, Taylor A, et al. Nature × nurture: Genetic vulnerabilities interact with physical maltreatment to promote conduct problems. Dev Psychopathol [Internet]. 2005 Mar 7;17(01). Available from: http://www.journals.cambridge.org/abstract_S0954579405050042
  61. 61. Fontaine NMG, Rijsdijk F V., McCrory EJP, Viding E. Etiology of Different Developmental Trajectories of Callous-Unemotional Traits. J Am Acad Child Adolesc Psychiatry [Internet]. 2010 Jul;49(7):656–64. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0890856710002959
  62. 62. Aspinwall LG, Brown TR, Tabery J. The Double-Edged Sword: Does Biomechanism Increase or Decrease Judges’ Sentencing of Psychopaths? Science (80-) [Internet]. 2012 Aug 17;337(6096):846–9. Available from: http://www.nature.com/articles/news.2009.1050 pmid:22904010
  63. 63. Feresin E. Lighter sentence for murderer with “bad genes.” Nature [Internet]. 2009 Oct 30; Available from: http://www.nature.com/articles/news.2009.1050
  64. 64. Scott S. Debate: ‘A rose by any other name’ would smell as sweet–myths peddled about the ills of diagnosing conduct disorders. Child Adolesc Ment Health [Internet]. 2022 Sep 26;27(3):302–4. Available from: https://onlinelibrary.wiley.com/doi/10.1111/camh.12589 pmid:35880324
  65. 65. Drerup LC, Croysdale A, Hoffmann NG. Patterns of behavioral health conditions among adolescents in a juvenile justice system. Prof Psychol Res Pract [Internet]. 2008;39(2):122–8. Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/0735-7028.39.2.122
  66. 66. Ferguson K, Ireland C. Attitudes towards sex offenders and the influence of offence type: a comparison of staff working in a forensic setting and students. Br J Forensic Pract [Internet]. 2006 May;8(2):10–9. Available from: https://www.emerald.com/insight/content/doi/10.1108/14636646200600009/full/html
  67. 67. Voisine DR. The influence of diagnostic labels, gender, and ethnicity on teacher perceptions, expectancies, and attributions: A consideration of closure, acceptance, and stigmatization [Internet]. University of Rhode Island; 2009. Available from: https://digitalcommons.uri.edu/dissertations/AAI3401121