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Child Neuropsychology: A Journal onNormal and Abnormal Development inChildhood and AdolescencePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/ncny20

Visual orientation in hospitalized boyswith early onset conduct disorder andborderline intellectual functioningJaap van der Meere a , Norbert Börger a & Silja Pirila ba Clinical and Developmental Neuropsychology , University ofGroningen , Groningen , The Netherlandsb Pediatrics , Tampere University Hospital , Tampere , FinlandPublished online: 27 Apr 2011.

To cite this article: Jaap van der Meere , Norbert Börger & Silja Pirila (2012) Visual orientation inhospitalized boys with early onset conduct disorder and borderline intellectual functioning, ChildNeuropsychology: A Journal on Normal and Abnormal Development in Childhood and Adolescence,18:1, 12-22, DOI: 10.1080/09297049.2011.555943

To link to this article: http://dx.doi.org/10.1080/09297049.2011.555943

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Child Neuropsychology, 2012, 18 (1), 12–22http://www.psypress.com/childneuropsychISSN: 0929-7049 print / 1744-4136 onlinehttp://dx.doi.org/10.1080/09297049.2011.555943

Visual orientation in hospitalized boys with early onset

conduct disorder and borderline intellectual functioning

Jaap van der Meere1, Norbert Börger1, and Silja Pirila2

1Clinical and Developmental Neuropsychology, University of Groningen, Groningen,The Netherlands2Pediatrics, Tampere University Hospital, Tampere, Finland

The aim of the present study is to investigate visual orientation in hospitalized boys with severe earlyonset conduct disorder and borderline intellectual functioning. It is tested whether boys with the dualdiagnosis have a stronger action-oriented response style to visual-cued go signals than the norm. To thisend, boys with the dual diagnosis were compared with a peer control group on Posner’s (1980) visual-spatial detection test. Here, on each trial, a visual cue points either in the direction of the location ofa subsequent go signal (valid cue), or points in the opposite direction away from the location of thesubsequent go signal (invalid cue). Findings indicated superior orientation (a strong action-orientedresponse style) of children with the dual diagnosis in valid-cued trials as well as in invalid-cued trialsin both the left and the right visual hemifield. Findings were controlled for attention scores on theChild Behavior Checklist -Teacher Form and IQ scores.

Keywords: Early onset conduct disorder; Borderline intellectual functioning; Visual orientation;Impulse control; Antisocial behavior.

Epidemiological studies indicate that many children with Conduct Disorder (CD;Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV; AmericanPsychiatric Association, 1994]) progress towards antisocial personality disorder (ASPD:DSM-IV) (Loeber, Burke, & Lahey, 2002). Nevertheless, the accuracy of predicting ofwhich children with CD will not become antisocial adults is greater than the prediction ofwhich children will become antisocial adults (Maugham & Rutter, 2001). Understandingchildhood predictors of later ASPD to inform research on preventing intervention is apressing priority for both the public health and criminal justice systems (Lahey, Loeber,Burke, & Applegate, 2005).

One factor that might be involved in the degree of continuity from CD to ASPDis concurrent attention deficit/hyperactivity disorder (ADHD) and its associated lack ofimpulse control (Connor & Doerfler, 2008; Harty, Miller, Newcorn, & Halperin, 2009;Mathias, Furr, Daniel, Marsch, Shannon, & Dougherty, 2007; Moffitt et al., 2008).

The study was funded by the Stichting Zorgverlening’s Heeren Loo/Stichting Steunfonds, Amersfoort,The Netherlands.

Address correspondence to Jaap van der Meere, University of Groningen - Clinical and DevelopmentalNeuropsychology, Grote Kruisstraat 2/1 Groningen 9711 HS, The Netherlands. E-mail: j.j.van.der.meere@rug.nl

© 2012 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business

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VISUAL ORIENTATION AND CD PLUS BIF 13

However, Lahey et al. (2005) suggested that CD but not concurrent ADHD significantlypredict subsequent ASPD.

