Transcript Behaviour Disorders in Adolescents: Clinical and

Behaviour Disorders in
Adolescents: Clinical and
Psychopathological Assessment
Mª.C. Ballesteros (Hospital Clínico
Universitario de Valladolid)
J.L. Pedreira (Hospital Infantil
Universitario Niño Jesús, Madrid)
Behaviour Disorders and International
Systems of Mental Disorders
Classification/1
• DSM-III (1980): Basic conditions are
sociabilization:
– Undersocialized, aggressive or not aggressive
– Socialized, aggressive or not aggressive
• DSM-III-R (1987): Basic conditions are
individual or grupal behaviour disorder or
aggressiveness
Behaviour Disorders and International
Systems of Mental Disorders
Classification/2
• DSM-IV (1994): Basic conditions are disocial
behaviour and age:
– Aggression on people and animals
– Destruction of property
– Deceitfulness or theft and serious violations rules
• ICD-10 (1992-94): Basic condition is context of
disocial disorder:
–
–
–
–
Disocial disorder only on family context
Disocial disorder undersocialized children
Disocial disorder socialized children
Oppositional defiant disocial disorder
HOLLISTIC AND COMPREHENSIVE
CLINICAL ASSESSMENT IN
BEHAVIOUR DISORDERS IN
ADOLESCENCE
Vulnerability
+
Risk factors
Symptoms
Clinical diagnosis
Pronogsis
Tretment
Therapeutic and
Preventive Interventions
GLOBAL AND DEVELOPMENTAL
ASSESSMENT OF BEHAVIOUR
DISORDERS IN ADOLESCENCE
VULNERABILITY + RISK FACTORS
•Genetic factors
•Temperament
mediators
Personality traits
Cognitive patterns
Neuropsychology
Neurophysiology
Neurotransmission
* Unspecific
* Especific:
- Sex
- Family
- School
- Social
SYMPTOMS
PROGNOSIS
*Developmental
symptoms
*Clinical
symptoms
- Diagnostic
criteria
- Subtypes
- Comorbidity
* Clinical
features
* Protective
factors
* Temperament
Mª C. Ballesteros-Alcalde & J.L. Pedreira-Massa (1999)
Comprehensive and Developmental
Assessment of Behaviour Disorders in
Adolescence/2
Vulnerability
• Genetic and Temperament factors as mediators
– Personality traits:
•
•
•
•
Aggressiveness
Socialization disorders
Impulsiveness
Hyperactivity
– Cognitive patterns:
•
•
•
•
Hostile attributions
Egocentric
Low and inconsistent problem-solving skills
Inadequate aims
Comprehensive and Developmental
Assessment of Behaviour Disorders
in Adolescence/3
• Vulnerability: Genetic and Temperament factors
as mediators
– Neuropsychology:
• Low IQ
• Language disorders
• Attention disorders
– Neurophysiology:
• Low dermal conductivity
• Loe cardiac rating
– Neurotransmissions:
• Dopamine, noradrenaline
• Serotonine
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/3
Risk Factors
• Parental Factors:
– Antisocial and criminal behaviour
– Alcoholism
– Untoward parent-child interaction:
•
•
•
•
•
Harsh punishment
Inconsistent punishment
Poor supervision
Coercitive exchanges (escalted aversive interactions)
Less parental warmth, support and comunication with
children
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/4
Risk Factors
• Family Factors:
–
–
–
–
–
Marital discord
Large family size
Birth order
Older siblings with antisocial behaviour
Few family activities
Disruptors of effective parenting
Family Demographics
Income
Parent education
Neighborhood
Ethnic group
Grand parental Traits
Antisocial behaviour
Poor family management
Parental Traits
Antisocial behaviour
Susceptible to stressors
Family Stressors
Unemployement
Marital conflict
Divorce
Disrupted
family-management
practices
Child antisocial behaviour
B. Lahey & R. Loeber (1994)
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/5
Risk Factors
• Child Factors:
– Child temperament
– Neuropsychological deficits (in verbal and
executive” functions)
– School (academic deficiencies, attendance, peers and
teacher relationship)
– Signs of antisocial behaviour: Early onset,
frequency (number of episodes), diversity (range of
different antisocial behaviours), breadth across situations,
