142 chapter 9 modified

Eric J. Mash

9

Conduct Problems

© Cengage Learning 2016

Description of Conduct Problems

• Age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal or property rights of others

• These disruptive and rule-violating behaviors range from:

– Annoying minor behaviors (e.g., temper tantrums) to serious antisocial behaviors (e.g., vandalism, theft, and assault)


Description of Conduct Problems (cont’d.)

• We must consider many types, pathways, causes, and outcomes of conduct problems

• Are associated with unfortunate family and neighborhood circumstances

– Circumstances do not excuse the behavior, but help us understand and prevent it


Context

• Antisocial behaviors appear and decline during normal development

– Behaviors vary in severity, from minor disobedience to fighting

– Some may decrease with age; others increase with age and opportunity

– Are more common in boys in childhood

– Children who are the most physically aggressive in early childhood maintain relative standing over time


Frequencies for Common Antisocial

Behavior


Social and Economic Costs

• Conduct problems are the most costly mental health problem in North America

• Early, persistent, and extreme antisocial behavior occurs in about 5% of children

– These children account 50% of all crime in the

U.S. and approximately 30-50% of clinic referrals

– Annual public costs (healthcare, juvenile justice, and educational systems) are $10,000 per child


Legal Perspectives

• Juvenile delinquency

– Legal definitions exclude antisocial behaviors of very young children

– Including property crimes (e.g. vandalism, theft), violent crimes (robbery, aggravated assault, homicide)

– Minimum age of responsibility is 12 ( in most states)

– Only a subgroup of children meeting legal definition of delinquency also meet definition of a mental disorder (needs to show persistent pattern)


Psychological Perspectives

• Conduct problems fall on a continuous dimension

– Externalizing dimension: Impulsive and overactive

• “Rule-breaking behavior”: running away, setting fires, stealing, dugs, vandalism, skipping school

• “Aggressive behavior” : Fighting , destructiveness, disobedience, defiance, threatening

– Overt (visible) –covert (hidden) dimension

– (Most children with CD display both)

– Destructive-nondestructive dimension

– Crossing the overt-covert with the destructive-nondestructive

• Yields four categories of conduct problems


Four Categories of Conduct Problems


Psychiatric Perspectives

• Conduct problems are viewed as distinct mental disorders based on DSM symptoms

– Disruptive behaviors are described as persistent patterns of antisocial behavior

– Represented by the categories of Conduct Disorder (CD) and

Oppositional Defiant Disorders (ODD)

• The diagnosis of antisocial personality disorder (APD) is relevant to understanding childhood conduct and their adult outcomes


Public Health Perspectives

• Blends the legal, psychological, and psychiatric perspectives with public health concepts of prevention and intervention

– Goal

• To reduce injuries, deaths, personal suffering, and economic costs associated with youth violence

• Cut across disciplines to:

– Understand conduct problems in youths

– Determine how these problems can be treated and prevented


DSM-5 Defining Features

• Two DSM-5 disruptive behavior disorders

– Oppositional defiant disorder (ODD)

– Conduct disorder (CD)

– Both have been found to predict future psychopathology and enduring impairment in life functioning


Oppositional Defiant Disorder

• Age-inappropriate recurrent pattern of stubborn, hostile, disobedient, and defiant behaviors

• Usually appears by age 8

• Severe ODD behaviors can have negative effects on parent-child interactions

• Symptoms can be grouped into

• 1)Negative affect ( angry, irritable mood)

• 2) Defiance (defiant/strong-head behavior


Diagnostic criteria for Oppositional Defiant

Disorder


Diagnostic criteria for Oppositional Defiant

Disorder (cont’d.)


Conduct Disorder

• Repetitive, persistent pattern of severe aggressive and antisocial acts

– May have co-occurring problems, e.g.,

ADHD, academic deficiencies, and poor peer relations

– Family child-rearing practices may contribute to problems

– Parents feel the children are out of control and feel helpless to do anything about it


Diagnostic Criteria for Conduct Disorder



(cont’d.)



(cont’d.)


Conduct Disorder Age of Onset

• Children with childhood-onset CD display at least one symptom before age 10

– More likely to be boys

– Show more aggressive symptoms

– Account for disproportionate amount of illegal activity

– Persist in antisocial behavior over time


Conduct Disorder Age of Onset (cont’d.)