Many laboratory studies have been carried out aimed to pinpoint more precisely thecognitive mechanisms underlying the lack of impulse control in children with CD onlyand children with CD plus ADHD. Results are confusing. Some research indicated thatthe lack of impulse control in children with CD is associated with concurrent ADHD, nottheir CD symptoms (Pennington & Ozonoff, 1996). Other research suggested the opposite:The lack of impulse control is associated with CD, not their concurrent ADHD (Toupin,Dery, Pauze, Mercier, & Fortin, 2000). Finally, it has been reported that children withADHD only and CD only showed more prominent lack of impulse control than chil-dren with ADHD plus CD (Albrecht, Banaschewsky, Brandeis, Heinrich, & Rothenberger,2005). The inconsistency in results may at least be partly the result of methodologicalissues such as sample strategy (recruitment of children from clinics rather than population-based samples) and gender (most of the studies are limited to males). Also, the manydefinitions of impulse control (including the lack of social responsibility, risk taking, andtask-inappropriate responding) may have contributed to the inconsistency in results. It isclear that more research is needed on impulse control in children with CD.

So far, virtually all of the cognitive studies on impulse control of children with CDwith or without concurrent ADHD are undertaken with samples with an IQ above 80. This,in spite of the fact that the prognosis is probably worst in children with early onset CD (atleast one CD criterion prior to age 10) in conjunction with low IQ (Moffitt, Caspi, Rutter,& Silva, 2001; Saterfield et al., 2007; Simonoff et al., 2004). As a result, there is lack ofstudies on impulse control in children with possibly the highest risk of developing ASPD.

To date, three studies focused on impulse control, defined in terms of task-inappropriate responding, are available on hospitalized boys with early-onset CD plus anIQ level between 70 and 85 (borderline intellectual functioning [BIF]; DSM-IV) (Van derMeer, & van der Meere, 2004; van der Meere, van der Meer, Borger, & Pirila, 2008; van derMeere, van der Meer, Kunert, Borger, & Pirila, 2008). To what extent the participating boysin these studies were also suffering from ADHD remains unknown. The participants of thestudies were placed in the institute under the Child Protection Act and credible reporters(parents) about the boys’ childhood behavior were not available: To qualify for the DSM-IVADHD diagnosis, the symptoms must be present prior to the age of 7 years old and wellrecognized in the home and at school. Therefore, the researchers had to rely on behav-ior ratings of professional staff members who completed the Child Behavior Checklist –Teacher form (CBCL-TRF; Achenbach, 1991). The list provides information about theextent of internalizing and externalizing problems.

The first two studies were Go/No-Go studies. The results indicated that, comparedto the norm, the boys with CD plus BIF were responding fast to both, go and to no-gosignals, producing many errors of commission (van der Meer & van der Meere, 2004; vander Meere, van der Meer, Borger, & Pirila, 2008). The result could be explained in termsof hasty decision making seen as an aspect of poor impulse control. In the third study,the participants were instructed to press the response button when a cross appeared on thescreen. The cross was preceded by an acoustic signal. It appeared that boys with CD plusBIF made many preliminary responses, that is, responses after the auditory cue but beforethe presentation of the visual “go” signal. This finding could be explained in terms of astrong action-oriented approach, that is, responding to any stimulus that appears, in thiscase an auditory cue (van der Meere, Van der Meer, Kunert, et al., 2008).

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14 J. VAN DER MEERE ET AL.

In sum, three studies indicated that boys with early onset CD and BIF havea lack of impulse control: They are hasty decision makers and they have difficultiesdelaying/inhibiting their responses to cues in the auditory domain. Findings were con-trolled for concurrent ADHD symptoms (the DSM scale ADHD of the CBCL-TRF) andIQ level. Thus, the lack of impulse control in the boys was associated with CD, not withADHD and/or their BIF.

The present study investigates whether hospitalized boys with early-onset CD plusBIF have a strong action-oriented response style in the visual domain. To this end, boyswith the dual diagnosis recruited from a residential setting are compared with the norm onPosner’s (1980) visual covert orienting task. The task taps covert shifts of attention (orien-tation) defined as a move of attention to an area of the peripheral or parafoveal visual fieldin the absence of eye movement. This process is commonly referred to as the endogenous-orienting mechanism, which is effortful and consciously directed. Reactions to go signalspreceded by valid cues are typically fast, because the person’s attention is already there. Ifthe go signal appears on the opposite side of the monitor, attention must be shifted to thatlocation. The difference in reaction times on valid and invalid trials measures how muchtime it takes to shift attention and gives an indication of the viability of the voluntary covertorienting system. In addition, the task allows comparison of the functional integrity of thetwo brain hemispheres (e.g., slow reaction times to an invalid-cued right visual field targetimplies pathology of the disengagement process in the left visual field, and thus pathologyof the right hemisphere and vice versa). It is hypothesized that relative to the norm, thetarget group is responding faster in both the valid and invalid trials, indicating an action-oriented responding style. In addition, it is tested whether the action-oriented respondingin the target group is connected with a field advantage.

