Commentary: Optimism for the future of research on disruptive behaviors - an appreciation of good science as illustrated by Nobakht, Steinsbekk & Wichstrom (2023).

This paper by Nobakht, Steinsbekk & Wichstrom (2023) is a model of good science in the study of oppositional defiant disorder and conduct disorder. Their approach illustrates a thoughtful research design, statistical modeling sufficient to empirically evaluate developmental processes, and a full consideration of the theoretical implications of their work. This contrasts with a broad history of research on ODD and CD that far too often has only reified biased assumptions about these phenomena rather than rigorously scrutinizing them. Their demonstration of a unidirectional developmental flow of influence from ODD to interparental aggression, and thence to CD highlights a set of complicated developmental processes involving these disorders and their environment. It expands on evidence of the toll that ODD exerts on parents and provides guidance for more specific intervention. Standards in developmental psychopathology research should include testing bidirectional processes and employing designs that could falsify rather than reify existing beliefs. Examining key mechanisms in such processes will more rapidly generate improvements in assessment and treatment.

Measuring Children's Reward and Punishment Sensitivity: An Initial Psychometric Evaluation of the Contingency Response Rating Scale.

Existing research shows that children's responses to rewards and punishments are essential for understanding attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and callous-unemotional traits. The present study developed the Contingency Response Rating Scale (CRRS) to fulfill the need for a reliable and valid measure of children's contingency response style that is brief, easy to use in applied settings, and provides additional information to existing clinical measures. We examined the psychometric properties of the CRRS in a sample of 196 children (ages 5-12), most of whom were referred to evaluate attention and behavior problems in an outpatient clinic. Using principal axis factoring, we identified five factors: (a) punishment ineffectiveness, (b) reward ineffectiveness, (c) punishment dysregulation, (d) reward dysregulation, and (e) contingency insensitivity. The subscales based on these factors showed acceptable test-retest and internal consistency reliability, and scale intercorrelations varied from low to moderate. The subscales also captured significant variance not explained by child or parent demographics and were associated with measures of psychopathology and impairment. The results provide preliminary evidence that the CRRS may be a helpful tool for assessing reward and punishment sensitivity in children with attention and behavior problems.

The amygdala volume moderates the relationship between childhood maltreatment and callous-unemotional traits in adolescents with conduct disorder.

CU traits, characterized by shallow affect, lack of fear, and absence of remorse, have been moderately associated with childhood maltreatment in a recent meta-analysis. However, the potential impact of brain structures remains undetermined. This paper examines the relationship between callous-unemotional (CU) traits, childhood maltreatment, and amygdala volumes. In this study, we used a region-of-interest (ROI) analysis to explore the interaction between the volumes of the amygdala, childhood maltreatment, and the manifestation of CU traits in adolescents diagnosed with conduct disorder (CD, N = 67), along with a comparison group of healthy-control youths (HCs, N = 89). The ROI analysis revealed no significant group differences in the bilateral amygdalar volumes. Significant positive correlation was discovered between all forms of child maltreatment (except for physical neglect) and CU traits across subjects. But the interaction of physical abuse and amygdala volumes was only significant within CD patients. Notably, a sensitivity analysis suggested that gender significantly influences these findings. These results contribute critical insights into the etiology of CU traits, emphasizing the need for customized clinical assessment tools and intervention strategies.

Alcohol milestones and internalizing, externalizing, and executive function: longitudinal and polygenic score associations.

