Download Conduct Disorder - UCF College of Sciences

2/24/2014
Conduct Disorder
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Biological
Influences
•Lower heart rate
•Lower skin conductance
•Increased risk if parent:
APD, Alcohol
Dependence, Mood
Disorders, Schizophrenia,
ADHD, CD
DSM-IV-TR Model of
Conduct Disorder
Core Features
•Aggression to people and
animals
•Destruction of property
•Deceitfulness or theft
•Serious violation of rules
Neurobiological
Substrate
Environmental/
Cognitive Demands
•Parental
rejection/neglect
•Inconsistent/harsh
parenting
•Physical or sexual abuse
•Lack of supervision
Secondary Features
Associated Features and
Outcomes
•Little empathy or concern for wellbeing, feelings, wishes of others
•Low or inflated self-esteem
•Callous, lacking guilt or remorse
•Misperceive intentions of others as
hostile or threatening
•Recklessness, risk-taking
•Early onset of substance use
Impaired
•Social functioning
•Academic functioning
•Occupational functioning
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DSM-V Organizational Structure and
Disorder Name
• Found Under – Disruptive, Impulse Control,
and Conduct Disorders
• Disorders Currently Proposed for the
Diagnostic Category:
1.
2.
3.
4.
5.
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct Disorder
Callous and Unemotional Specifier for Conduct
Disorder
Dyssocial Personality Disorder (Antisocial Personality
Disorder)
Disruptive Behavior Disorder Not Otherwise Classified
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DSM-V Revisions for Conduct Disorder
• Criterion A – Repetitive and persistent pattern of
behavior where the basic rights of others or
major age-appropriate societal norms or rules are
violated. Presence of three or more of the
following 15 criteria in the past 12 months from
any of the categories below, with at least one
criterion present in the past 6 months:
–
–
–
–
Aggression Toward People and Animals
Destruction of Property
Deceitfulness or Theft
Serious Violations of Rules
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DSM-V Revisions for Conduct Disorder
Aggression to People and Animals
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle,
knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of Property
(8) has deliberately engaged in fire setting with the intention of causing serious damage
(9) has deliberately destroyed others' property (other than by fire setting)
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DSM-V Revisions for Conduct Disorder
Deceitfulness or Theft
(10) has broken into someone else’s house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering; forgery)
Serious Violations of Rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years . (In adults,
often violates rules of family life, e.g., neglects basic needs of a child.)
(14) 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. (In adults, often violates major societal norms, e.g.,
rulings of the court or conditions of parole/probation or rules of a public agency or residential
setting.)
(15) is often truant from school, beginning before age 13 years. (In adults or adolescents not in school,
often violates rules of the workplace, e.g., chronic work absenteeism without acceptable reason.)
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Specifier for Callous and Unemotional
Traits in Conduct Disorder
• Display at least two of the following traits persistently
over at least 12 months and in multiple relationships
and settings. These traits reflect a typical pattern of
interpersonal and emotional functioning, not just
occasional occurrences in some situations. Multiple
information sources are necessary. In addition to selfreport, it is necessary to consider reports by others
who have known the individual for extended periods of
time (e.g., parents, teachers, co-workers, extended
family members, peers).
–
–
–
–
Lack of Remorse or Guilt
Callous-Lack of Empathy
Unconcerned about Performance
Shallow or Deficient Affect
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Specifier for Callous and Unemotional
Traits in Conduct Disorder
Lack of Remorse or Guilt: Does not feel bad/guilty after doing
something wrong (exclude remorse expressed only
when caught/facing punishment). Shows general lack
of concern about negative consequences of his/her
actions. Not remorseful after hurting someone or does
not care about the consequences rule breaking. Rarely
admits being wrong. Typically blames others for
negative consequences of his/her behavior.
Callous-Lack of Empathy: Disregards/unconcerned about
the feelings of others. Cold and uncaring. Appears
more concerned about the effects of his/her actions on
him or herself, rather than their effects on others, even
when they result in substantial harm to others.
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Specifier for Callous and Unemotional
Traits in Conduct Disorder
Unconcerned about Performance: Doesn’t show
concern about poor/problematic performance at
school, work, or in other important activities.
Doesn’t put forth effort necessary to perform well,
even with clear expectations. Typically blames
others for poor performance.
Shallow or Deficient Affect: Doesn’t express feelings or
show emotions to others, except in ways that seem
shallow, insincere, or superficial (e.g., actions
contradict emotion displayed; can turn emotions
“on” or “off” quickly) or when emotional
expressions are used for gain (e.g., emotions
displayed to manipulate or intimidate others).