METHOD

Participants

The experiment took place in a residential setting specialized in treating childrenwith learning disabilities (IQ level below 85) and concurrent severe disruptive behavior.In order to prevent sample heterogeneity, boys with concurrent psychiatric disorders (i.e.,psychosis), neurological impairments, and internalizing disorders were excluded.

Thirty boys with a mean age of 12 years 1 month (SD = 16 months) participatedin the study on a strictly voluntary basis. Three years before the experiment started, theywere diagnosed as having early-onset CD plus BIF (mean Full Scale IQ = 74, SD = 8;mean Verbal IQ = 71, SD = 10; mean Performance IQ = 78, SD = 7). Whether the boysfulfilled the ADHD DSM-IV criteria remained an open question. To qualify for the DSM-IV ADHD diagnosis, the symptoms must be present prior to the age of 7 years old andwell recognized in the home and at school. However, parents were not available (manyboys were placed in the institute under the Child Protection Act) or were unwilling tocooperate and to provide this important information. IQ was assessed using the WechslerIntelligence Scale for Children–Third Edition (WISC-III; The Psychological Corporation,1991). Criteria for residential placement were the presence of both a dysfunctional family(boys were often abused) and disruptive behavior in the community, which would precludefoster-care placement. The boys had a long history of care and were admitted because allprevious treatment had failed. The reason why the study focused on boys was that therewere few girls with early-onset CD living in the participating institute.

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VISUAL ORIENTATION AND CD PLUS BIF 15

A few weeks before the experiment started, the diagnosis of the boys was checkedindependently by a child psychiatrist and clinical psychologist. It appeared that at leastthree CD symptoms were still present. Boys’ kinds of disruptive behavior may be bestdescribed in terms of aggressive CD (attacks, blaming others, cruel fights, bullies, andspiteful behavior) and intermediate aggressive CD (stealing, lying, fire setting, vandalism,and cruelty to animals) (Lahey & Loeber, 1994). In sum, the CD problems of the boys wereversatile (at least three symptoms) and stable over time (at least three years).

Weeks before the experiment started, staff professionals working on a daily routinewith the boys completed the CBCL-TRF. The CBCL was administered because the listgives a good indication of possible concurrent internalizing behaviors and ADHD. With amean T-score of 68 (range 65–70) for aggressive behavior, boys scored in the problematicrange. Mean scores for social problems and delinquent behavior were both 65 (range 55–68). The mean score for ADHD was 60 (range 55–68) (six boys had an ADHD score withinthe problematic range). Scores for the other domains, including internalizing behaviors,were around 50.

The control group consisted of 188 boys with a mean age of 11 years 7 months (SD =10 months). The boys were recruited from normal schools and can be best described as arandom school population. The parents of the boys were informed about the aim of thestudy by a letter and by an information session. They had to give written consent for theparticipation of their children. The boys themselves participated on a voluntary basis andreceived no reward for their participation. All boys had an IQ score above 90, estimatedusing the subtests Arithmetic, Vocabulary, and Block Design of the WISC-III. Their CBCLscores fell within the normal range. The boys were not checked for neurologic disturbances.The control group and the group with the dual diagnosis did not differ with respect totheir age.

Task

The boys with the dual diagnosis were tested in the residential setting. The controlboys were tested at their schools. Although the two groups of boys were tested in differentsettings, all boys used equivalent stimulus response devices and had equivalent testingenvironments (e.g., level of comfort, ease of responding). The testing session did alwaysoccur in a distraction-free setting.