seriousness
A visual heuristic describing the
developmental levels model
Advanced CD
Intermediate CD
Oppositional
Mug Truant
Cruel Steal
Force sex Run away
Break, enter
Use weapon Lie
Bully
Vandalize
Fight
Set fires
Hurt animals
Temper tantrums Irritable
Defiant
Spiteful
Blame others
Annoy others
Angry
Argumentative
B. Lahey & R. Loeber (1994)
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/6
Risk Factors
• Social Risk Factors:
–
–
–
–
–
Poverty
Unemployed
Marginal behaviours or life styles
Migration
Low culture
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/7
Symptoms
• Diagnostic criteria (symptoms: type, number and
frequency)
– DSM-IV
– ICD-10
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/8
Clinical Symptoms
• The subtypes of the Disorders
–
–
–
–
Subtypes based on age at onset
Subtypes based on aggression
Subtypes based on socialization
Subtypes based on comorbid conditions
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/9
Clinical Symptoms
• Subtypes based on age at onset
– Childhood onset vs. Adolescence onset
(Longitudinal follow-up study: Farrington, 1979; Dunedin
Longitudinal Study; Moffit, 1990 & McGee, 1992)
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/10
Clinical Symptoms
• Subtypes based on aggression
– Overt vs. Covert (1st Bipolar Dimensional Type;
Loeber et al, 1985)
– Destructive vs. Nondestructive (2nd Bipolar
Dimensional Type; Frick et al., 1993)
– Proactive vs. Reactive (theoretical model based;
dichotomy; Dodge et al., 1991)
– Affective vs. Predatory (connection with
Autonomous/neurotransmission; Vitello et al., 1990)
– Constraint
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/11
Clinical Symptoms
• Subtypes based on Sociabilization
– Socialized vs. undersocialised (Biological functioning
is different; Quay et al., 1987)
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/12
Clinical Symptoms
• Subtypes based on Comorbid Conditions
– ADHD
– Cognoscitive Disfuctions
– Emotional Disorders
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/13
Clinical Symptoms
• Comorbidity
–
–
–
–
–
ADHD
Impulse-control Disorders
Alcohol or Drug abuse
Anxiety, Depression
Sociabilization Disorders
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/14
Pronogsis
• Clinical Features associated with bad
pronogsis:
– Age at onset: Childhood
– Subtypes of aggression
• Destructive
• Proactive
• Predatory
– Sociabilization: Undersocialized
– Comorbid conditions: ADHD and/or Cognitive
Disfuctions
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/15
Pronogsis
• Protective Factors:
–
–
–
–
–
Higher self-esteemand locus of control
Family support and supervission
Continuity in therapeutic intervention
Early diagnosis and therapeutic intervention
Good accessibility to Child and Adolescent
Psychiatric Services
– Social support (peer and social context)
– School support
Hollistic and Developmental Assessment
of Behaviour Disorders in Adolescence/16
Pronogsis
• Individual Factors:
– Temperament
– Personality traits
– Perception disorder by himself/herself
Assessment of Behaviour Disorders in
Adolescence/1
• Diagnostic Assessment:
–
–
–
–
–
Obtain patient’s history
Obtain family history
Interview with patient
School information
Physical evaluation
AACAP (1997)
MªC. Ballesteros; JL Alcázar; JL Pedreira & A de los Santos (1998)
Assessment of Behaviour Disorders in
Adolescence/2
• Diagnostic Formulation:
– Identify ICD-10/DSM-IV target symptoms
– Biopsychosocial stressors, enviromental and
developmental factors
– Subtype of the Behaviour Disorders
– Comorbidity
AACAP (1997)
MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
Assessment of Behaviour Disorders in
Adolescence/3
• Obtain patient’s history:
– Prenatal ahd birth history (substance abuse by
mother, maternal infections or medications)
– Developmental history (attachment diosrders e.g.
