Transcript ODDCD

Disruptive
Behavior
Disorders
Disruptive Behavior Disorders

DSM-IV
1.
2.
3.



Oppositional Defiant Disorder
Conduct Disorder
Disruptive Behavior Disorder Not Otherwise
Specified
Juvenile Delinquency
Antisocial Personality
Noncompliance
Disruptive Behavior Disorders

Children who display a broad range of behaviors that
bring them into conflict with their environment


Age-inappropriate actions and attitudes that violate family
expectations, societal norms, and personal property rights
of others
Heterogeneous

Behaviors fall along a continuous dimension of externalizing
behavior, which includes a pattern of
 Impulsivity
 Over-activity
 Defiance
 Aggressiveness
 Delinquency (*legal term)
Prevalence:
General Disruptive Behavior




50% of preschoolers display disobedience
26% of preschoolers destroy property
60% of teenagers engage in more than one
type of delinquent behavior
Referrals for males outnumber females
anywhere from 4:1 to 6:1
Prevalence:
Diagnosable Behavior Problems

One of the most common referrals (1/32/3 of all child referrals)

8-12% of children meet specific DSM
criteria for diagnosis of ODD and/or CD
DSM-IV Criteria
Oppositional Defiant Disorder
A recurrent “pattern of negativistic, hostile, and defiant
behavior”
 Lasting > 6 months
 During which > 4 of the following are present:
a) often loses temper
b) often argues with adults
c) often actively defies or refuses to comply with adults' requests
or rules
d) often deliberately annoys people
e) often blames others for his or her mistakes or misbehavior
f) is often touchy or easily annoyed by others
g) is often angry and resentful
h) is often spiteful or vindictive

Video Clip
ODD – Development and Key Features

Average Age of Emergence
(NYU Child Study Center)
Age 3 – Child acts stubborn
 Age 5 – Defies adults, temper tantrums
 Age 6 – Irritable, argumentative, blames
others
 Age 7 – Annoys others, spiteful & angry


Extreme negative impact on parent-child
interactions
Oppositional Defiant Disorder


Characteristics should occur more often
than expected for age and developmental
level
Developmental considerations




Toddlers: difficult temperament, frustration with
novelty
Preschool: discipline problems
Middle childhood: poor peer relationships,
diversification of negative overt behaviors
Adolescence: association with deviant peers,
covert conduct problems, delinquency
Case Examples

Brandon's teachers in the daycare center
report that he is the "terrorist of the 4- yearolds." He punches or bites children and
pushes them off the swings in the
playground without provocation. He swings
the class pet rabbit by the tail in spite of
being told how it hurts the animal. His
parents report that he has been difficult to
manage since he was an infant.

What is different from ODD?
Case Examples

Eleven-year-old Paul, known as The
Prankster in his family, was suspended
from school after leaving half-eaten candy
bars in all the girls' lockers. He had
previously been suspended for leaving
poison pills for the frogs in the biology class
lab.

What is different from ODD?
Case Examples

Robin, l6: "When I was 13, that summer
was a blast. One time we picked up some
older guys in a bar and tried a new kind of
speed. We got really wild and we smashed
in some car windows and somebody called
the police. My mother freaked out and tried
to punish me by locking me in my room, but
I would just skip out on her through the
window.“

