Conduct problems among middle adolescents in the community settings: A concept analysis

Abstract

Background

Adolescent problem behavior in research and practice has been traditionally categorized as Oppositional Deviant Disorder and Conduct Disorder. However, a significant number of adolescents remain underdiagnosed. To address this issue, the term “Conduct Problem” has emerged as a commonly used descriptor for those who have not yet received a formal diagnosis, particularly within the community. It is crucial for nurses to comprehend the characteristics of these conduct problems to address them effectively.

Objective

This concept analysis aimed to clarify the concept of conduct problems among adolescents aged 14 to 16, specifically within community settings.

Methods

The concept analysis followed Walker and Avant’s approach. The usage of the concept was examined in five databases (PsyINFO, ProQuest, PubMed, ScienceDirect, Scopus), which yielded 41 relevant studies for comprehensive analysis.

Results

The identified attributes of conduct problems in adolescents included oppositional problems, antisocial problems, and criminal-related problems. These conduct problems were found to have antecedents stemming from personal, parental, and environmental factors. Furthermore, the consequences of conduct problems significantly impacted both middle adolescents and their parents.

Conclusion

The findings of this concept analysis contribute to a better comprehension of the concept of conduct problems among middle adolescents in community settings. The insights gained from this analysis will assist in using this term more effectively in research and nursing practice, ultimately leading to improved care and support for affected adolescents and their families.

Background

Middle adolescents refer to individuals aged 14-16 who exhibit specific developmental characteristics. During this stage, they demonstrate abstract thinking abilities and improved decision-making skills. However, middle adolescents are also more susceptible to peer influence and engage in risky behaviors (UNICEF, 2005). Additionally, middle adolescence marks the onset of negative tendencies, including challenging behaviors, disruptive behaviors, poor social skills, and learning delays (Kewley, 1999). Furthermore, compared to other age groups within the adolescent population, studies have shown that individuals aged 14-16 years old face an increased risk of experiencing behavioral difficulties, which can lead to the development of moderate or weak mental health statuses and a higher prevalence of behavioral problems (Dhamayanti et al., 2018; López-Romero et al., 2017; Pandia et al., 2021; Sulistiowati et al., 2019).

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are two commonly observed behavioral disorders in children and adolescents. Research indicates that in community settings, children tend to exhibit more ODD-related behaviors, whereas adolescents demonstrate a higher prevalence of CD-related behaviors (Fergusson et al., 2009; Schoenmacker et al., 2020). ODD encompasses a set of behaviors characterized by irritable mood (difficulty controlling anger), defiant behavior (difficulty controlling arguments), and vindictiveness (inability to forgive others’ mistakes). On the other hand, CD is defined as a persistent and repetitive engagement in behaviors that violate social norms and accepted rules. Such behaviors may include aggression towards people and animals, destruction of property, dishonesty, and stealing (American Psychiatric Association [APA], 2013).

However, the terms ODD and CD have not been widely used in existing studies due to the low clinical diagnosis rate of only 20% among adolescents in hospital settings (Keyes et al., 2018). This highlights the significance of using an applicable term within the community, as most adolescents aged 14-16 remain undiagnosed and untreated in community settings. Unfortunately, these behavioral issues can have negative consequences that affect not only the adolescents themselves but also their families (parents or primary caregivers, siblings) and society at large, particularly within their local neighborhoods and school environments (McMahon & Frick, 2005). Therefore, there is a need for an alternative term that encompasses and describes the behavioral problems exhibited by adolescents in community settings, even in regions with limited access to child psychiatric hospitals. In conclusion, it is crucial for nurses to promptly intervene and provide appropriate care to this population by utilizing community-based terminology. This enables community and mental health nurses to screen behaviors in public health centers or community clinics.