Parental depression, substance abuse; temperament,
oppositionality, aggression, attention, socialization,
impulse control)
– Physical/sexual abuse history
– History of symptoms development (impact on
family and peer relationship, academic problems)
– Medical history (CNS pathology, chronic illnesses,
somatizations)
AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
A developmental progression for
antisocial behavior
Rejection by
normal peers
Poor parental
discipline
and monitoring
Commitment
to deviant
peer group
Child
conduct
problems
Deliquency
Academic
failure
Early Childhood
Middle Childhood
Late Childhood
and Adolescence
Multidimensional causal models:
Longitudinal model
Prior Delinquent
Behaviour
Family
-
Delinquent Peers
+
School
+
Delinquent
Behaviour
-
Elliot, Huizinga & Ageton (1985) (Condensed & adapted)
Median Age of Onset Reported by Parent of Symptoms of
oppositional Defiant Disorder and Conduct Disorder ª
B. Lahey & R. Loeber (1994)
Median age
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5
10.0
10.5
11.0
11.5
12.0
12.5
13.0
ª This combines retrospective and prospective ages of onset over four annual
assessment in the Developmental Trends Study.
Oppositional defiant disorder
Conduct disorder
Stubborn
Defies adults, temper tantrums.
Irritables, argues.
Blames others.
Annoys others.
Spiteful.
Angry.
Swears.
Lies.
Fights.
Bullies, sets fires.
Uses weapon.
Vandalizes.
Cruel to animals.
Physical cruelty.
Steals, runs away from home.
Truant, mugs. Breaks and enters.
Forces sex.
The families of adolescents:
The “strop cycle”
Harsh criticism from others
Identity definition
by opposition
Precarious self-esteem
P. Hill (1992)
Assessment of Behaviour Disorders in
Adolescence/4
• Obtain family history:
– Family coping style, stressors, resources socioeconomic status, social support/isolation, problemsolving skills, conflict-resolution skills, parenting skills,
limit-setting, abuse/neglect, permissiveness,
inconsistency, management child’s aggression, parent’s
and patient’s coercitive interaction cycles leading to
reiforcement of noncompliance
AACAP (1997)
MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
Assessment of Behaviour Disorders in
Adolescence/6
• Interview patient (may precede parental interview):
– Capacity for attachment, trust and empathy
– Tolerance for and discharge of impulses
– Capacity for showing restraint, accepting
responsability for actions, experiencing
guilt,user anger constructively, acknowleding
negative emotions
– Cognitive functioning
AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
Assessment of Behaviour Disorders in
Adolescence/7
• Interview patient/2 (may precede parental interview):
– Mood, affect, self-esteem, suicide potencial
– Peer relationship (loner, popular, drug-, crime-, or
gang oriented friends)
– Disturbances of ideation (suggestibility, disociation)
– History of early, persistent use of tabacco,
alcohol or other substances
– Psychometric self-report instruments might
provide
AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
Assessment of Behaviour Disorders in
Adolescence/8
• School information:
– Functioning (IQ, achievement test data, academic performance and
behaviour)
– Standard parent and teacher rating scales of the
patient’s behaviour
– Referral for IQ, speech and language and learning
disability and neuropsychiatric testing if available test
data are nor sufficient
– Data may be obtained inperson, by phone or though
written reports from appropiate staff, such as school
principal, psychologist, teacher and nurse
AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
Cross-Sectional model
Parental Monitoring
-
Deviant
Peers
-
Behaviour problems/
Social Competence
+
+a
Delinquent
Behaviour
-
Academic Skills
Patterson & Dishion (1985) (adapted)
a: High behaviour problems and low social competence
Assessment of Behaviour Disorders in
Adolescence/9
• Physical examination:
– Collaboration with family doctor, paediatrician or other
health care providers
– Vision and hearing screening
– Evaluation of medical and neurological conditions (e.g.