Each boy sat in front of a monitor screen (15”) with the head positioned on a headrest.The eyes-to-screen distance was 40 cm. Boys were instructed to focus on a fixation dot (0.8× 0.6 cm) with a visual angle of 0.5◦ presented in the middle of the screen. An arrow (0.8× 1 cm) was then presented at fixation (central cueing). In 50% of the trials (n = 100),the arrow pointed to the right and in the other 50% to the left. After the arrow presentation,the go signal (letter X: 0.8 x 1 cm) was presented horizontally equidistant to the right or tothe left side of the former arrow fixation with a distance of 6.5 cm and with a visual angleof 0.94◦. Each participant was instructed to press a response button as fast as possiblewith the index finger of his dominant hand when the go signal appeared on the screen(simple detection). In 80% (n = 160) of the trials, the arrow pointed in the direction of thesubsequent target location (the valid-cue condition). In 20% (n = 40) of the trials, the arrowpointed in the opposite direction away from the subsequent target location (the invalid-cuecondition). The experiment including instruction and training lasted about 15 minutes.

First, probabilistic cueing was used because it prevents the start of disengagementand attention move operations as a result of building-up expectations about whether the

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16 J. VAN DER MEERE ET AL.

coming cue is valid or not (Alvarez & Freides, 2004). Second, the interval between thepresentation of the arrow (cue) and the target letter (X) varied from 275 to 400 ms. Suchintervals were used to tap endogenous disengagement/orienting/reengagement of attentionto the new target location (Alvarez & Freides, 2004). The intertrial interval was 2000 ms.The cue duration was 150 ms. The target duration was 50 ms. The stimuli were black on awhite background. Third, like many recent studies (Alvarez & Freides, 2004), we adoptedthe argument of Jonides and Mack (1984) not to use neutral stimuli in the experiment.When used, they are less frequent than validly cued trials and may consequently changeparticipant’s level of arousal.

Instruction and Administration

The boys were instructed about the meaning of the test and were told to react asquickly as possible but to maintain a high level of accuracy. Boys were instructed to keeptheir eyes focused on the fixation dot and not to move them during a trial. During theentire experiment, the experimenter was seated next to the boys to monitor eye movementsvia a mirror placed above the screen (McDonald, Bennett, Chambers, & Castiello, 1999).Trials with eye movements were discarded if the experimenter detected eye movementsaway from the fixation dot during the execution of the response. These reaction times wereafterwards excluded from the reaction time (RT) analyses. The boys practiced until theyfully understood the intention of the test (criterion training). No feedback of response speedand accuracy was given by the computer or by the experimenter during the experiment.

Design and Analysis

The design was a repeated-measurement ANOVA design with group (two levels:children with the dual diagnosis versus control children) as the between-subject factor. Thewithin-subject factors were trail type (valid versus invalid cue) and visual field (left versusright target presentation). The dependent variables were mean RT, the standard deviation ofRT, and number of errors of commission. Reaction times greater than 1800 ms, or absent,were registered as omission errors. Assumptions for parametric analyses were met. Thenonsignificant p values for mean RT, standard deviation of RT, and errors of commission(p >. 10, p >.20, and p >.45, respectively) on the Levene’s test indicated that the errorvariance of the dependent variables was equal across the trial types with valid and invalidcues. In addition, findings on the Kolmogorov-Smirnov test indicated that the variableswere normally distributed.

RESULTS

Both groups showed a low percentage of error trials (the error rates of the controlgroup and the CD group plus BIF were respectively eye movements (1% against 2%),preliminary responses (2% against 5%), inhibition errors or omission errors (3% against1%), and there were no significant differences (p > .5) between the two groups. Figure 1presents the mean RT of both groups under valid and invalid trial types.

Mean RT was faster under the valid trial type relative to the invalid trial type:the trial type main effect was F(1, 215) = 18.1, p < .0001. Overall, the groupwith the dual diagnosis responded faster than the control group: the group maineffect was F(1, 215) = 36.6, p < .0001. After including the ADHD scores on the

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VISUAL ORIENTATION AND CD PLUS BIF 17

Mean reaction time

200

300

400

500

600

Valid InvalidTrials

mse

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CD + BIF

Figure 1 Mean reaction time.