Among various terms used to describe behavioral problems in adolescents, conduct problems (CP) is widely utilized, along with interchangeable terms like “conduct behaviors” and “conduct problem behaviors” (Ghanizadeh, 2015). McMahon and Frick (2005) have defined CP as a broad range of excessive actions, encompassing both mild oppositional behaviors (e.g., temper tantrums and yelling) and severe antisocial behaviors (e.g., aggression, physical destructiveness, and theft). This definition suggests that CP includes behaviors associated with both ODD and CD. However, further investigation is necessary to determine how the term CP is utilized in research, particularly among middle adolescents in the community.

This exploration aims to ascertain the applicability of the term in the future direction of nursing research and practice, including how existing literature has applied the definition and attributes of conduct problems. By understanding the characteristics of CP, nurses can take proactive measures without waiting for formal diagnoses, thereby minimizing the severity of CP among adolescents and preventing long-term behavioral impacts. This study seeks to conceptualize the description of CP and provide valuable insights for future nursing interventions and prevention strategies.

Concept Analysis of Conduct Problems

A concept analysis approach based on Walker and Avant (2019) was employed to examine the concept of conduct problems among middle adolescents in the community. A comprehensive literature review was conducted by searching five databases: PsycINFO, Scopus, PubMed, ScienceDirect, and ProQuest. The search strategy focused on obtaining the most recent publications within the past five years that addressed conduct problems among adolescents aged 14-16 years old in community settings. The search terms used were “children” OR “adolescents” AND “community” AND “definition” AND “conduct problems”.

The selected articles had to meet specific inclusion and exclusion criteria. The inclusion criteria were as follows: (1) written in English, (2) “conduct problems” mentioned in the titles and abstracts, (3) utilized various study designs, (4) provided a definition of “conduct problems,” (5) focused on individuals aged 14-16 years old, and (6) conducted in a community setting. Conversely, the exclusion criteria were: (1) the use of alternative related terms, whether specific or broad, (2) the use of “conduct problems” as the population descriptor, and (3) non-research articles, such as editorials and commentaries. In total, 41 articles were reviewed, comprising seven descriptive/survey studies, 18 correlational studies, 11 predictive studies, three quasi-experimental studies, and two randomized controlled studies (Figure 1).

Figure 1.

Flow diagram of selected studies

The authors conducted three rounds of screening during the article selection process. Initially, a check for duplicates was performed, resulting in the exclusion of 5,403 articles due to replication or unrelated topics. In the second screening, articles were evaluated based on the presence of the term “Conduct Problems (CP)” in the titles and/or abstracts. This step led to the exclusion of 161 articles that did not mention the term. Subsequently, the remaining articles were screened for adherence to the exclusion criteria excluding 54 articles that violated the criteria. Finally, the 41 articles that met the inclusion criteria were subjected to analysis using Walker and Avant’s approach to conceptual analysis. The authors synthesized the information by grouping similar findings and presenting the results in tables and figures. Discussions and re-analyses were conducted to ensure agreement among the authors. The review process for the selected papers was carried out from March to September 2022.

Selecting the Concept

The concept of conduct problems was chosen for analysis due to its global variation and increasing prevalence over time. Fergusson et al. (2009) indicate that the prevalence of conduct problems in the adolescent population within the community can exceed 10%. This figure is significantly higher compared to the prevalence rates of oppositional defiant disorder (ODD) and conduct disorder (CD), which range from 1% to 11% and 2% to 10%, respectively (American Psychiatric Association [APA], 2013). Interestingly, the prevalence of conduct problems in Middle Eastern countries has reached as high as 32.9% (Salmanian et al., 2017), while Indonesia reported rates of 38.5% in 2010, increasing to 40% in 2019 (Djaya et al., 2019; Wiguna et al., 2016).

Additionally, the issue of conduct problems among middle adolescents in the community holds significant importance due to several reasons. Firstly, it represents one of the frequently encountered mental health problems in community clinics. Secondly, it contributes to substantial social costs, particularly in incarceration expenses resulting from adolescent criminal behavior. These costs can have detrimental effects on the overall quality of life. Thirdly, conduct problems can lead to difficulties in life adjustment for affected individuals.