Head injury, chronic illness)
– Urine and blood drugs screening as indicated, especially
when clinical evidence suggest substance use
AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)
Selected Measures of Behaviour Disorders
in Adolescents/1
• In order to discriminate clinical and no clinical
people: High discriminant reliability
–
–
–
–
Child Behavior Checklist, Achenbach, 1978
Revised Behavior Problems Checklist, Quay, 1983
Eyberg Child Behavior Inventory, Eyberg, 1978
Conners Rating Scales (Parents and Teachers)
Achenbach-Connors-Quay Questionnaire
(ACQ) delinquent and aggressive
behaviour dimensions
Delinquent behavior
Aggressive behaviour
Cheats
Doesn’t feel guilty
Hangs around kids who get in trouble
Lies
Runs away from home
Sets fires
Steals at home
Steals outside home
Swears; uses obscene language
Talks or thinks about sex too much
Truancy
Uses alcohol
Uses drugs
Vandalizes older kids
Argues
Brags
Bullies; is mean to others
Destroys others’ things
Demands attention
Destroys own things
Disobedient at school
Jealous
Irritable
Loud
Physically attacks people
Screams
Shows offor clowns
Stars fights
Stubborn
Sudden mood changes
Talks too much
Teases other kids
Temper tantrums
Threatens
Selected Measures of Behaviour Disorders
in Adolescents/2
• In order to evaluate the treatment impact: High
predictive reliability
– Child Behavior Checklist, Achenbach, 1978
– Eyberg Child Behavior Inventory, Eyberg, 1978
– Conners Rating Scales (Parents and Teachers)
• In order to require shortness or treatment
evaluation or developmental impact: Short Scales
– Short’s Conners Rating Scale
– Iowa-Conners Teacher Rating Scale
– Eyberg Child Behavior Inventory
Selected Measures of Behaviour Disorders
in Adolescents/3
• In order to assess behaviour competences or
adolescent behaviour profile:
– Child Behavior Checklist, Achenbach, 1978
• In order to consider the setting:
– Child and Adolescent Psychiatric Services, or
comorbidity screening: ABC, CBC, TBP and Conners
Scales
– Behaviour specific setting: Eyberg Child Behavior
Inventory
Family Assessment of Behaviour
Disorders in Adolescents/1
• Parenting Profiles:
– Parenting Scale (Arnold, 1993)
– Parent Practices Scale (Stayhom & Widman, 1998)
– Alabama Parenting Questionaire (Frick, 1991)
• Parent and Teacher Social Cognitions:
– Parenting sense of Competende Scale (Johnston, 1989)
– Cleminshaw-Guidubaldi Parent Satisfaction Scale
(1985)
– Parental Locus of Control Scale (Campis et al., 1986)
Family Assessment of Behaviour
Disorders in Adolescents/2
• Parental perceptions of personal and marital
adaptation or emotional state: Screening of
depressive and mood psychopathology, disocial
behaviour and substance or alcohol abuses
• Family Stress:
– Parenting Daily Hassles (Greener, 1990)
– Parenting Stress Index (Abidin, 1995)
• Parental functioning in extrafamily context:
– Community Interaction Checklist (CIC, Wahler, 1979)
Family Assessment of Behaviour
Disorders in Adolescents/3
• Parent conflicts:
–
–
–
–
–
O’Leary-Porter Scale (1980)
Conflict Tactics Scale (Partner-Strauss, 1979, 1990)
Parenting Alliance Inventory (Abidin, 1988)
Child Rearing Disagreements (Jouriles et al., 1991)
Parents Problems Checklist (Dadds & Powell, 1991)
• Parental satisfaction with treatment procedures:
– Parent’s Consumer Satifaction Questionaire
(Forehandy & McMahon, 1981; mcMahon, 1984)
Diagnostic Formulation of the Adolescents
with Behaviour Disorders/1
• Identify ICD-10/DSM-IV target symptoms
• When suggests BD consider the following:
– Biopsychosocial stressors (sexual and physical abuse, divorse or
death or key attachment figures)
– Educational potential, disabilities, achievement
– Peer, sibling and family problems and strengths
– Enviromental factors (disorganized home, lack of psychiatric
illness or drug or alcohol abuse in parents, enviromental neurotoxins e.g.