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Callous-unemotional traits – also referred to as “Deficient Affective
Experience” or the “Affective Factor”
 Lack of guilt
 Lack of empathy
 Callous use of others for one’s own gain
CU Traits Predict:
 Violent sexual offenders
 Early onset disruptive behavior disorder diagnosis
 Adult measures of psychopathy at ages 18-19 even after controlling for
early CD problems and other risk factors
 More severe CD problems, violence, aggression, & delinquency
 A more severe and stable pattern of antisocial behavior
CU Stability:
 .71 over 4-year follow-up (Frick et al., 2003; for intraclass correlations)
 .50 across 9-years (parent report; Obradovic et al., 2007)
 Lanam et al., 2007: not entirely immutable; some youths exhibit
reduction in level of CU traits over 4-years
 .60 from late adolescence (age 17) to early adulthood (age 24) –
(Blonigen et al., 2006)
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Conduct Disorder
Hare et al.’s (1991) two-factor model of psychopathology includes two
partially independent psychological dimensions:
 First Dimension -- includes interpersonal characteristics and emotional
style that have been the hallmarks of the psychopathic personality:
Interpersonal Characteristics:
Superficial charm
Callous use of others
Absence of empathy
Emotional Style:
Absence of guilt
Shallow emotions
Lack of anxiety
 Second Dimension -- includes the unstable and antisocial lifestyle that
defines antisocial personality disorder:
 Multiple marriages
 Poor employment history
 Multiple arrests
 Aggression
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Frick et al. (1994; 1997): Identified two separable
psychological dimensions from factor analysis:
1.Callous-Unemotional (CU) Interpersonal Style
 Hypothesized to be related to a temperamental style characterized
by a lack of fearful inhibitions, which in turn, make a child less responsive
to cues of punishment.
 Development of CU traits places a child at high risk for showing
antisocial behavior.
Absence of empathy, lack of guilt, and a callous use of others make a
child more likely to act against parental and societal norms and to
violate the rights of others.
 Not all children who develop conduct problems show CU traits or
the temperament style that is proposed to underlie these traits.
 Implication: children with CU trait develop their behavioral problems
through a process that is different from other children with conduct problems
(e.g., not by means of parental socialization practices)
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1. Callous-Unemotional (CU) Interpersonal Style
(continued)
 Implication: children with CU trait develop their behavioral problems
through a process that is different from other children with conduct
problems (e.g., not by means of parental socialization practices).
 Potential Hypothesis: The development of conduct problems will be
relatively independent of parenting practices because their unique
motivational and affective style makes them relatively unresponsive
to typical socialization practices.
2. Poor Impulse Control and Conduct Problems
(associated with traditional behavioral definitions of
conduct problems and oppositional defiant behavior)
 Thought to be due to parental socialization practices
(Patterson et al., 1992).
 Children without CU traits should show vulnerability to parental child
rearing practices (e.g., increased CD with increased coercive parenting
and parent psychopathology).
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Wootton, J. M., Frick, P. J., Shelton, K. K., & Silverthorn, P. (1997). Ineffective
parenting and childhood conduct problems: The moderating role of callousunemotional traits. Journal of Consulting and Clinical Psychology, 65, 301–308.
A sample of 6- to 13-year-old clinic-referred (n = 136) and volunteer (n = 30) participants
was investigated for a potential interaction between the quality of parenting that a child
receives and callous–unemotional traits in the child for predicting conduct problems.
Ineffective parenting was associated with conduct problems only in children without
significant levels of callous (e.g., lack of empathy, manipulativeness) and unemotional
(e.g., lack of guilt, emotional constrictedness) traits. In contrast, children high on these
traits exhibited a significant number of conduct problems, regardless of the quality of
parenting they experiences. Results are interpreted in the context of a model that
proposed that callous–unemotional traits designate a group of children with conduct
problems who have distinct causal factors involved in the development of their
problematic behavior.
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Callous-unemotional traits
Genetics:
 42%-43% variation in CU traits accounted for by genetic effects
[Larson et al., 2006; Taylor et al., 2003].
 Viding et al. (2005) examined 3,687 twin pairs and divided them into
children high and low on CU traits – combined group level
heritability was .68, but differed depending on the CU factor, viz.,
.30 for children low on CU, .81 for children high on CU.