Furthermore, the implications of undetected and unmanaged conduct problems in adolescents are concerning, as they may develop more severe behavioral patterns and mental health issues in adulthood (Biederman et al., 2008; Young, 2015). This includes the potential emergence of psychotic-like experiences during adolescence (Nehemiah & Turnip, 2018). Thus, addressing and effectively managing conduct problems in middle adolescents is crucial for promoting better outcomes and preventing long-term adverse effects.

Determining the Aim of the Analysis

This concept analysis aimed to clarify the conduct problems’ definition of adolescents aged 14-16 in the community, as well as the dimensions and characteristics of the concept.

Identifying the Uses of the Concept

The definition of conduct problems was explored using online dictionaries. According to the Merriam-Webster Dictionary (2021a), conduct refers to a mode or standard of personal behavior based on moral principles, while problems are defined as something difficult to deal with or a source of trouble or worry (Merriam-Webster Dictionary, 2021b). Therefore, conduct problems can be understood as individual difficulties related to behaviors that do not align with moral principles. Furthermore, the Macmillan Dictionary (2021a) defines conduct as doing something in an unorganized way, and problems as something that causes trouble or difficulties ((Macmillan Dictionary, 2021b). Based on this definition, conduct problems can be described as difficulties in performing tasks or actions in an organized manner.

The dictionary-based definition of conduct problems aligns with the definitions found in the existing literature. The literature review revealed that conduct problems are commonly described as challenging behaviors displayed by adolescents. These behaviors range from moderately oppositional behaviors, such as anger, disobedience, fighting, lying, and stealing (Burt et al., 2020; Dadds et al., 2019; El Asam et al., 2019; Gutman, 2019; Muñoz-Silva et al., 2017; Piotrowska et al., 2020; Ren et al., 2018; Schoeps et al., 2020), to more severe challenging behaviors, including aggressive behaviors, property destruction, dishonesty, stealing, and violations of rules (Andreou et al., 2018; Bégin et al., 2020; Gutman, 2019; Hawes et al., 2020; Hogue et al., 2017; Molleda et al., 2017; Roberts et al., 2018; Wesseldijk et al., 2018).

Some studies characterized conduct problems as antisocial behaviors (Kloft et al., 2017; Molleda et al., 2017) and associated them with a higher risk of psychopathic behaviors (Bégin et al., 2020). Other research defined conduct problems as age-inappropriate misbehaviors and highlighted their association with criminal actions (Andretta et al., 2019; Crum et al., 2017) and violations of the justice system, such as engaging in unauthorized driving, drug dealing, and encountering law enforcement issues (Khoddam & Leventhal, 2016). Moreover, conduct problems were observed in the school context and linked to behaviors like truancy or school avoidance (Blakey et al., 2021; Defoe et al., 2019; Khoddam et al., 2018; Sentse et al., 2017).

In social science, conduct problems among middle adolescents are closely connected to the concept of juvenile delinquency. Juvenile delinquency, as defined by Sampson (2001), refers to criminal behaviors committed by individuals who are not yet legally considered adults. Over time, delinquency has been seen as a type of misbehavior that requires punishment, treatment, or rehabilitation to address problematic actions. Juvenile delinquency falls under a socio-legal category and entails consequences related to breaking the law (Sheldrick, 1995).

Furthermore, the concept of juvenile delinquency encompasses more severe forms of adolescent misbehavior and is intricately linked to crime. Preventing criminal behaviors is one of the key goals in the context of juvenile delinquency, with preventive measures implemented at the primary, secondary, and tertiary levels (Moore, 2001). On the other hand, the concept of conduct problems does not always revolve around crime or violations of the justice system. The main focus of the conduct problems concept is not centered solely on criminal behaviors but rather depends on the spectrum of conduct problems themselves (American Psychiatric Association [APA], 2013; Fergusson et al., 2009; McMahon & Frick, 2005). As a result, conduct problems emphasize the prevention of more severe forms of behavioral problems, such as antisocial and psychopathic behaviors.