Lead)
– Adolescent or Child ego development, especially ability to
form and maintain relationships
AACAP (1997)
Diagnostic Formulation of the Adolescents
with Behaviour Disorders/2
• The subtype of the disorder:
–
–
–
–
Childhood onset vs. Adolescent onset
Overt vs. Covert versus authority
Under-restrained vs. Over-restrained
Socialized vs. Undersocialized
AACAP (1997)
Diagnostic Formulation of the Adolescents
with Behaviour Disorders/3
• The syndromes may be confused or cuncurrent
with:
–
–
–
–
–
–
–
–
–
ADHD
Organic Brain and seizure disorder
ODD
Specific developmental disorder
Intermittent explosive disorder
Schizophrenia
Substance use disorder
Paraphilias
Mood disorder (bipolar and depressive)
PTSD and Disociative disorder
Mental retardation
Borderline personality disorder
Somatization disorder
Narcisistic personality disorder
Adjustment disorder
AACAP (1997)
Dimensional Assessment of Behaviour
Disorders in Adolescents/1
• Individual dimensions:
–
–
–
–
–
–
–
Developmental preocess and moral development
Aggressiveness’ subtypes
Self-esteem and self-likeness
Empathy and impulse control
Comorbility
Poor interpersonal relations
Cognitive and atttributional processes: Deficits and disttorsions in
cognitive problem-solving skills, atributions or hostile intant to others,
resentment and suspiciousness illustrate
– Risk factor and vulnerability
– Temperament
– Clinical features (specially with sign of antisocial behaviour)
AACAP (1997)
Dimensional Assessment of Behaviour
Disorders in Adolescents/2
• Family dimensions:
– Parenting and attachment styles
– Psychopathology (including drug and alcohol abuses)
– Untoward parent-child interactions (physical and sexual
abuses)
– Poor or inconsistent supervision
– Marital conflicts
– Other family members with antisocial behaviour
– Family risk factors
– Genetic factors
AACAP (1997)
Disruptors of effective
parenting
Family Demographics
Income
Parent education
Neighborhood
Ethnic group
Grandparental Traits
Antisocial behaviour
Poor family management
B. Lahey & R. Loeber (1994)
Parental Traits
Antisocial behaviour
Susceptible to stressors
Family Stressors
Unemployement
Marital conflict
Divorce
Disrupted
family-management
practices
Child antisocial
behaviour
Dimensional Assessment of Behaviour
Disorders in Adolescents/3
• School dimensions:
– Acedemic deficiencies
– Neuropsychological deficits (in verbal and “executive”
functions)
– Behaviour disorder in preschooler’s level
– Peer’s relationship and perception of behaviour
– Teacher’s supervision and authority
AACAP (1997)
Dimensional Assessment of Behaviour
Disorders in Adolescents/4
• Social and contextual dimensions:
–
–
–
–
–
–
Identification with a subculture or group
Alienation of the individual from the wider social group
Delinquency areas
Poverty and marginalization behaviour
Legal problems
Social support
AACAP (1997)
Cross-Sectional model
Neighborhood Disorder
Criminal Subculture
+
+
Neighborhood
organization
Neighborhood
Stability
Family
Stability
Age
School
-a
+
-a
Severe
Delinquent
Behaviour
Delinquent
Peers
-
+
Simcha-Fagan & Schwartz (1986)
(condensed and adapted)
a: These parameters are counterintuitive and probably sampling and measurement limitations
Potential
sources
of data
Yourself
scales
Parents
scales
Initial
screem
1
yes
3
yes
Is deviance
confined to the
same syndrome
in all sources?
Teacher
scales
Clinical
interview
Any scales in
Clinical range?
2
no
4
Differential
diagnosis
no
no
Conclusion:
Child’s problems
correspond to a
single Syndrome
e.g. aggresive
Taxonomic
decision tree for
using quantitative
multi-informant
data to make
categorical
decisions
6
5
yes
Conclusion:
Child’s problems
comprise multiple
syndrome or
profile pattern
8
Achanbach (1993)
(modified)
Are the same
syndrome deviant
in all sources?
yes
Peers and
Social
scales
Conclusion:
No evidence of
clinical deviance.
check key items,
e.g. Suicidal
behaviour
Does child’s
behaviour
actually differ
much among
contexts?
