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2/24/2014 Conduct Disorder 1 2/24/2014 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 2 2/24/2014 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 3 2/24/2014 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 4 2/24/2014 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) 5 2/24/2014 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.) 6 2/24/2014 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 7 2/24/2014 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. 8 2/24/2014 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). 9 2/24/2014 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) 10 2/24/2014 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 11 2/24/2014 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) 12 2/24/2014 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). 13 2/24/2014 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. 14 2/24/2014 15 2/24/2014 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. 16 2/24/2014 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 17 2/24/2014 Suppressor Variable Effect Conduct Problems r = .30 Anxiety r = .41 w/CU CU Traits 18 2/24/2014 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) 19 2/24/2014 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 20 2/24/2014 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 21 2/24/2014 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 22 2/24/2014 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 23 2/24/2014 Current Research Genetics Latent externalizing behavior factor Common genetic risk factor for CD, ODD, ADHD Association between familial negativity and adolescent antisocial behavior 24 2/24/2014 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 25 2/24/2014 Developmental Pathways of Conduct Problems/Conduct Disorder Loeber & Hay, 1994 26 2/24/2014 Entire Sample 4%/5% Younger group/Older group 3%/5% 20%/7% 27%/25% 16%/5% 59%/51% 48%/64% 22%/18% 60%/56% 27 2/24/2014 Younger group/Older group 7%/5% 11%/20% 11%/6.5% 28 2/24/2014 Children with CD dx Younger group/Older group 30%/30% 9%/18% 3%/18% 5%/25% 29 2/24/2014 30 2/24/2014 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 31 2/24/2014 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) 32 2/24/2014 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 33 2/24/2014 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 34 2/24/2014 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 35 2/24/2014 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 36 2/24/2014 Current Research Medical Treatments Randomized Controlled Trials (RCTs) Mood Stabilizers: Lithium Carbamazepine Typical antipsychotics: Haloperidol Molindone Thioridazine Atypical antipsychotic: Risperidone Psychostimulant Methylphenidate Clonidine 37 2/24/2014 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 38 2/24/2014 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 39 2/24/2014 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 40 2/24/2014 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 41 2/24/2014 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? 42 2/24/2014 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) 43 2/24/2014 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? 44 2/24/2014 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 45 2/24/2014 Cognitive Contributors to Aggression Cognitive Factors Low intelligence Inattention vs. Hyperactivity/Impulsivity Negative attributions 46 2/24/2014 Comorbidity and Trajectories ODD ADHD (35% chance hyperactivity) Anxiety Mood Disorders (27% chance) Depression Bipolar Disorder Substance Use APD 47 2/24/2014 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 48 2/24/2014 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 49 2/24/2014 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 50