The concept of conduct problems is widely utilized in mental health science and frequently employed in community-based research (Table 1). It is applied in various community settings, such as general community studies (Andreou et al., 2018; Bares et al., 2020; Blakey et al., 2021; Brandt et al., 2019; Brunborg & Burdzovic Andreas, 2019; Burt et al., 2020; Cardinale et al., 2019; Catone et al., 2021; Crum et al., 2017; Defoe et al., 2019; Fanti et al., 2018; Ghandour et al., 2019; Hawes et al., 2020; Kersten et al., 2017; Keyes et al., 2018; McDonough-Caplan et al., 2018; Piotrowska et al., 2020; Roberts et al., 2018; Sönmez et al., 2019; Wesseldijk et al., 2018), particularly in the school setting (Bégin et al., 2020; Bjertnaes et al., 2020; Bordin et al., 2022; Dadds et al., 2019; El Asam et al., 2019; Gutman, 2019; Hosseinkhani et al., 2021; Idris et al., 2019; Kawabe et al., 2021; Khoddam et al., 2018; Khoddam & Leventhal, 2016; López-Romero et al., 2017; Luzanil & Turnip, 2021; Ren et al., 2018; Schoeps et al., 2020; Sentse et al., 2017). It is also applied in specific community settings, including associations of families of children and adolescents with ADHD, educational assistance centers, such as in Huelva, Spain (Muñoz-Silva et al., 2017), family service agencies, community programs serving youth centers (Hogue et al., 2017), and detention settings in a mid-Atlantic city court’s intake facilities (Andretta et al., 2019).

Table 1.

Characteristics of selected studies (n = 41)

No	Types of Study	Authors (Year)	Setting	Instruments
1.	RCT	Molleda et al. (2017)	Community clinic	RBPC
2.		López-Romero et al. (2017)	School	DCRS
3.	Quasi-Experiment	Kloft et al. (2017)	Community clinic	DISCAP
4.		Piotrowska et al. (2020)	Community	SDQ-CP
5.		Dadds et al. (2019)	Community	SDQ-CP
6.	Predictive study	Schoeps et al. (2020)	School	SDQ-CP
7.		Ren et al. (2018)	School	SDQ-CP
8.		Gutman (2019)	School	SDQ-CP
9.		Sentse et al. (2017)	School	CBCL
10.		Muñoz-Silva et al. (2017)	Educational center	SDQ-CP
11		Hogue et al. (2017)	Family service agency	YSR
12.		Andretta et al. (2019)	Detention house	CBRS
13.		El Asam et al. (2019)	School	SDQ-CP
14.		Bégin et al. (2020)	School	CBCL
15.		Defoe et al. (2019)	Community	YSR
16.		Kawabe et al. (2021)	School	SDQ-CP
17.	Correlational study	Andreou et al. (2018)	Community	Self-developed
18.		Roberts et al. (2018)	Community	SDQ-CP & CASI
19.		Bares et al. (2020)	Community	YSR
20.		Burt et al. (2020)	Community	SDQ-CP
21.		Cardinale et al. (2019)	Community	CBCL
22.		Catone et al. (2021)	Community	SDQ-CP
23.		Fanti et al. (2018)	Community	CYAI
24.		Hawes et al. (2020)	Community	YSR
25.		Sönmez et al. (2019)	Community	SDQ-CP
26.		Khoddam and Leventhal (2016)	School	Self-developed
27.		Wesseldijk et al. (2018)	Community	CBCL & YSR
28.		Bjertnaes et al. (2020)	School	SDQ-CP
29.		Bordin et al. (2022)	School	SDQ-CP
30.		Brandt et al. (2019)	Community	SDQ-CP
31.		Brunborg and Burdzovic Andreas (2019)	Community	SDQ-CP
32.		Kersten et al. (2017)	Community	SADS-PL
33.		Khoddam et al. (2018)	School	Self-developed
34.		Hosseinkhani et al. (2021)	School	SDQ-CP
35.	Descriptive study	Crum et al. (2017)	Community	SDQ-CP
36.		McDonough-Caplan et al. (2018)	Community	CBCL
37.		Keyes et al. (2018)	Community	Self-developed
38.		Blakey et al. (2021)	Community	SDQ-CP
39.		Idris et al. (2019)	School	SDQ-CP
40.		Luzanil and Turnip (2021)	School	SDQ-CP
41.		Ghandour et al. (2019)	Community	Self-developed