Conclusion:
Different behaviours
may have to be
targeted for changes
in different contexts
9
7
no
Conclusion:
Some informants’
Perceptions may
Have to be
Targeted for change
Treatment of Behaviour Disorders in
Adolescents/1
• General aims:
– Treatment shold be provided in a continuum of care that allows flexible
application of modelities by a cohesive treatment team
– Outpatient’s treatment includes intervention in family, school and peer
group
– The predominance of externalizing symptoms in multiple domains of
functioning call for interpersonal psychoeducational modalities
– As a chronic condition requires extensive treatment and long-term
follow-up
– Patients with severe BD are likely to have comorbidities that requiare
treatment
AACAP (1997)
Treatment of Behaviour Disorders in
Adolescents/2
• Treat comorbid disorders
• Family interventions include parent guidance,
training and family therapy:
– Identify and work with parental strengths
– Train parents to stablish consistent positive and negative
consequences and well-defined
– Arrange for treatment of parental psychopathology
AACAP (1997)
Treatment of Behaviour Disorders in
Adolescents/3
• Individual and group psychotherapy with
adolescent:
– Technique of intervention (supportive vs. behavioural)
depends on patient’s age, processing style and ability to
engage in treatment
– A combination of behavioural and explorative approaches is
indicated, especially when there are internalizing and
externalizing comorbidities
• Psychosocial skill-building training should
supplement therapy
AACAP (1997)
Conclussions/1
• Behaviour disorder refers to instances when children
or adolescent evince a pattern of antisocial behaviour,
when there is significant impairment in everyday
functioning at home or school, or when the
behaviours are regarded as unmanageable by
significant others
• BUT:
– When are the behaviour problems a normal developmental
variations? Or
– Are the behaviour disorders an clinical syndrome with different
clinical features and developmental expressions? And
– When are the behaviour problems, the clinical symptom of
disocial behaviour or antisocial personality disorder?
Conclussions/2
• Behaviour disorder is multifaceted and symptomatic
complex in so far as it includes many symptoms and
effects many domains of functioning
• Although the disorder is discussed as a constellation
of symptoms within the child, there are parent and
family features often associated with the disorder
• The nature of the disfunction has important
implications for assessment and intervention both in
the context of clinical work and research
Conclussions/3
• Behaviour disorder represents a special
challenge given the multiple domains of
functioning that are affected
• It is meaningful to consider alternative
constellation of symptoms, various subtypes
and developmental paths and trajectories
• Research identified differences among
subtypes: Aggressive and delinquent types
and childhood onset vs. Adolescent onset
receiving major attention
Conclussions/4
• We need longitudinal follow-up research based on
developmental psychopathology methodology, in
order to clarify the continuity vs. Discontinuity of
the behaviour disorders
• Understanding the confluence of multiple factors
(children’s characteristics, features of behaviour disorder,
parent and family functioning and contextual influences)
• Peer influences have been implicated in the onset
and maintenance of antisocial behaviours including
substance use and abuse and deliquency
• Poor bonding to home and school were related to
subsequent bonding to deviant peers
Conclussions/5
• Assessment issues:
– Assessment involves different sources of
information, the challenges for research and clinical
work consist to integrate multi-informant data
– Although parents are in an excellent position to
report on their children’s behaviour, the evaluation
cannot be assumed to be free from systematic
influences or basis
– It is useful to mention the specificity of performance
because in many cases symptoms are restricted to
once or a few situations
Conclussions/6
• Assessment issues/2:
– The BDs are the “open door” in order to develop
other psychopathological disorder
– Evaluation of a symptom and set of symptoms needs
to be developmentally based
– In our opinion the assessment process includes an
hollistic and comprehensive procedures:
Vulnerability and risk factors, symptoms and clinical
features and pronogsis in order to develop the
treatment (therapeutic and preventive interventions)
Conclussions/7
• The assessment of risk and protective factors
has been relied upon to develop both
therapeutic and preventive interventions
• Advances in understanding behaviour
disorders have derived from trying to move
to understanding the interrelation of factors
and how they operate on a day-to-day basis
in producing antisocial behaviour and its
legal and/or ideological implications