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Transcript
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).