Notes: Child and Adolescent Symptom Inventory = CASI, Child Behavior Checklist = CBCL, Conduct Behavior Rating Scale = CBRS, Checkmate plus Youth and Adult Inventories = CYAI, Disruptive Conduct Rating Scale = DCRS, Diagnostic Interview Schedule for Children, Adolescents, and Parent = DISCAP, Kiddle Schedule for Affective Disorder and Schizophrenia – Present and Lifetime = K-SADS-PL, Revised Behavior Problem Checklist = RBPC, Randomized Control Trials = RCT, Strengths and Difficulties Questionnaire-Conduct Problems = SDQ-CP, Youth Self Report = YSR.

Determining the Defining Attributes

The dimensions of conduct problems are the distinguishing characteristics that differentiate them from other concepts (Walker & Avant, 2019). By identifying frequently used synonymous words and creating a keyword cluster, the authors determined the dimensions of conduct problems. After reaching an agreement, three attributes emerged as commonly reported in defining conduct problems among adolescents aged 14-16: oppositional, antisocial, and criminal-related problems (Table 2). Therefore, conduct problems were conceptually defined as behavioral problems displayed by individuals aged 14-16, encompassing oppositional, antisocial, and criminal-related problems.

Table 2.

Attributes, sub-attributes, and indicators of conduct problems among middle adolescents

Attributes	Sub-attributes	Indicators
Oppositional problems	Irritable mood	Anger (Muñoz-Silva et al., 2017) Temper tantrum (Brandt et al., 2019) Inability to control anger (Catone et al., 2021)
	Defiant behaviors	Arguing (Blakey et al., 2021) Disobeying order (Dadds et al., 2019; Piotrowska et al., 2020)
	Nonaggressive conduct problems	Lying (Brandt et al., 2019; Dadds et al., 2019)
Antisocial problems	Aggressive behaviors	Verbal aggression: assaulting (Fanti et al., 2018); bullying (Blakey et al., 2021); Physical aggression (Andreou et al., 2018; Hogue et al., 2017; López-Romero et al., 2017; Molleda et al., 2017) Fighting (Schoeps et al., 2020)
	Destructive behaviors	Property damage (Andreou et al., 2018; Keyes et al., 2018) Destroy things that belong to others (Burt et al., 2020)
	Deceitfulness	Deceptive behaviors (Sentse et al., 2017)
	Rules violation	Truancy (Bégin et al., 2020; Defoe et al., 2019) Skipping school Vandalism (Hawes et al., 2020) Running away from home (Khoddam & Leventhal, 2016)
Criminal-related problems	Risk-taking behaviors	Driving without permission, selling drugs, and getting into trouble with the police (Andreou et al., 2018; Khoddam & Leventhal, 2016)
	Severe conduct behaviors	Use and carry the weapon (Andreou et al., 2018; Andretta et al., 2019)
	Theft	Stealing (Andreou et al., 2018; Defoe et al., 2019) Burglary and robbery (Andretta et al., 2019)

Oppositional problems

Oppositional problems, a well-supported attribute in the literature, represent moderately impacted behaviors. This dimension includes irritable mood, defiant behaviors, and vindictiveness. Irritable mood encompasses manifestations such as anger, temper tantrums, and difficulty managing anger. Defiant behaviors involve arguing and disobeying orders. Furthermore, nonaggressive conduct problems are characterized by vindictiveness, lying, and delinquent behaviors.

Antisocial problems

Antisocial problems, another prevalent dimension of CP among middle adolescents, encompass severely impacted behaviors. This attribute includes the following behaviors: 1) aggressive behaviors, which involve physical aggression, fighting, assaulting, and bullying; 2) destructive behaviors, characterized by property damage and destroying others’ belongings; 3) deceitfulness, encompassing deceptive behaviors; and 4) rules violation, which includes truancy, skipping school, vandalism, and running away from home.