What is different from ODD?
DSM-IV Criteria
Conduct Disorder
A. "a repetitive and persistent pattern of behavior
in which the basic rights of others or major ageappropriate societal norms or rules are
violated”
 4 Symptom Domains
1.
2.
3.
4.
aggressive behaviors
behaviors that result in property loss or damage
deceitfulness or theft
other serious rule violations (e.g., running away
from home, truancy)
DSM-IV Criteria
Conduct Disorder
As manifested by the presence of three (or more) of the following
criteria in the past 12 months, with at least one criterion present in
the past 6 months:
1. Aggression to people and animals
a) often bullies, threatens, or intimidates others
b) often initiates physical fights
c) has used a weapon that can cause serious physical harm to
others (e.g., a bat, brick, broken bottle, knife, gun)
d) has been physically cruel to people
e) has been physically cruel to animals
f) has stolen while confronting a victim (e.g., mugging, purse
snatching, extortion, armed robbery)
g) has forced someone into sexual activity
DSM-IV Criteria
Conduct Disorder
2.
3.
Destruction of property
h) has deliberately engaged in fire setting with the
intention of causing serious damage
i) has deliberately destroyed others' property (other
than by fire setting)
Deceitfulness or theft
j) has broken into someone else's house, building, or
car
k) often lies to obtain goods or favors or to avoid
obligations (i.e., "cons" others)
l) has stolen items of nontrivial value without
confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery)
DSM-IV Criteria
Conduct Disorder
4. Serious rule violations
m) often stays out at night despite parental
prohibitions, beginning before age 13 years
n) has run away from home overnight at least
twice while living in parental or parental
surrogate home (or once without returning for a
lengthy period)
o) is often truant from school, beginning before
age 13 years
CD: Key Features


Severe behavior
Experience accompanying problems




E.g., Poor school adjustment
E.g., Poor peer relationships
Parents feel helpless
Families often have own problems

Marital discord, unemployment, psychological
problems
DSM-IV Criteria
Conduct Disorder

Childhood-Onset Type: 1+ problem with conduct before age 10





Adolescent-Onset Type: no problems before age 10





More likely male
More likely aggressive
PERSISTS
Linked to neurological deficits that interfere with development of
language, memory, and self-control
Equal male/female
Less likely to commit violent offenses
Less likely to persist over time
Linked to temporary situational factors
Severity:
 Mild (minor harm) to Severe: (considerable harm)
Video Clip
Deficits in CD

Emotional


Moral


Little concern for feelings & well-being of others
Cognitive


Lack empathy & feelings of guilt
Misperceive the intentions of others in ambiguous
situations as more hostile and threatening
Behavioral

Fail to inhibit antisocial behavior regardless of
knowledge of potential punishment
CD – Development & Course


Typically, mild delinquent behaviors emerge 1st followed
by more severe behaviors gradually surfacing later
Average Age of Emergence of CD symptoms
(NYU Child Study Center)






Age 8 – Lies, fights
Age 9 – Bullies, fire setting, weapon use
Age 10 – Vandalizes
Age 11 – Physical cruelty
Age 12 – Steals, runs away from home, truant,
breaks and enters
Age 13 – Forced sexual activity
CD: Associated Features

Cognitive and verbal deficits


School and learning problems


Rejection
Family problems


Inflated, unstable
Peer problems


Underachievement, grade retention, dropout
Self-esteem deficits


Lower IQ
Discord, instability, harsh discipline, conflict
Health-related problems

Risky- behaviors (drug use, sexual promiscuity)
Adult CD Outcomes





Unplanned
parenthood
School dropout
Substance abuse
Disabling injuries
Unemployment





Difficulty forming
lasting relationships
Divorce
Criminal behavior
Imprisonment
Poor parenting
Empirical Dimensions of
Disruptive Behavior Disorders




Frick et al. 1993:
meta-analysis of 60 factor analytic studies
228,401 children/adolescents with conduct
problems
Conclusions: Most Conduct Problems could
be classified by
 2 orthogonal dimensions
1.
“Covert – Overt”
2.
“Destructive –Nondestructive”
Disruptive Behavior Classification
Frick, et al., (1993)
Stealing
Aggression
Substance Abuse
Oppositionality
Less social
More resentful
More anxious
More irritable
Low social support
High family conflict
Disruptive Behavior Classification
vandalism fighting
truancy
arguing
Classification – Age Progression
CD - Property/Deceit
Stealing, fire setting,
vandalism, lying (3rd)
CD – Aggression
Cruelty, assault,
fighting, bullying,
spite, animal cruelty
(2nd) ***HIGH RISK
CD – status offenses
Truancy, substance
abuse, running away,
curfew violations (4th)
ODD (1st)
Tantrums, arguing,
noncompliance,
Defiance, annoying
Etiology
Etiology of Disruptive Behavior Disorders

Biological influences




Genetic contribution ~50% of variance
Difficult temperament
Reward deficiency syndrome
Neurobiological factors



