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Disruptive Behavior Disorders Gregg Selke, Ph.D. PSY 4930 September 19, 2006 Disruptive Behavior Disorders DSM-IV 1. 2. 3. Oppositional Defiant Disorder Conduct Disorder Disruptive Behavior Disorder Not Otherwise Specified Juvenile Delinquency Acting-out Externalizing Antisocial Noncompliant Disruptive Behavior Disorders Children who display a broad range of behaviors that bring them into conflict with their environment Heterogeneous Including behaviors described as coercive or oppositional To more severe, that represent a greater threat to those around them and/or may lead to juvenile justice system Noncompliance Tantrums Disruptions Verbal Abuse Running Away Aggression Property Destruction Stealing Lying Fire-setting Prevalence: Diagnosable Behavior Problems One of the most common referrals (1/32/3 of all child referrals) Epidemiological studies of children displaying more general conduct disordered features have suggested that somewhere between 3.2 and 6.9% of the general child/adolescent population may be affected 8-12% of children meet specific DSM criteria for diagnosis of ODD and CD Prevalence: General Disruptive Behavior 60% of teenagers engage in more than one type of delinquent behavior 50% of preschoolers display disobedience 26% of preschoolers destroy property Referrals for males outnumber females anywhere from 4:1 to 6:1 Oppositional Defiant Disorder (ODD) http://www.fox.com/nanny911/ Janice and Kerry Delaney Prevalence rates 2.1 – 15.4 % in epidemiological studies (Loeber et al., 2000) 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 DSM-IV Criteria Oppositional Defiant Disorder Criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. The symptoms cause clinically important distress or impair work, school or social functioning The symptoms do not occur in the course of a Mood or Psychotic Disorder The symptoms do not fulfill criteria for Conduct Disorder If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder Oppositional Defiant Disorder Characteristics should occur more often than expected for age and developmental level Developmental considerations Toddlers Preschool Middle childhood Adolescence ODD – Development 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 Case Examples (NYU Study Center) 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 (NYU Study Center) 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 (NYU Study Center) 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? Conduct Disorder (CD) 6-16% of males & 2-9% of females under the age of 18 1.3 – 4 million children & adolescents –U.S. http://www.fox.com/nanny911/ The Arilotta Family Possible precursors to CD?? 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 B. These symptoms cause clinically important job, school or social impairment C. If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder DSM-IV Criteria Conduct Disorder Childhood-Onset Type: 1+ problem with conduct before age 10 Adolescent-Onset Type: no problems before age 10 Severity: Mild (both are required): 3-4 endorsements and behavior causes minor harm Moderate: number and effect of conduct problems is between Mild and Severe Severe: 10 endorsements and/or behavior causes considerable harm Emotional Deficits in CD They may……. Lack empathy & feelings of guilt Little concern for feelings & well-being of others Misperceive the intentions of others in ambiguous situations as more hostile and threatening Fail to inhibit antisocial behavior regardless of knowledge of potential punishment CD – Etiology & Correlates (may also be risk factors for ODD) Child Risk Factors Inappropriate early aggression Hyperactivity Impulsivity – sensation seeking Difficult temperament Neuropsychological deficits – learning deficits Male gender Association with delinquent peer group Poor interpersonal problem-solving skills CD – Etiology & Correlates Family Risk Factors Inconsistent parenting Authoritarian or harsh parenting Parent conflict – divorce Use of physical aggression Little involvement in child’s activities http://www.fox.com/nanny911/ Heidi & Craig Morris Family Longairc-Green Family Family dynamics: Interaction of cause and effect Family Risk Factors Poverty ↑ parent stress Single parent households ↓ financial and community resources ↑ community dangers, e.g., gangs, drugs Negative peer influences CD – Etiology & Correlates Family Risk Factors History of parental Alcohol dependence Mental illness ADHD Conduct Disorder Antisocial Personality Disorder CD – Correlates Neurologic Correlates: Limited evidence for for ↓ right temporal lobe frontal lobe abnormalities Physiologic Correlates: Underaroused ↓ resting heart rate ↓ heart rate reactivity ↓ skin conductance reactivity ↓ startle response to victimization pictures CD – 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 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 – Course, Outcomes, & Future Risks Early onset of Drinking Smoking Sexual behavior illegal drug use Increased risk for future Criminal behavior Incarceration Alcohol abuse Marital discord Occupation impairment Social impairment Up to 40% of children with CD will meet criteria for Antisocial Personality Disorder in Adulthood 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 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) ODD – CD Relationship Persistent ODD symptoms often precede and predict early onset of CD (Loeber et al., 2000) ODD and CD