Criminal-related problems

Criminal-related problems represent the most severe manifestations of CP among middle adolescents. This dimension comprises three problematic behaviors that violate the justice system: risk-taking behaviors, severe conduct behaviors, and theft. Risk-taking behaviors include driving without permission, selling drugs, and getting into trouble with the police. Severe conduct behaviors are exemplified by the use and carrying of weapons. Lastly, theft encompasses stealing, burglary, and robbery.

Identifying Model Case

“M, a 15-year-old boy, has been referred to a community mental health clinic by his mother due to his challenging behaviors. He frequently argues with his older brother and physically harms his younger brother without hesitation. He even engaged in harmful activities like tying up his sister’s cat for fun. Disregarding orders to stay home at night, M repeatedly leaves without permission and has already left home three times. Neighbors have also lodged complaints about his behavior. M attempted to steal mobile phones by breaking a neighbor’s car window, leading to further concerns. Teachers have also expressed concerns, as he bullies classmates and forcefully demands money from them. On one occasion, he broke down a classroom door after the teacher forbade him from leaving. Consequently, he started skipping school and eventually dropped out.”

Based on this model case, M displays considerable conduct problems, given the severe harm he inflicts on others through threatening behaviors, such as physical cruelty towards his siblings and animals, stealing in front of victims, bullying peers, and forcibly demanding money from them. This case illustrates all attributes of conduct problems.

Identifying Additional Cases

This article includes three additional cases to distinguish the concept of conduct problems from others: borderline case, related case, and contrary case. A borderline case exemplifies a situation where only some attributes are present. It is essential to have a borderline case because it depicts a similar scenario but with incomplete behavioral characteristics, preventing it from being grouped in the same category. On the other hand, a related case provides an example of a concept closely associated with conduct problems and often used interchangeably. This case is significant in distinguishing the concept of CP from other similar concepts. Lastly, the contrary case presents an example that does not exhibit the attributes of conduct problems. The contrary case is essential as it demonstrates entirely different behavioral characteristics unrelated to the behavioral difficulties of conduct problems.

Borderline case

“B is a 14-year-old living with his mother after their parents divorced. His mother, feeling overwhelmed, has taken him out of school because she cannot afford it. Now, B helps his mother make money, often dealing with people on the street. He has started smoking and has been involved in fights with his friends over cigarettes. When his mother tried to advise him, they ended up arguing. He once left home but returned after three days when he ran out of money.”

Based on the presented case, B displays some challenging behaviors such as smoking, fighting, and arguing, but the number of behaviors is not sufficient to categorize him as an adolescent with conduct problems. Additionally, he skipped school due to a lack of money, not due to his behaviors, and he left home fewer than three times. This borderline case demonstrates that only two attributes of conduct problems are present: oppositional problems and antisocial problems, while the attribute of criminal-related problems is not evident, so it cannot be categorized as conduct problems.

Related case

“R, a 16-year-old boy, is the leader of the “Breakthrough The Limit (BTL)” group, a well-known gang in their neighborhood. R and his girlfriend, along with three other male members, are frequently involved in antisocial activities such as stealing bikes, fighting, smoking, and vandalizing public facilities. They also engage in illegal sexual activities within their group. All members of BTL have dropped out of school and no longer live with their families. R mentions that his parents have disowned him and have never made contact since he left home. Recently, R and his friends have turned to drug dealing and were eventually apprehended by the police. As a result, they have been sentenced to three months in a detention facility. R expresses his enjoyment in engaging in dangerous acts and takes pride in being recognized as a troubled individual. It is possible that R and his friends may have exhibited conduct problems during their childhood, but because these issues went unnoticed and untreated, they have escalated into more serious problems. It is worth noting that a history of childhood conduct problems serves as a predictor for juvenile delinquency.”

This related case exemplifies the characteristics of juvenile delinquency, which shares similarities with conduct problems. However, it is essential to emphasize that not all adolescents with conduct problems necessarily end up being arrested by the police.