 Influence of shared environment was substantial for children in the
low CU group, but negligible for children with high CU traits.
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Callous-unemotional traits
Other Factors:
 Youths with CU traits do NOT show abnormalities in processing stimuli
with positive emotional content.
 Youths with CU traits show deficits in processing stimuli with negative
emotional content, particularly signs of fear and distress others.
 High CU youths tend to be less sensitive to punishment cues.
 High CU youths tend to show more positive outcome expectancies
in aggressive situations with peers (Pardini et al., 2004).
 High CU is positively associated with measures of fearlessness and
thrill seeking behaviors (Frick et al., 1999).
 High CU is negatively associated with trait anxiety and neuroticism
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Suppressor Variable Effect
Conduct
Problems
r = .30
Anxiety
r = .41
w/CU
CU Traits
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Empirical Research
 Prevalence Rate: 2-16%
 By age
 By gender
 By SES
 Estimate by Census:
 Between 1.5 million and 12 million (3-18 years of age)
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Current Research
Ratio M:F 3(or 2):1
Diagnosis Differences
Onset Differences
Male
• Violations and behaviors
more overt
Childhood or Adolescence
Female
• Violations and behaviors
more covert
Usually Adolescence
 Diagnosis of CD in girls problematic
 CD criteria may be gender specific
 Socialization differences in males and females
 Girls more adept at hiding aggression and delinquency
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Current Research
 Age of Onset
 Childhood onset – before 10 years (sometimes by 7 years,
depends on ODD diagnosis)
 Adolescent onset – after 10 years (usually around puberty)
 Type of Onset
 Childhood onset - acute
 Adolescent onset - acute
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Current Research
 Mean/range duration of symptoms
 Childhood onset
 More severe and chronic
 Severity/number/variety of symptoms at earliest onset predicts the severity
over time
 Persistent but fluctuating - symptoms fluctuate above or below diagnostic
threshold from year to year
 With C-U, more severe and chronic
 Without C-U, moderate to mild, more likely to desist
 Adolescent onset
 Onset with puberty
 Related to peer networks (e.g. gang-related behaviors)
 Less severe, chronic – more likely to desist
 Less association with C-U
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Current Research
 Typical course
25-40%
APD in adulthood
Childhood
onset
80% APD
symptoms, not
full criteria in
adulthood
Adolescent
onset
Typically limited
to adolescence
 Hypothesized Trajectory
ODD
Early onset +
C-U CD
APD
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Current Research
Genetics
 Latent externalizing behavior factor
 Common genetic risk factor for CD, ODD, ADHD
 Association between familial negativity and adolescent
antisocial behavior
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Age of Onset
Behavior (N)
Age (25th percentile,75th percentile)
Stubborn (222)
9 (3,13)
Covert (lying, stealing) (319)
10 (7,12)
Defiance (209)
11 (7,13)
Aggression (218)
12 (8,13)
Property Damage (231)
12 (9,13)
Moderate Delinquency (pickpocketing,
joyriding) (225)
13 (11,14)
Serious Delinquency (false checks, illegal credit
card use, breaking and entering, selling drugs)
(161)
13 (11,14)
Authority Avoidance (373)
13 (12,14)
Fight (204)
13 (12,14)
Violence (100)
13 (11,14)
Loeber et al., 1993
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Developmental Pathways of Conduct
Problems/Conduct Disorder
 Loeber & Hay, 1994
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Entire Sample
4%/5%
Younger group/Older group
3%/5%
20%/7%
27%/25%
16%/5%
59%/51%
48%/64%
22%/18%
60%/56%
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Younger group/Older group
7%/5%
11%/20%
11%/6.5%
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Children with CD dx
Younger group/Older group
30%/30%
9%/18%
3%/18%
5%/25%
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Empirical Support for the Tripartite
Model
 Janson & Kjelsberg (2006)
 1087 admitted patients (from previous study)
 DSM-IV CD diagnosis
 Conducted a factor analysis of the 15 CD diagnostic criteria and
a cluster analysis
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Empirical Support for the Tripartite
Model
Strongest Factor Loadings
Delinquency
Aggression
Rule Breaking
Destroyed property
Bullies/threatens
Often out at night
Break-ins
Initiates fights
Often truant
Lies/cons
Has used a weapon
Stealing/shoplifting
Cruel to people
*Fire setting (boys only)
Fire setting (girls only)
*Run away from home
•Clusters identified
•Non-symptomatic
•Delinquent
•Rule breaking and delinquent
•Aggressive and delinquent
•Multi-symptomatic
Janson & Kjelsberg (2006)
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Empirical Support for the Tripartite
Model
 Nagin & Tremblay (1999)
 Fewer boys evinced externalizing behaviors (aggression, oppositionality, and
hyperactivity) as age increased
 Data did not suggest that there are two distinct onsets
 Boys who were physically aggressive/oppositional at risk for later CP
 Loeber, Keenan, and Zhang (1997)
 Differentiated between persisters and experimenters
 Persisters more likely to enter pathways at their first stage
 Persisters are more likely to progress through all three stages (applies to all
three pathways) and in the order predicted by Loeber’s model