BACKGROUND: Although the link between alcohol involvement and behavioral phenotypes (e.g. impulsivity, negative affect, executive function [EF]) is well-established, the directionality of these associations, specificity to stages of alcohol involvement, and extent of shared genetic liability remain unclear. We estimate longitudinal associations between transitions among alcohol milestones, behavioral phenotypes, and indices of genetic risk. METHODS: Data came from the Collaborative Study on the Genetics of Alcoholism (n = 3681; ages 11-36). Alcohol transitions (first: drink, intoxication, alcohol use disorder [AUD] symptom, AUD diagnosis), internalizing, and externalizing phenotypes came from the Semi-Structured Assessment for the Genetics of Alcoholism. EF was measured with the Tower of London and Visual Span Tasks. Polygenic scores (PGS) were computed for alcohol-related and behavioral phenotypes. Cox models estimated associations among PGS, behavior, and alcohol milestones. RESULTS: Externalizing phenotypes (e.g. conduct disorder symptoms) were associated with future initiation and drinking problems (hazard ratio (HR)⩾1.16). Internalizing (e.g. social anxiety) was associated with hazards for progression from first drink to severe AUD (HR⩾1.55). Initiation and AUD were associated with increased hazards for later depressive symptoms and suicidal ideation (HR⩾1.38), and initiation was associated with increased hazards for future conduct symptoms (HR = 1.60). EF was not associated with alcohol transitions. Drinks per week PGS was linked with increased hazards for alcohol transitions (HR⩾1.06). Problematic alcohol use PGS increased hazards for suicidal ideation (HR = 1.20). CONCLUSIONS: Behavioral markers of addiction vulnerability precede and follow alcohol transitions, highlighting dynamic, bidirectional relationships between behavior and emerging addiction.

Moving forward. Use of the START NOW skills training program for female youth with ODD and CD - a commentary on Stadler et al. (2024).

Female youth with oppositional defiant disorder (ODD) and conduct disorder (CD) are an under studied and underserved population at high risk for poor adjustment in later life. Stadler et al. (2024) attempt to redress this situation for adolescent females with CD or ODD with an adapted version of the skills training program START NOW. They describe the results of an ambitious randomized control trial, comparing START NOW with standard care in youth welfare settings in Germany, Switzerland, and The Netherlands. The findings appear promising, but the paper is especially valuable for the spotlight it shines on the needs of this underserved population and those caring for them, together with the importance of undertaking such trials despite their challenges. This commentary seeks to encourage readers to engage with the START NOW trial.

Does the Relationship between Age and Brain Structure Differ in Youth with Conduct Disorder?

Conduct disorder (CD) is characterised by persistent antisocial and aggressive behaviour and typically emerges in childhood or adolescence. Although several authors have proposed that CD is a neurodevelopmental disorder, very little evidence is available about brain development in this condition. Structural brain alterations have been observed in CD, and some indirect evidence for delayed brain maturation has been reported. However, no detailed analysis of age-related changes in brain structure in youth with CD has been conducted. Using cross-sectional MRI data, this study aimed to explore differences in brain maturation in youth with CD versus healthy controls to provide further understanding of the neurodevelopmental processes underlying CD. 291 CD cases (153 males) and 379 healthy controls (160 males) aged 9-18 years (Mage = 14.4) were selected from the European multisite FemNAT-CD study. Structural MRI scans were analysed using surface-based morphometry followed by application of the ENIGMA quality control protocols. An atlas-based approach was used to investigate group differences and test for group-by-age and group-by-age-by-sex interactions in cortical thickness, surface area and subcortical volumes. Relative to healthy controls, the CD group showed lower surface area across frontal, temporal and parietal regions as well as lower total surface area. No significant group-by-age or group-by-age-by-sex interactions were observed on any brain structure measure. These findings suggest that CD is associated with lower surface area across multiple cortical regions, but do not support the idea that CD is associated with delayed brain maturation, at least within the age bracket considered here.

The Interplay between Fear Reactivity and Callous-Unemotional Traits Predicting Reactive and Proactive Aggression.

Research has indicated that youths with CU traits are fearless, and this fearlessness plays a bidirectional role in both the development of CU traits and engagement in aggressive behavior. However, research specifically testing the role of fear in the association between CU traits and aggression is scarce. The goal of the current study was to test if fear reactivity, both conscious (self-report) and automatic (skin conductance reactivity; SCR), moderated the association between CU traits and aggression subtypes (reactive and proactive aggression). Participants included 161 adolescents (Mage = 15 years) diagnosed with conduct disorder. CU traits were assessed using the self-report Inventory of Callous-Unemotional Traits. Conscious and automatic fear reactivity were measured during a virtual reality rollercoaster using the Self-Assessment Manikin and skin conductance reactivity (SCR), respectively. Hierarchical regressions found that high fear reactivity on SCR moderated the link between CU traits and reactive aggression, while feeling more excited during fear induction moderated the link between CU traits and proactive aggression. Overall, a possible explanation of our divergent findings between conscious and automatic fear may be the difference between the instinctual biological response to threat versus the cognitive and emotional appraisal and experience of threat. Implications for intervention strategies targeting emotional recognition and regulation in reducing aggression in CD populations are discussed.