Contrary case

“C, a 15-year-old boy, recently moved to a new city with his family. Upon enrolling him in a nearby school, their neighbors warned them about the misbehaving kids attending that school. After a month, C’s mother noticed a change in his behavior as he began lying and stealing money from his family. These behaviors were unfamiliar to him, and when confronted, he admitted his mistakes and explained that his friends had influenced him to engage in such activities. He assured his mother that he would no longer participate in those behaviors. Recently, C started attending a different school where he appears to be an ordinary student. He actively participates in extracurricular activities and sports events, even achieving his first victory in a swimming competition.”

This case demonstrates that C does not exhibit any serious behavioral issues and is developing like a typical adolescent. While he had previously engaged in lying and stealing, he quickly recognized his mistakes and ceased these behaviors after receiving guidance from his mother. This contrary case presents behavioral characteristics completely different from conduct problems, as none of the mentioned behaviors align with the attributes associated with conduct problems.

Identifying Antecedents and Consequences

Based on the literature review, the antecedents of conduct problems among middle adolescents were personal, parental, and environmental factors. Firstly, personal factors included gender (Kawabe et al., 2021; Keyes et al., 2018), age (Keyes et al., 2018), neurophysiological markers (Fanti et al., 2018), genetic (Wesseldijk et al., 2018), adolescent’s body image (Ren et al., 2018), increased Body Mass Index (Bjertnaes et al., 2020), self-discrepancy (Kawabe et al., 2021), callous-unemotional traits (Cardinale et al., 2019), spent more time on social media (Brunborg & Burdzovic Andreas, 2019), maltreatment (Andreou et al., 2018), depression and anxiety (Ghandour et al., 2019; McDonough-Caplan et al., 2018). Secondly, parental factors included education (Hosseinkhani et al., 2021) and parent discrepancy (Kawabe et al., 2021). Lastly, environmental factors included peer attachment (Schoeps et al., 2020), child-parent relationship (Gutman, 2019), racial discrimination (Blakey et al., 2021), violence exposure, such as physical punishment for young adolescents, peer aggression for old adolescents, victimization for girls, and community violence (Bordin et al., 2022; Kersten et al., 2017) and living in violent-crime neighborhood (Crum et al., 2017).

Furthermore, existing studies also revealed the consequences of conduct problems in middle adolescents, such as psychopathic traits (Bégin et al., 2020), nicotine use (Khoddam et al., 2018), criminal-related behaviors (Andretta et al., 2019), risk-taking behaviors (Brandt et al., 2019), overuse of internet (El Asam et al., 2019), cannabis use (Defoe et al., 2019), marijuana and alcohol use (Khoddam et al., 2018), poorer general family functioning (Roberts et al., 2018), maladjustment behaviors (Sentse et al., 2017), maternal stress (Muñoz-Silva et al., 2017), more severe externalizing problems, delinquent acts, and other substance use (Hogue et al., 2017; Khoddam & Leventhal, 2016) (Figure 2).

Figure 2.

Antecedents, attributes, and consequences of CP in middle adolescents in the community

Identifying Empirical Referents

Of the 41 selected studies, 23 articles (53%) utilized the Conduct Problems subscale of the Strengths and Difficulties Questionnaire (SDQ-CP) to assess conduct problems in adolescents aged 14-16 years old (Table 1). The SDQ-CP encompasses all the attributes associated with conduct problems, including oppositional problems (such as temper tantrums, lying/cheating, and disobedience), antisocial problems (fighting), and criminal-related problems (stealing). The SDQ, developed by Goodman (1997), comprises five dimensions: emotional symptoms, peer problems, hyperactivity, conduct problems, and prosocial behavior. It can be completed by parents or teachers of children aged 4-17, while self-report versions are available for adolescents aged 11-17. The questionnaire consists of 25 statements, with response options of “not true,” “somewhat true,” and “certainly true.” The total difficulties score on the SDQ ranges from 17 to 40, and the conduct problem score falls between 4 and 10. The reliability coefficients for parent reports were reported as 0.87 (0.83-0.9) and for teacher reports as 0.85 (0.78-0.93) (Goodman, 1997). The SDQ-CP instrument has been deemed suitable for the initial screening of conduct problems in individuals aged 5-17 years old in the general community, with a suggested cutoff point of 4 (Luzanil & Turnip, 2021; Roberts et al., 2018; Schoenmacker et al., 2020; Scourfield et al., 2004). It has also been found to be user-friendly for community and mental health nurses in clinics (Ristkari et al., 2020).