CBCL-TRF and IQ as covariates, the group main effect remained significant, respectively,F(1, 214) = 17.3, p < .0001 and F(1, 214) = 17.9, p < .0001. Relative to the control group,the group with the dual diagnosis gained the most benefit from the valid-cue information;that is, their responses were faster in the valid trial type relative to the invalid trial type: Theinteraction group by trial type was F(1, 215) = 33.7, p < .0001. The interaction remainedsignificant after controlling for the ADHD scores on the CBCL-TRF, F(1, 214) = 30.3,p < .0001, and after controlling for IQ, F(1, 214) = 29.1, p < .0001. In addition, the inter-action remained significant after excluding the 6 boys who scored within the problematicrange of ADHD, F(1, 208) = 27.1, p < .0003.

Figure 2 shows that the group with the dual diagnosis had overall a significantlysmaller standard deviation of responses than the control group: The group main effectfor standard deviation of RT was F(1, 215) = 17.1, p < .0001. The group main effect

Mean standard deviation of RT

0

100

200

300

400

Valid InvalidTrials

mse

c Controls

CD + BIF

Figure 2 Mean standard deviation of RT.

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18 J. VAN DER MEERE ET AL.

Errors of commission

0

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Valid InvalidTrials

nu

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Figure 3 Errors of commission.

remained significant after controlling for the ADHD scores on the CBCL-TRF and IQ,respectively, F(1, 214) = 14.4, p < .001 and F(1, 214) = 12.9, p < .001. The group maineffect remained significant after excluding the 6 children who scored within the problem-atic range of ADHD, F(1, 208) = 14.7, p < .001. No significant effect of trial type wasfound for the standard deviation: The condition main effect was F(1, 215) = 2.0, p = .15.The two-way interaction group by trial type was F(1, 215) = 2.3, p = .13.

Figure 3 presents the number of errors of commission of the two groups under validand invalid trial types. Less errors of commission were made under the valid trial type thanunder the invalid trial type: The trial type main effect for errors was F(1, 215) = 85.9, p <

.0001. The group with the dual diagnosis made fewer errors of commission compared to thecontrol group: The group main effect was F(1, 215) = 22.5, p <.0001. After controlling forthe ADHD scores on the CBCL-TRF and IQ, this effect remained significant, respectivelyF(1, 214) = 20.9, p < .0001 and F(1, 214) = 18.9, p <.0004. The trial type effect forerrors was most pronounced in the control group: The interaction between group and trialtype was F(1, 215) = 5.0, p < .03. The effect remained significant when controlling forthe ADHD scores on the CBCL-TRF and IQ, respectively, F(1, 214) = 4.7, p < .04 andF(1, 214) = 4.8, p < .04. In addition, the effect remained significant after excluding the 6boys who scored within the problematic range of ADHD, F(1, 208) = 4.3, p < .04.

No performance asymmetry was found: Responses to targets in the left visual hemi-field were no longer than those presented in the right visual hemifield, F(1, 215) = 2.7,p < .15. No performance asymmetry was found in the cost/benefit pattern of the RTs com-paring valid- and invalid-cued trials, F(1, 215) = 1.7, p < .10. No interactions betweenvisual field, trial type, and group were significant (p values varied between .10 and .40).

DISCUSSION

Boys with early-onset CD plus BIF showed superior orienting to valid and invalidcues relative to the norm. More specific, they showed a greater validity effect and had morebenefit from having directed attention to the valid-cued location and less costs in having

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VISUAL ORIENTATION AND CD PLUS BIF 19

to relocate the attention focus. Both the validity effect and their superior looking outof the corner of one’s eye could be interpreted as an action-oriented responding style andunderlines the traditional view of sensation seeking in children with externalizing disorders(Zuckerman, 1983).

There was not found a visual field advantage. On the one hand, this finding maysuggest that lateralization of orientation may not be well established around the age of12 years. On the other hand, the present task might have been not sufficiently demand-ing to detect hemispheric specialization; that is, the go signal was presented alone inthe visual field in the absence of competing distracting information. There is evidencethat left field advantage may arise in particular under increased task demands (Evert,McGlinchey-Berroth, Verfaellie, & Milberg, 2003).

One important issue to account for concerns the small amount of preliminaryresponses given by the boys with the dual diagnosis during the interval between the pre-sentation of the arrow (cue) and the target letter (X). This finding is in contrast with theoutcome of the earlier discussed study of van der Meere, Van der Meer, Kunert, et al.(2008). Here, boys with the dual diagnosis made many preliminary responses betweenthe acoustic cue and the presentation of the go signal. One possible explanation for thisinconsistency in findings is that auditory cues are more arousing than visual cues.