The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders.

BACKGROUND: The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression. METHODS: A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires. RESULTS: Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression. CONCLUSIONS: These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

The Child Behavior Check List Usefulness in Screening for Severe Psychopathology in Youth: A Narrative Literature Review.

OBJECTIVE: This article will review the use of the CBCL to diagnose youth with psychopathological disorders focusing on: ADHD, Mood Disorders, Autism Spectrum disorders, and Disruptive Disorders. METHOD: Using a narrative review approach, we investigate the usefulness of the CBCL as a screening tool to detect childhood onset psychopathology across different diagnostic syndromes. RESULTS: The available literature supports the use of the CBCL for ADHD screening and as a measure of ADHD severity. While some studies support a specific profile linked with childhood bipolar disorder, replication studies for this profile found mixed results. The CBCL was also found to be useful in screening for patients presenting with Autism Spectrum Disorders, Conduct Disorder, and Childhood Bipolar Disorder all of which presents with more severely impaired scores. CONCLUSION: The CBCL holds promise as a screening tool for childhood psychopathology.

Prevalence of mental disorders in closed educational centers in France.

INTRODUCTION: Closed educational centres (CEC) receive young offenders who most often have a conduct disorder (CD). Mental disorders other than conduct disorder are a negative factor in the effect of educational actions. Moreover, adverse life experiences are frequent vulnerability factors in this population. This article aims to document the prevalence and links between psychiatric disorders, exposure to trauma, and the psycho-behavioural characteristics of adolescents placed in CEC. METHOD: We conducted a multicentre epidemiological study on a sample of 101 adolescents placed in nine closed educational centres in France. Psychiatric disorders were measured by the MINI-KID 2 and Conners Rating Scale questionnaires. Several questionnaires were used to collect sociodemographic data and the psychological profile of each adolescent. RESULTS: Among the adolescents, 90.2% had at least one mental disorder with a predominance of conduct disorder (80%). Comorbidity was also frequently found: among the subjects with conduct disorder, 37% had at least one other psychiatric disorder. Interestingly, the intensity of conduct disorder and the Adverse Childhood Experiences (ACE) score were significantly correlated. Furthermore, two subgroups were identified: adolescents with isolated conduct disorder (44.6%) and adolescents with other psychiatric disorders (45.7%) with or without conduct disorder. The latter subgroup showed higher vulnerability and poorer outcomes in terms of attachment patterns, feelings of abandonment, hostility and impulsivity. CONCLUSION: This study is the first French epidemiological study of mental disorders in juvenile offenders. It suggests that the detection of psychiatric disorders in young people in CEC is an important prerequisite for the implementation of targeted interventions according to different profiles. Furthermore, collaboration between the medical-psychological and judicial fields, in the form of an operational partnership, is necessary to guarantee better support for these young people.

Randomized controlled trial of individualized arousal-biofeedback for children and adolescents with disruptive behavior disorders (DBD).

Disruptive behavior disorders [including conduct disorder (CD) and oppositional defiant disorder (ODD)] are common childhood and adolescent psychiatric conditions often linked to altered arousal. The recommended first-line treatment is multi-modal therapy and includes psychosocial and behavioral interventions. Their modest effect sizes along with clinically and biologically heterogeneous phenotypes emphasize the need for innovative personalized treatment targeting impaired functions such as arousal dysregulation. A total of 37 children aged 8-14 years diagnosed with ODD/CD were randomized to 20 sessions of individualized arousal biofeedback using skin conductance levels (SCL-BF) or active treatment as usual (TAU) including psychoeducation and cognitive-behavioral elements. The primary outcome was the change in parents´ ratings of aggressive behavior measured by the Modified Overt Aggression Scale. Secondary outcome measures were subscales from the Child Behavior Checklist, the Inventory of Callous-Unemotional traits, and the Reactive-Proactive Aggression Questionnaire. The SCL-BF treatment was neither superior nor inferior to the active TAU. Both groups showed reduced aggression after treatment with small effects for the primary outcome and large effects for some secondary outcomes. Importantly, successful learning of SCL self-regulation was related to reduced aggression at post-assessment. Individualized SCL-BF was not inferior to active TAU for any treatment outcome with improvements in aggression. Further, participants were on average able to self-regulate their SCL, and those who best learned self-regulation showed the highest clinical improvement, pointing to specificity of SCL-BF regulation for improving aggression. Further studies with larger samples and improved methods, for example by developing BF for mobile use in ecologically more valid settings are warranted.