• Children with adolescent-onset CD

– As likely to be girls as boys

– Do not show the severity or psychopathology characterizing the early-onset group

– Are less likely to commit violent offenses or persist in their antisocial behavior over time


Are CD and ODD Separate?

• Nearly half of all children with CD have no prior ODD diagnosis

• Most children who display ODD do not progress to more severe CD

• For most children, ODD:

– Is an extreme developmental variation

– Is a strong risk factor for later ODD

– Does not signal an escalation to more serious conduct problems


Antisocial Personality Disorder (ADP) and

Psychopathic Features

• Pervasive pattern of disregard for and violation of the rights of others; involvement in multiple illegal behaviors

– As many as 40% of children with CD later develop APD

– Adolescents with APD may display psychopathic features

– Signs of lack of conscience occur as young as

3-5 years


Antisocial Personality Disorder (ADP) and

Psychopathic Features (cont’d.)

• A subgroup of children with CD are at risk for extreme antisocial and aggressive acts and for poor long-term outcomes

– Display callous and unemotional (CU) interpersonal style

• Lack guilt and empathy; do not show emotions; display narcissism and impulsivity; and lack behavioral inhibition

– Different developmental processes may underlie behavioral and emotional problems


Associated Characteristics

• Many factors are associated with conduct problems in youths

– Cognitive and verbal deficits

– School and learning problems

– Self-esteem deficits

– Peer problems

– Family problems

– Health-related problems


Cognitive and Verbal Deficits

• Most children with conduct problems have normal intelligence

• Verbal deficits are present in early development: may interfere with self-control, emotional regulation, receptive listening, expressive speech

• Deficits in executive functioning

– Co-occurring ADHD may be a factor

– Types of executive function exhibited may differ cool : attention, working memory, planning and inhibition , (such as in ADHD) versus hot executive functions: involve incentive and motivation (more often in

CD).


Deficits in Executive Functions

• Rarely consider the consequences of their behavior or the impact on others

• Fail to inhibit their impulsivity

• Fail to consider future rewards

• Fail to adapt their action to future circumstances

• May be related to the comorbidity with

ADHD


School and Learning Problems

• Underachievement, grade retention, special education placement, dropout, suspension, and expulsion

• Relationship between conduct problems and underachievement is firmly established by adolescence

– May lead to anxiety or depression in young adulthood


Family Problems

• General family disturbances

• Specific disturbances in parenting practices and family functioning

• High levels of conflict are common in the family, especially between siblings

• Lack of family cohesion and emotional support

• Deficient parenting practices

• Parental social-cognitive deficits


Peer Problems

• Young children with conduct problems display poor social skills and verbal and physical aggression toward peers

• Often rejected by peers, although some are popular

– Children rejected in primary grades are five times more likely to display conduct problems as teens

– Some become bullies


Peer Problems (cont ’d.)

• Often form friendships with other antisocial peers

– Predictive of conduct problems during adolescence

• Underestimate own aggression and its negative impact, and overestimate others ’ aggression toward them


Peer Problems (cont’d.)

• Reactive-aggressive children display hostile attributional bias

• Proactive-aggressive view their aggressive actions as positive


Self-Esteem Deficits

• Low self-esteem is not the primary cause of conduct problems

– Instead, problems are related to inflated, unstable, and/or tentative view of self

• Youths with conduct problems may experience high self-esteem

– Over time may permit them to rationalize their antisocial conduct


Health-Related Problems

• High risk for personal injury, illness, drug overdose, sexually transmitted diseases, substance abuse, and physical problems as adults

• Rates of premature death (before age 30)

– Are 3 to 4 times higher in boys with conduct problems


HealthRelated Problems (cont’d.)

• Early onset and persistence of sexual activity and sexual risk-taking by age 21

• Substance use disorders and adolescent antisocial behavior are strongly associated

• Childhood conduct problems are a risk factor for adolescent and adult substance abuse

– Mediated by drug use and delinquency during early and late adolescence


Accompanying Disorders and Symptoms

• Attention-Deficit/Hyperactivity Disorder

– More than 50% of children with CD also have

ADHD

– Possible reasons for overlap

• A shared predisposing vulnerability may lead to both ADHD and CD

• ADHD may be a catalyst for CD

• ADHD may lead to childhood onset of CD

– Research suggests that CD and ADHD are distinct disorders


Accompanying Disorders and Symptoms

(cont ’d.)