Overactive behavioral activation system:
stimulate behavior in response to
reward/punishment
Underactive behavioral inhibition system:
produces anxiety and inhibits behavior
Testosterone levels
Etiology of Disruptive Behavior Disorders

Social cognitive factors: egocentrism and
lack of perspective taking





Encoding: Seek less information before acting
Interpretation: attribute hostile intentions to
ambiguous situations
Response Search: generate fewer and more
aggressive responses
Response Decision: choose aggressive solution
Enactment: poor verbal communication; strike
out physically
Etiology of Disruptive Behavior Disorders

Family Factors




Poor disciplinary practices
Lack of parental supervision
Family conflict and violence
Coercion theory (Patterson) Box 6.5



Child learns to use increasingly intense forms of
aversive behavior to escape and avoid unwanted
parental demands
Poor attachment/bond to parents – thought to
lead to association with deviant peers
Family instability and stress
Etiology of Disruptive Behavior Disorders

Peer influences


Rejection
Association with deviant peers
Etiology of Disruptive Behavior Disorders

Societal Factors




Poverty
Neighborhood crime
Family disruption
Media: TV violence
Etiology



Multiple interacting etiologies in the
development of CD
No one factor has been determined to be “the
cause”
Rather than finding a single etiological factor, it
seems more likely that there are numerous
possible combinations of contributing variables
that can result in the clinical manifestations of
CD and ODD
ODD – CD Relationship


Persistent ODD symptoms often precede and
predict early onset of CD (Loeber et al., 2000)
Achenbach and Edelbrock (1981) study of 2,600
children (4- 16 yrs)




Data collected from mothers on symptoms at different ages
Youngest children tended to display oppositional behaviors
At later ages, behaviors such as stealing and fire setting
increased
Other serious conduct disordered behaviors such as truancy,
vandalism, and involvement in substance abuse developed
later
Disruptive Behavior: A Continuum
Typical Child
Behavior Problems
2/3 of children with
ODD do not go on
to develop CD
Oppositional
Defiant Disorder
Conduct Disorder
Almost half of children
with CD also meet criteria
for a diagnosis of ODD
Antisocial Personality
Disorder
Antisocial Personality Disorder



“pervasive pattern of disregard for, and
violation of, the rights of others that begins
in childhood or early adolescence and
continues into adulthood”
Must have history of some CD symptoms
before age 15
Risk factor for psychopathy
Antisocial Personality Disorder
Three or more of the following:
1. Failure to conform to social norms (behaviors
warranting arrest)
2. Deceitfulness (lying, conning, deceit)
3. Impulsivity
4. Irritability and aggressiveness
5. Reckless disregard for safety of others or self
6. Consistent irresponsibility
7. Lack of remorse (indifference or
rationalization)
Comorbidity
Common Comorbid Disorders

Between 34.7 and 48 % of children and adolescents
with ODD/CD also show evidence of ADHD

Common factors: impulsivity and poor self
regulation
~ 25% of children with ADHD diagnosed with CD


Compared to CD and ADHD alone


ADHD/CD more serious and earlier onset of antisocial
behaviors, traffic offenses, failing a grade, school
suspension & expulsion
ADHD/CD ↑ Antisocial Personality Disorder (APD) in
adulthood
Common Comorbid Disorders

Comorbidity estimates ranging from 12-18%
have been found for depressive disorders



Increased risk for suicide
As many as 19% of children/adolescents with
ODD/CD qualify for a diagnosis of anxiety
disorder
Substance Use
Assessment
Assessment of Disruptive
Behaviors

Use of parent-report questionnaires:

Specific Behavior Problems


Eyberg Child Behavior Inventory (ECBI): parents
endorse the frequency and intensity of problems
Broad Measures: frequency ratings


Behavior Assessment System for Children (BASC)
Child Behavior Checklist (CBCL)
Assessment of Disruptive Behavior
Disorders
 Interview:
should include both parents
and the child
Important to ask about the child’s
misbehavior and strengths
 Parenting styles and discipline strategies
 Semi-Structured Diagnostic Interviews