Recognition and management of children and adolescents with conduct disorder: a real-world data study from four western countries.

BACKGROUND: Conduct disorders (CD) are among the most frequent psychiatric disorders in children and adolescents, with an estimated worldwide prevalence in the community of 2-4%. Evidence-based psychological outpatient treatment leads to significant improvement in about two-thirds of cases. However, there seems to be considerable variation in rates of CD diagnoses and implementation of evidence-based interventions between nations. The aim of this study was to compare administrative prevalence and treatment patterns for CD in children and adolescents seen in health care systems across four Western countries (Denmark, Germany, Norway, and the USA). METHODS: Cross-sectional observational study using healthcare data to identify children and adolescents (aged 0-19 years) with an ICD-10 code for CD within the calendar year 2018. Within each country's study population, the prevalence of CD, psychiatric comorbidity, psychopharmacological treatment, and psychiatric hospitalisation was calculated. RESULTS: The prevalence of diagnosed CD differed 31-fold between countries: 0.1% (Denmark), 0.3% (Norway), 1.1% (USA) and 3.1% (Germany), with a male/female ratio of 2.0-2.5:1. The rate of psychiatric comorbidity ranged from 69.7 to 86.1%, with attention-deficit/hyperactivity disorder being most common. Between 4.0% (Germany) and 12.2% (USA) of youths with a CD diagnosis were prescribed antipsychotic medication, and 1.2% (Norway) to 12.5% (Germany) underwent psychiatric hospitalisation. CONCLUSION: Recognition and characteristics of youths diagnosed with CD varied greatly by country. In some countries, the administrative prevalence of diagnosed CD was markedly lower than the average estimated worldwide prevalence. This variation might reflect country-specific differences in CD prevalence, referral thresholds for mental health care, diagnostic tradition, and international variation in service organisation, CD recognition, and availability of treatment offers for youths with CD. The rather high rates of antipsychotic prescription and hospitalisation in some countries are remarkable, due to the lack of evidence for these therapeutic approaches. These findings stress the need of prioritising evidence-based treatment options in CD. Future research should focus on possible reasons for inter-country variation in recognition and management of CD, and also address possible differences in patient-level outcomes.

Impaired Punishment Learning in Conduct Disorder.

OBJECTIVE: Conduct disorder (CD) has been associated with deficits in the use of punishment to guide reinforcement learning (RL) and decision making. This may explain the poorly planned and often impulsive antisocial and aggressive behavior in affected youths. Here, we used a computational modeling approach to examine differences in RL abilities between CD youths and typically developing controls (TDCs). Specifically, we tested 2 competing hypotheses that RL deficits in CD reflect either reward dominance (also known as reward hypersensitivity) or punishment insensitivity (also known as punishment hyposensitivity). METHOD: The study included 92 CD youths and 130 TDCs (aged 9-18 years, 48% girls) who completed a probabilistic RL task with reward, punishment, and neutral contingencies. Using computational modeling, we investigated the extent to which the 2 groups differed in their learning abilities to obtain reward and/or to avoid punishment. RESULTS: RL model comparisons showed that a model with separate learning rates per contingency explained behavioral performance best. Importantly, CD youths showed lower learning rates than TDCs specifically for punishment, whereas learning rates for reward and neutral contingencies did not differ. Moreover, callous-unemotional (CU) traits did not correlate with learning rates in CD. CONCLUSION: CD youths have a highly selective impairment in probabilistic punishment learning, regardless of their CU traits, whereas reward learning appears to be intact. In summary, our data suggest punishment insensitivity rather than reward dominance in CD. Clinically, the use of punishment-based intervention techniques to achieve effective discipline in patients with CD may be a less helpful strategy than reward-based techniques.