generally emerge at different ages 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 ODD – CD Relationship Some scientists have questioned whether CD and ODD are truly distinct disorders or whether a new classification system is needed ODD with aggression versus ODD without aggression ODD with aggressive CD symptoms versus Nonaggressive CD behaviors 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 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) CD – status offenses Truancy, substance abuse, running away, curfew violations (4th) ODD (1st) Tantrums, arguing, noncompliance, Defiance, annoying Disruptive Behavior Classification 4 categories appear to correspond to categories of antisocial behavior often used by the Juvenile Justice system Consistent with other systems for classifying conduct disordered and delinquent behavior (e.g., oppositional behavior, aggressive behavior, property violations, status offenses) Psychopathy- Another way to classify Personality Type Related but unique from APD (behaviorally- based) Grandiose, Impulsive, Manipulative, Lack Empathy, Callous, Selfish, Shallow, Parasitic, Irresponsible, Glib, Dishonest, Boredom Susceptible, Criminal Acts Adult Psychopath Criminals 90% adult psychopaths have APD (Lynam, 1998) Only 25% of APD are psychopaths ↑ violent, ↑ crimes, ↑ recidivism than non-psychopathic criminals “Future Psychopathic Adult” (Lynam, 1996, 1997, 1998) Children with CD + ADHD may be at greatest risk Common Comorbid Disorders with ODD & CD Between 34.7 and 48 % of children and adolescents with ODD/CD also show evidence of ADHD ~ 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 with ODD & CD Comorbidity estimates ranging from 12-18% have been found for depressive disorders As many as 19% of children/adolescents with ODD/CD qualify for a diagnosis of anxiety disorder Assessment of Disruptive Behaviors Use of parent-report questionnaires: Eyberg Child Behavior Inventory (ECBI): parents endorse the frequency and intensity of child behavior problems Behavior Assessment System for Children (BASC): parents rate frequency of child behavior problems and other issues 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 strategies Semi-Structured Diagnostic Interviews Children’s Interview for Psychiatric Syndromes-Parent Version (PChIPS); Structured Clinical Interview for DSM-IV-TR (KID-SCID) Observation of parent-child interaction (DPICS) Child-directed and parent-directed interaction + clean-up Record parents commands, questions, criticisms, and positive play skills Treatment of Disruptive Behavior Disorders Most popular approach is behavioral in nature The work of Patterson and colleagues is most representative of this basic approach parents pinpoint problem behaviors (e.g. aggressive responses, noncompliant responses) Monitor more appropriate responses as well utilize various child behavior management techniques to decrease problem behavior and increase desirable behavior Treatment of Disruptive Behavior Disorders Other behavioral procedures: reinforcement of appropriate behaviors extinction (withdrawal of reinforcement) time out procedures for dealing with undesirable behaviors School personnel may be involved in order to deal with the child's behavior in that setting as well This multifaceted behavioral approach has been shown to be highly effective in treating a range of conduct problems See: http://www.effectivechildtherapy.com Treatment of Disruptive Behavior Disorders Other behavioral approaches have been used to deal with specific behaviors (or classes of behaviors) displayed by behavior disordered children One example involves Videotaped Parent Training developed by Carolyn Webster-Stratton at Washington and the work of Forehand & McMahon with non-compliant children at Georgia Of special note is the work of Eyberg and Boggs with ParentChild Interaction Therapy, that is designed to modify oppositional/defiant behavior and the aggressiveness sometimes seen in ODD children, as well as improve parentchild attachment. Guest lecture in future Treatment of Oppositional Defiant and Conduct Disorders Kazdin (1993) has also developed another more cognitively oriented approach, Problem-Solving Skills Training This approach focuses on the modification of cognitions such as attributions of hostile intent, which may precipitate aggressive behavior, and maladaptive self-statements which may mediate other expressions of antisocial behavior An additional focus is on helping the child learn and use effective problem solving skills in dealing with problematic interpersonal situations he/she may encounter Treatment of Oppositional Defiant and Conduct Disorders While such cognitive-behavioral procedures have been shown to be somewhat effective in dealing with older conduct disordered children, questions still remain regarding the clinical significance of observed treatment effects and the precise nature of those variables that contribute to effectiveness 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 term “delinquency” is applicable to such children and adolescents Juvenile Delinquency Delinquency is a legal term rather than a psychological construct. 