Another commonly utilized instrument was the Achenbach System of empirically-based Assessment (ASEBA), employed in 7 studies (16%). Among these, four studies (9%) utilized the Youth Self Report (YSR), and three studies (7%) used the Child Behavior Checklist (CBCL). The ASEBA aims to assess emotional and behavioral problems in children and adolescents. The YSR is a self-report questionnaire for adolescents aged 11-18, while the CBCL is a parent-reported questionnaire. The CBCL comprises a total of 113 items (Achenbach & Rescorla, 2011), with reported Cronbach’s alpha values ranging from 0.90 to 0.93, and specifically, the conduct problems scale had a Cronbach’s alpha of 0.88 (Achenbach & Rescorla, 2011). The YSR’s externalizing scale, particularly the conduct problem subscale, was utilized to measure conduct problems and consists of 15 items, with Cronbach’s alpha ranging from 0.70 to 0.84 (Bares et al., 2020; Defoe et al., 2019). However, it is important to note that these instruments primarily assess the attribute of antisocial behaviors (aggressive behaviors) and are typically employed by doctors or psychologists.

Implications to Nursing Knowledge and Practice

The concept analysis of conduct problems (CP) among adolescents aged 14-16 holds significant nursing implications for research and practice. This study has shed light on the three attributes of CP: oppositional problems, antisocial problems, and criminal-related problems. In terms of nursing research, the term conduct problems can be employed to address the underdiagnosis of middle adolescents in community settings. It can be incorporated into various research designs, and the Strengths and Difficulties Questionnaire for Conduct Problems (SDQ-CP) can be utilized to screen and evaluate nursing interventions' effectiveness. As for nursing practice, community and mental health nurses working in public health centers or community clinics can use the SDQ-CP to screen for conduct problems among middle adolescents. Furthermore, they can implement nursing interventions to reduce the severity of conduct problems and prevent potential long-term consequences in adulthood.

Conclusion

The concept analysis approach utilized by Walker and Avant has provided comprehensive insights into conduct problems among adolescents aged 14-16 in the community. This analysis explored various aspects, including the attributes, antecedents, consequences, model cases, additional cases, and empirical referents of conduct problems. The findings of this study hold the potential to enhance the understanding and application of nursing students and psychiatric nurses in both research and clinical settings. The study identified several antecedents of conduct problems, such as personal, parental, and environmental factors. While some factors like age, gender, genetics, and neurophysiological markers are non-modifiable, it is crucial to focus on intervening in modifiable factors for future nursing research and practice. By addressing these modifiable factors, direction can be provided to reduce the severity and long-term impacts of conduct problems among adolescents in their future lives.

Declaration of Conflicting Interest

The authors declare that there is no conflict of interest in this study.

Funding

Graduate Scholarship Program for ASEAN and Non-ASEAN Countries, Chulalongkorn University, Thailand. Recipient: Fauzan Saputra.

Author’s Contribution

All authors met the authorship criteria, were accountable at every study’s stage, and approved the final version of the manuscript to be published.

Authors’ Biographies

Fauzan Saputra, S.Kep, Ners, MNS is a PhD candidate at the Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand.

Dr. Penpaktr Uthis is an Associate Professor at the Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand.

Dr. Sunisa Sukratul is an Assistant Professor at the Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand.

Ethical Consideration

Ethical approval for this article is not applicable. This paper is a part of the dissertation of the first author (FS) entitled “A path analysis of aggression among middle adolescents with conduct problems in the community, Indonesia.”

Data Availability

All data generated or analyzed during the concept analysis are included in this published article.