Novel Oppositional Defiant Disorder or Conduct Disorder 24 Months After Traumatic Brain Injury in Children and Adolescents.

OBJECTIVE: The authors sought to identify predictive factors of new-onset or novel oppositional defiant disorder or conduct disorder assessed 24 months after traumatic brain injury (TBI). METHODS: Children ages 5 to 14 years who had experienced TBI were recruited from consecutive hospital admissions. Soon after injury, participants were assessed for preinjury characteristics, including psychiatric disorders, socioeconomic status (SES), psychosocial adversity, and family function, and the presence and location of lesions were documented by MRI. Psychiatric outcomes, including novel oppositional defiant disorder or conduct disorder, were assessed 24 months after injury. RESULTS: Of the children without preinjury oppositional defiant disorder, conduct disorder, or disruptive behavior disorder not otherwise specified who were recruited in this study, 165 were included in this sample; 95 of these children returned for the 24-month assessment. Multiple imputation was used to address attrition. The prevalence of novel oppositional defiant disorder or conduct disorder was 23.7 out of 165 (14%). In univariable analyses, novel oppositional defiant disorder or conduct disorder was significantly associated with psychosocial adversity (p=0.049) and frontal white matter lesions (p=0.016) and was marginally but not significantly associated with SES. In the final multipredictor model, frontal white matter lesions were significantly associated with novel oppositional defiant disorder or conduct disorder (p=0.021), and psychosocial adversity score was marginally but not significantly associated with the outcome. The odds ratio of novel oppositional defiant disorder or conduct disorder among the children with versus those without novel depressive disorder was significantly higher for girls than boys (p=0.025), and the odds ratio of novel oppositional defiant disorder or conduct disorder among the children with versus those without novel attention-deficit hyperactivity disorder (ADHD) was significantly higher for boys than girls (p=0.006). CONCLUSION: Approximately 14% of children with TBI developed oppositional defiant disorder or conduct disorder. The risk for novel oppositional defiant disorder or conduct disorder can be understood from a biopsychosocial perspective. Sex differences were evident for comorbid novel depressive disorder and comorbid novel ADHD.

Umbrella Review of the Global Prevalence of Conduct Disorder in Children and Adolescents.

With the ever-increasing prevalence of mental health issues worldwide, a robust synthesis of existing epidemiological data on the prevalence of Conduct disorder (CD) in children and adolescents is needed to strengthen the knowledge base. This quantitative umbrella review aims to provide a robust synthesis of evidence on the prevalence of CD children and adolescents from meta-analytic systematic reviews. We searched PubMed, Web of Science, PsychINFO, and Scopus to identify relevant articles. The study protocol has been registered with PROSPERO (CRD42023447620). The methodological quality of the studies was evaluated by using a Measurement Tool to Assess Systematic Reviews (AMSTAR). Invariance variance weighted random-effect meta-analysis was performed to pool prevalence estimates from the included articles. Seven meta-analyses, encompassing 138 primary studies and slightly over 48 million CD cases were included in this umbrella review. The quantitative analysis of these studies found a pooled prevalence of CD 3.0% (95%CI 2.0-5%) in children and adolescents, based on random effect meta-analyses. In a stratified analysis, the prevalence estimate of CD was 2.6 times higher in boys compared to girls. Evidence from our quantitative umbrella review showed that the prevalence of CD is relatively high in children and adolescents with boys 2.6 times more likely to experience the disorders when compared to girls. Our findings underlie that attention should be given to preventing, identifying, and treating CD in children and adolescents.

START NOW: a cognitive behavioral skills training for adolescent girls with conduct or oppositional defiant disorder - a randomized clinical trial.