 Cote et al. (2001)
 high levels of early conduct problems were significantly related to later CD (4.46
times more likely to be diagnosed girls expressing few early conduct problems)
 65% of diagnosed girls showed at least moderate levels of early conduct problems
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Adolescence-Limited/Life-CoursePersistent Theory
 Moffitt (1993)
 Each type of onset has distinct etiology, developmental course, and prognosis
Life-Course-Persistent Trajectory
Reciprocal interaction of neurological
predispositions and temperament (personal
characteristics) and parenting and environmental
factors render individual increasingly vulnerable to
delinquency and conduct problems
Adolescence-Limited Trajectory
Adolescents begin AB/delinquency via social
mimicry, committed to gain earlier access to power
and privilege that is withheld (maturity gap) at a
time in development when peer influence and
independence are important
•Relative minority of individuals display antisocial
behaviors early in childhood and persist
•Larger proportion of adolescents begin AB in adolescence
and desist in later adolescence/young adulthood
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Neurobiological Model of Childhood
Antisocial Behavior
 Serotonergic functioning and stress-regulating subsystems (HPA axis
and ANS) explain individual differences in ASB (van Goozen et al., 2007)
Genetic Factors
Neurobiological
Deficits
Early Childhood
Adversity
Disinhibited
Cognitive and
Emotional
Problems
Early Behavior
Problems
Antisocial
Behavior
Problems
Time
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Biological Influences
•Genetics: parental psychopathology
– APD, ADHD, CD, etc
With
C-U
Core Features
•Early, severe, stable,
persistent and aggressive
conduct problems
•Less environmental effect
on conduct problem
severity or improvement
•Less verbal deficits
Outcomes
•Higher rates of
delinquency
•More likely meet criteria
for APD in adulthood
•Deficient affective
experience
Childhood
Onset
Neurobiological
Subsytems/Substrates
•Serotonin (5-HT dysfunction)
•Cortisol (Reduced stress response)
•Autonomic Underarousal
•Amygdala dysfunction
•Prefrontal cortex deficits
Without
C-U
Core Features
•High comorbidity with
ODD, ADHD, etc.
•Persistent, stable,
moderately harmful
conduct problems
Outcomes
•Rejection by peers
• Deficits in academic,
social, and occupational
functioning
• May exhibit symptoms of
APD in adulthood without
meeting full criteria
Environmental and Cognitive Demands
•Parenting/discipline style, consistency
• SES, neighborhood
•Attachment
Adolescent
Onset
Core Features
•Mild severity in level of
symptoms
•Symptoms related to peer
groups and social network
Outcomes
•Typically limited to
adolescence
Revised DSM Model
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Current Research
Medical Treatments
 Randomized Controlled Trials (RCTs)
 Mood Stabilizers:
 Lithium
 Carbamazepine
 Typical antipsychotics:
 Haloperidol
 Molindone
 Thioridazine
 Atypical antipsychotic:
 Risperidone
 Psychostimulant
 Methylphenidate
 Clonidine
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Current Research
Primary Treatments
Type of Treatment
Individual interventions
Parent and family treatment
Community-based interventions
Examples
-Anger control/stress inoculation
-Assertiveness training
-Rational-emotive therapy
-Child-focused problem solving skills
-Moral development interventions
-Behavioral Therapy + MPH
-Waschbusch et al. (2007)
-Multimodal treatment
-Parent Management Training (PMT)
-Combining parent and child training
-Parent-child interaction training (PCIT)
-Treatment foster care
-School-based prevention programs
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Current Research
Neurobiological Substrates
 Serotonin
 Terminal regions include the amygdala, hypothalamus, prefrontal
cortex, and hippocampus
 5-HT (serotonin) and aggression (van Goozen et al., 2007)
 5-HT function: Prolactin response to fenfluramine (Halperin et al., 2006)
 Cortisol
 Lower salivary levels (van Goozen et al., 2007)
 Current state of research on cortisol measurements
 Fairchild et al., 2008
 Addressed diurnal rhythm
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Current Research
Biological Subsystems
 Low resting heart rate (LHR)
 Best replicated correlate of antisocial behavior, aggression
 Relationship not artifactual (not due to differences in weight,
height, etc)
 Relationship confirmed in prospective designs (Delinquency
doesn’t lead to LHR), replicated in 6 different countries
 Diagnostically specific (related to CD and no other disorder);
independently predicts violence
 Heritable
 Characteristic of life-course persistent antisocial individuals –
both male and female
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Current Research
Biological Subsystems
 Autonomic Underarousal
 Mechanism by which LHR predisposes individuals to aggression
and antisocial behavior
 LHR measure of autonomic arousal
 Sensation Seeking Theory
 Fearlessness Theory
 Reduced Vagal Tone – associated with aggressive children
 Reduced noradrenergic functioning
 Reduced right hemisphere functioning
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Current Research
Biological Subsystems
 Frontal cortex deficits
 Adult violent offenders
 functional deficits in anterior region,
particularly the frontal region
 Reduced glucose metabolism
 increased aggressive and impulsive acts
 Deficit in executive functions
 Related to ADHD comorbidity?