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 Juvenile Delinquency Considered within the context of DSM-IV, the concept of delinquency overlaps with conduct disorders While many delinquents do meet criteria for a diagnosis of conduct disorder, many youths who come into contact with the juvenile justice system do not show the pattern of seriously antisocial behavior associated with the diagnosis of conduct disorder Likewise, many conduct disordered youth are never considered delinquent as their illegal behaviors escape detection Juvenile Delinquency Given that juvenile delinquency is essentially a “legal” category used to designate those who have committed any of numerous offenses, delinquents represent a heterogeneous group However, research studies have often focused on the causes, correlates, and treatment of delinquency without taking this variability into account. This has often led to unreplicated findings and inconclusive results. Juvenile Delinquency Due to the variability within this group, some researchers have considered that various dimensions of delinquency may exist Quay (1964; 1987b): developed the most widely cited, empirically based, classification scheme for delineating dimensions of delinquent behavior Juvenile Delinquency In this early research, factor analyses of ratings of behavioral traits obtained from the case histories of institutionalized male delinquents yielded four independent groupings: 1. 2. 3. 4. socialized-subcultural delinquency unsocialized-psychopathic delinquency disturbed-neurotic delinquency inadequate-immature delinquency Juvenile Delinquency Socialized-subcultural - strong allegiance to selected peers, being accepted by delinquent subgroup, having bad companions, staying out late at night, and having low ratings on shyness and seclusiveness Juvenile Delinquency Unsocialized-psychopathic –solitary rather than group-oriented; rated high on such traits as inability to profit from praise or punishment, defiance of authority, quarrelsomeness, irritability, verbal aggression, and assaultiveness Juvenile Delinquency Disturbed-neurotic - unhappy, shy, timid and withdrawn, and prone to anxiety, worry, and guilt over their behavior Inadequate-immature - not usually accepted by delinquent peers, passive and preoccupied, picked on by others, and easily frustrated, poorly developed behavioral repertoire 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 Treatment of Juvenile Delinquency Reinforcement is with points which can be cashed in for a wide variety of back-up reinforcers (e.g., allowance, snacks, TV viewing) Important treatment component: generalizing to the outside environment so that gains will maintain after release from the program Some support for the general effectiveness of this program, although relapse rates are typically high Treatment of Juvenile Delinquency Another relatively new non-institutional approach to treatment is Multisystemic Therapy (MST), which is designed to address the role of multiple, interconnected systems in which the adolescent is embedded This approach recognizes the effects of family, school, work, peer, community and cultural institutions on the adolescents functioning and in the initiation and maintenance of delinquent behavior Intervention occurs on multiple levels Treatment of Juvenile Delinquency The length of MST averages between 13 and 17 sessions Therapists employ empirically-based treatment techniques, including those used in structural family therapy and cognitive-behavioral therapy, to tailor interventions to the needs and strengths of each family member 9 treatment principles (e.g., “Focus on systemic strengths” “Interventions should be developmentally appropriate”) Treatment of Juvenile Delinquency MST has been shown to result in longterm reduction in delinquent activity In a longitudinal investigation, MST improved family cohesion, reduced the number of incarcerations at a 59-week follow-up, and significantly reduced peerrelated aggression Re-arrest rates were also reduced at a 2year follow-up Treatment of Juvenile Delinquency In another study, MST was found to reduce violent and criminal activity at a 4year follow-up Documented efficacy with ethnic minority populations Cost-effectiveness in comparison to incarceration. One of the most promising, empiricallysupported treatment approaches for this population Diagnostic criteria for Adjustment Disorders A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically significant as evidenced by either of the following: 1. marked distress that is in excess of what would be expected from exposure to the stressor 2. significant impairment in social or occupational (academic) functioning C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. D. The symptoms do not represent Bereavement. E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify if: Acute: < than 6 months versus Chronic: > 6 months or longer Subtypes 309.0 With Depressed Mood 309.24 With Anxiety 309.28 With Mixed Anxiety and Depressed Mood 309.3 With Disturbance of Conduct 309.4 With Mixed Disturbance of Emotions and Conduct 309.9 Unspecified Intermittent Explosive Disorder (312.34) Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors (little or no provocation). The aggressive episodes are not better accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or AttentionDeficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease). V71.02 Child or Adolescent Antisocial Behavior This category can be used when the focus of clinical attention is antisocial behavior in a child or adolescent that is not due to a mental disorder (e.g., Conduct Disorder or an Impulse-Control Disorder). Examples include isolated antisocial acts of children or adolescents (not a pattern of antisocial behavior).