BACKGROUND: Conduct disorder (CD) and oppositional defiant disorder (ODD) both convey a high risk for maladjustment later in life and are understudied in girls. Here, we aimed at confirming the efficacy of START NOW, a cognitive-behavioral, dialectical behavior therapy-oriented skills training program aiming to enhance emotion regulation skills, interpersonal and psychosocial adjustment, adapted for female adolescents with CD or ODD. METHODS: A total of 127 girls were included in this prospective, cluster randomized, multi-center, parallel group, quasi-randomized, controlled phase III trial, which tested the efficacy of START NOW (n = 72) compared with standard care (treatment as usual, TAU, n = 55). All female adolescents had a clinical diagnosis of CD or ODD, were 15.6 (±1.5) years on average (range: 12-20 years), and were institutionalized in youth welfare institutions. The two primary endpoints were the change in number of CD/ODD symptoms between (1) baseline (T1) and post-treatment (T3), and (2) between T1 and 12-week follow-up (T4). RESULTS: Both treatment groups showed reduced CD/ODD symptoms at T3 compared with T1 (95% CI: START NOW = -4.87, -2.49; TAU = -4.94, -2.30). There was no significant mean difference in CD/ODD symptom reduction from T1 to T3 between START NOW and TAU (-0.056; 95% CI = -1.860, 1.749; Hedge's g = -0.011). However, the START NOW group showed greater mean symptom reduction from T1 to T4 (-2.326; 95% CI = -4.274, -0.378; Hedge's g = -0.563). Additionally, secondary endpoint results revealed a reduction in staff reported aggression and parent-reported irritability at post assessment. CONCLUSIONS: Although START NOW did not result in greater symptom reduction from baseline to post-treatment compared with TAU, the START NOW group showed greater symptom reduction from baseline to follow-up with a medium effect size, which indicates a clinically meaningful delayed treatment effect.

Proposed Specifiers for Conduct Disorder (PSCD) scale: A Latent Profile Analysis with At-Risk Adolescents.

The Proposed Specifiers for Conduct Disorder (PSCD; Salekin in Pers Disord: Theory Res Treat 7:180-191, 2016) scale was designed to assess interrelated psychopathic trait domains in conjunction with symptoms of Conduct Disorder (CD) in children and adolescents (i.e., grandiose-manipulative, callous-unemotional, daring-impulsive). Variable-centered studies have provided support for a four-factor PSCD structure (Salekin et al. in Psychol Assess 34(10):985-992, 2022) in line with other adolescent and adult studies. The current person-centered study used latent profile analysis of the PSCD domains to examine whether theoretically meaningful and empirically robust PSCD subtypes emerged from a diverse sample (70.9% White, 20.1% Black, 3.6% Hispanic, and 5.4% other) of adolescents (modal age = 17) in a military style residential facility (N = 409; Males = 80.6%). As hypothesized, a four-class solution was best, consistent with adult psychopathy subtyping research (Hare et al. in Handbook of Psychopathy 39-79, 2018; Roy et al. in Pers Disord: Theory Res Treat, in press). The PSCD subtype profiles were uniform across sex and race/ethnicity. Adolescents evincing a psychopathic trait propensity profile (elevated on all four PSCD domains) displayed the greatest number of arrests and higher overall externalizing psychopathology, compared to the other three latent classes, as well as higher internalizing psychopathology compared to adolescents with general delinquency. The PSCD provides a sound measure of psychopathic trait propensities in youth and our results offer investigators and clinicians a means for understanding person-centered psychopathic traits versus antisocial profiles among at-risk adolescents. Taken together, the current results may offer a viable approach for examining specific treatment targets based on PSCD subtype profiles.

Heritable Composite Phenotypes Defined by Combinations of Conduct Problem, Depression, and Temperament Features: Contributions to risk for Alcohol Problems.

The genetic architectures underlying symptoms of conduct problems and depression have largely been examined separately and without incorporating temperament, despite evidence for their genetic overlap. We examined how symptoms and temperament dimensions were transmitted together in families to identify highly heritable composite phenotypes, and how these composite phenotypes predicted alcohol outcomes in young adulthood. Participants (N = 486) were drawn from the third generation of families oversampled for alcohol use disorder in the first generation. Conduct problems, depression, and temperament were reported at 11-19 years old and alcohol outcomes at 18-26 years old. Using principal components of heritability analysis, we found seven highly heritable composite phenotypes, five of which predicted alcohol outcomes: three characterized by co-occurring conduct problems and depression and two by conduct problems. Novel composite phenotypes that were characterized by both conduct problems and depression showed different types of symptoms, temperament features, and genetic underpinnings. Children manifesting differing composite phenotypes might benefit from distinct treatments based on their unique etiologies.