Children’s Interview for Psychiatric Syndromes-Parent
Version (P-ChIPS); Structured Clinical Interview for DSM-IVTR (KID-SCID)
Assessment of Disruptive
Behaviors

Observation of parent-child interaction
(DPICS)


Child-directed and parent-directed interaction +
clean-up
Record parent’s and child’s

Negative behaviors
 Parent: commands, questions, criticisms
 Child: non compliance

Positive behaviors
 Parents: reflection, praise, description, affection
 Child: non compliance, aggression
Treatment
Treatment of Disruptive Behavior
Disorders


Most promising: EARLY and
PARENT/TEACHER INVOLVEMENT
Most popular approach is behavioral in nature
Treatment

Parent Management Training (PMT)
 Psychoeducation
 Contingency management techniques

Reinforcement of prosocial behavior
 Praise/Acknowledgement/Recognition
 Tangible Rewards (e.g., Token economy system)

Punishment of antisocial behavior
 Time-out
 Removal of privileges


Focus on Communications
Monitoring/Supervision
Treatment of Disruptive Behavior
Disorders

Parent-Child Interaction Therapy
Treatment of Oppositional Defiant
and Conduct Disorders

Problem-Solving Skills Training (PSST)
 Effective problem solving skills






Identify problem
Brainstorm possible solutions
Evaluate solutions
Choose a solution
Evaluate outcome
Modification of cognitions
 Hostile attribution bias
 Maladaptive self statements
Treatment of Oppositional Defiant
and Conduct Disorders

Multisystemic Treatment


Intensive approach
Involves external systems




School, family, juvenile justice etc
Involves: PMT, PSST, Marital Therapy,
Specialized academic interventions
Home visits
Addresses hypothesized etiological factors
Juvenile Delinquency


Some children not only show oppositional
defiant behavior and features of conduct
disorder – they also come into conflict with
the juvenile justice system.
The legal term “delinquency” is applicable
to such children and adolescents
Juvenile Delinquency


It refers to a juvenile (usually under 18 years)
who is brought to the attention of the juvenile
justice system for committing a criminal act or
displaying a variety of other behaviors not
allowed under the law
These "other behaviors" are usually referred to
as status offenses:


truancy, curfew violations, running away, the use of
alcohol
These are only violations of the law due to the
child's age and his/her status as a minor
Treatment of
Juvenile Delinquency



Treatment of children has frequently been
conducted in institutions or within community
based programs
Research suggests that treatment within
standard institutional programs is often
unsuccessful, with as many as 70-80% being
rearrested within a year or so after release
However, data suggests that the inclusion of
well-conceived behaviorally-based programs
can result in positive outcomes
Treatment of
Juvenile Delinquency


Illustrative of such an approach is the Cascadia
Project, conducted in Tacoma, Washington by
Irwin Sarason and his colleagues at the
University of Washington
In this program residents were provided with:


modeling and role-play/discussion experiences
taught a variety of adaptive skills to decrease the
likelihood of future delinquent behaviors (e.g., learning
how to resist temptation from peers, to delay gratification,
to apply for a job, how to behave appropriately when
stopped by police, etc.)
Treatment of
Juvenile Delinquency




Gains were seen at post-treatment
5-year follow up data evidenced recidivism rates
for treated youths was less than half than that of
those who did not receive treatment
Conclusion:
skills-based treatments that
promote a pro-social lifestyle may be of value in
decreasing the likelihood of future delinquency
Booster-sessions after release may maximize
the durability of skills
Treatment of
Juvenile Delinquency



Teaching Family Model (Achievement
Place) from University of Kansas
Community-based program
Residents live in a home-like setting with 78 other residents and 2 house parents
trained in behavior management skills
Treatment of
Juvenile Delinquency
Residents attend school and have a
variety of work responsibilities
 An extensive token economy program
serves as the basic focus of treatment



rewards for appropriate behaviors (e.g.,
completing homework assignments, increased
academic performance, improving conversational
skills with adults, modifying aggressive
statements, improving problem solving skills with
parents)
fined for showing inappropriate behaviors