The present findings fit well with the idea that fast shifting of visual attention isrelated with impulsiveness as a personality trait (Avila & Parcet, 2002). It is tempting to dis-cuss the results in light of literature using Posner’s task in adults with ASPD. Before doingso, it is underlined that findings on adult populations reflect a result of the developmentalprocess rather than the cause (Raine, Venables, & Williams, 1990). Until longitudinal andcross-sectional studies are carried out on carefully defined groups of children at high riskfor chronic antisocial behavior later in life, any theorizing regarding the role of cognitivevariables in the etiology of ASPD is speculative (Arnett, 1997). That said, testing chil-dren with high risk around the age of 13 provides a reliable estimate of the contributionof cognitive deficits to ASPD later in life (Toupin et al., 2000). Boys who participated inthe present study were around this age. Their performance on Posner’s task shows somesimilarities with research outcome on adults with ASPD. Harpur and Hare (2003) reportedstrong endogenous orienting of attention in this patient group. Howland, Kosson, Patterson,and Newman (1993) reported that adults with ASPD made more errors than the controlgroup on invalid-cued trials with left-sided imperative stimuli, suggesting a strengthenedorienting response difficult to override.

Factors that may have affected the interpretation are the following. One importantissue to account for is the question to what extent findings were associated with possiblesymptoms of ADHD in the target group. ADHD and CD often coexist, and especially thiscombination predicts to a high extent later serious maladjustment, such as delinquency(Lahey & Waldman, 2003). Because reliable informants (parents) were not available con-cerning the symptom history of the boys, we had to rely on behavior ratings of professionalstaff members who completed the CBCL-TRF. A covariance analysis indicated that supe-rior orientation of the target group was not associated with ADHD symptoms. In addition,the primary findings remained significant after excluding the 6 boys with ADHD CBCL-TRF scores in the clinical domain. Thus, in the participating target sample, early-onset CDis associated with an action-oriented responding style even after associations with ADHDsymptoms were taken into consideration. Moreover, within the perspective of a possiblerole of ADHD symptoms in the target group, it is also worth noting that ADHD research

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using Posner’s task has, so far, produced mixed findings: Some studies reported slow disen-gagement of attention, others did not (Alvarez & Freides, 2004). But, no study on ADHDreported superior performance compared to peer controls.

The second issue to account for is that CD is a heterogeneous disorder. In order toprevent sample heterogeneity, the present study focused on boys with early onset CD plusBIF with no concurrent internalizing disorders. A covariance, controlling for IQ indicatedthat this group of children had an action-oriented response style, which was independentof their IQ level.

The results of the study are limited to a subset of the CD domain. Therefore, a futurestudy creating nonoverlapping/unique groups with conduct disordered children of vary-ing intellectual levels with and without clear ADHD is needed to see whether a strongaction-oriented responding unit has the potential to differentiate subtypes. In addition, lon-gitudinal studies are needed to test whether a strong action-oriented response style in theindividual child with early-onset CD helps to predict long-term prognosis.

That only boys took part in the study may be considered another limitation.Epidemiological studies indicate that CD is the second most common psychiatric disor-der in adolescent girls (Zoccolillo, Vitaro, & Tremblay, 1996). This finding points towardsthe need for the inclusion of girls in future studies of conduct problems. Another limita-tion is that the participating boys were hospitalized, which introduced the possibility thatthe study outcome is associated with treatment referral rather than CD plus BIF per se.Socioeconomic status was not taken as a covariate in the analysis (such data were not gath-ered in the control group). It is more than likely that the children with the dual diagnosiscame from impoverished homes and neighborhoods characterized by poverty, crime, andviolence.

In spite of these shortcomings, the small set of available studies on children withearly onset CD plus BIF suggests strong orientation towards auditory cues (van der Meere,van der Meer, Kunert, et al., 2008) and visual cues (present study) together with com-promised decision making (Van der Meer, & van der Meere, 2004; van der Meere, Vander Meer, Borger, & Pirila, 2008). Hopefully, findings like these may be of help in theidentification of childhood predictors of serious problem behavior later in life.

Original manuscript received January 20, 2010Revised manuscript accepted January 12, 2011

First published online June 24, 2011

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