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Current Research
Biological Subsystems
 Amygdala hypoactivity
 Sterzer et al., 2005
 After controlling for depression/anxiety, aggressive behavior (CBCL)
significantly predicted decreased left amygdala response
 Emotional dysregulation (Marsh et al., 2008; Jones et al., 2009)
 reduced amygdala response to fearful faces (but not neutral or angry faces) in
CD/ODD children relative to controls/ADHD children
 Reduced right amygdala activation (children high CU)
 Reduced physiological responses to affective-evocative stimuli
 Reduced startle response (van Goozen et al., 2007)
 CD/high CU trait children had smaller change in HR than CD and control
children in response to an emotion evocative scene (AnastassiouHadjicharalambous & Warden, 2008)
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Environmental and Socialization
Factors
 Family Factors
 Mother-infant relationship
 Disciplinary practices
 Peer Influences
 Rejection
 Social networks
 Neighborhood Factors
 Low SES
 Fight-or-suffer hypothesis
•Early Health
•Birth complications
•Minor physical anomalies
•Nicotine during pregnancy
•Nutrition
 Adaptive or maladaptive?
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Temperamental and Emotional
Contributors to Aggression
 Temperament and Emotion Regulation
 Difficult vs. Easy Temperament
 Mother’s Meta-emotion
 Callous-Unemotional Traits
 Lack of empathy, remorselessness, dampened affect
 Heritability
 Larsson, Andershed, & Lichtenstein (2006)
 1090 monozygotic and dizygotic twins at age 16-17
 Viding et al., 2008
 AB more heritable with concomitant CU than without; more pronounced when
hyperactive symptoms controlled
 CD Severity (Enebrink, Andershed, & Langstrom, 2005)
 CP more pervasive, variable, and severe
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Cognitive Contributors to Aggression
 Cognitive Factors
 Low intelligence
 Inattention vs. Hyperactivity/Impulsivity
 Negative attributions
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Comorbidity and Trajectories
 ODD
 ADHD (35% chance hyperactivity)
 Anxiety
 Mood Disorders (27% chance)
 Depression
 Bipolar Disorder
 Substance Use
 APD
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Girls with Conduct Disorder
 Gender and comorbidity
 Increased rate of ADHD, Anxiety, Mood, Substance Abuse
Disorders
 Comorbidity predictable
 Internalizing disorders
 Gender paradox
 Depression risk and outcome disparity
 Substance use
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Current Research
Primary Assessments
 Structured Interviews
 DISC-IV, DICA-IV
 Semi-structured Interviews
 K-SADS, CAPA
 Rating Scales
 Disruptive Behavior Disorders section of Children’s Symptom Inventory-4
(CSI-4)
 Parent/Teacher
 Callous/Unemotional Traits
 Antisocial Process Screening Device
 20-Item behavior rating scale
 Impulsivity, Narcissism, Callous/Unemotional Dimensions
 Parent/Teacher rating scale
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Limitations of the Current Research
and Models
 Cross-sectional vs. prospective, longitudinal research
 Measurement of CD, C-U, APD
 Primarily dependent on parent/teacher rating scales
 Operational Definitions
 Differential Diagnosis
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