• Depression and anxiety

– About 50% of children with conduct problems also have depression or anxiety

• ODD best accounts for the connection between conduct problems and depression

• Increasing severity of antisocial behavior is associated with increasing severity of depression and anxiety

• Anxiety may serve as a protective factor to inhibit aggression


Prevalence

• ODD is more prevalent than CD during childhood; by adolescence, prevalence is equal

• Lifetime prevalence rates

– 12% for ODD (13% for males, 11% for females)

– 8% for CD (9% for males, 6% for females)

• Prevalence for CD and ODD across cultures of Western countries are similar


Gender

• Gender differences are evident by 2-3 years of age

– During childhood, rates of conduct problems are about 2-4 times higher in boys

– Boys have earlier age of onset and greater persistence

– Early symptoms for boys are aggression and theft; early symptoms for girls are sexual misbehaviors


Explaining Gender Differences

• Possible explanations

– Genetic, neurobiological, environmental risk factors, and definitions of conduct problems that emphasize physical violence

• Girls use indirect, relational forms of aggression

• Early maturing boys and girls are at risk for recruitment into delinquent behavior by peers


General Progression

• Earliest sign is difficult temperament in infancy

• Hyperactivity and impulsivity during preschool ad early school years

• Oppositional and aggressive behaviors peak during preschool years

• Diversification - new forms of antisocial behavior develop over time


General Progression (cont’d.)

• Covert conduct problems begin during elementary school

• Problems become more frequent during adolescence


General Progression (cont’d.)

• Some children break from the traditional progression

– About 50% of children with early conduct problems improve

– Some don’t display problems until adolescence

– Some display persistent low-level antisocial behavior from childhood/adolescence through adulthood


Different Forms of Disruptive And Antisocial

Behavior


Two Common Pathways

• Life-course-persistent (LCP) path begins early and persists into adulthood

– Antisocial behavior begins early

• Subtle neuropsychological deficits heighten vulnerability to antisocial elements in social environment

– Complete, spontaneous recovery is rare after adolescence

– Associated with family history of externalizing disorders


Two Common Pathways (cont’d.)

• Adolescent-limited (AL) path begins at puberty and ends in young adulthood

– Less extreme antisocial behavior, less likely to drop out of school, and have stronger family ties

– Delinquent activity is often related to temporary situational factors, especially peer influences


The Changing Prevalence Of Participation

In Antisocial Behavior Across The Lifespan


Adult Outcomes

• 50% of active offenders decrease by early

20s, and 85% decrease by late 20s

• Negative adult outcomes are seen, especially for those on the LCP path

– Males - criminal behavior, work problems, and substance abuse

– Females - depression, suicide, and health problems


Causes

• Early theories focused on a child’s aggression

• No single theory explains all forms of antisocial behavior

• Today conduct problems are seen as resulting from:

– The interplay among a predisposing child, family, community, and cultural factors operating in a transactional fashion over time


Genetic Influences

• Aggressive and antisocial behavior in humans is universal

– Run in families within and across generations

• Adoption and twin studies

– Indicate 50% or more of variance in antisocial behavior is hereditary

– Suggest contribution of genetic and environmental factors


Prenatal Factors and Birth Complications

• Pregnancy and birth factors

– Low birth weight

– Malnutrition (possible protein deficiency) during pregnancy

– Lead poisoning

– Mother’s use of nicotine, marijuana, and other substances during pregnancy

– Maternal alcohol use during pregnancy


Neurobiological Factors

• Overactive behavioral activation system

(BAS) and underactive behavioral inhibition system (BIS)

• Variations in stress-regulating mechanisms

• Structural and functional brain abnormalities in amygdala, prefrontal cortex, anterior cingulate, and insula


Neurobiological Factors (cont ’d.)

• Early findings suggest three neural systems are involved:

– Subcortical neural systems

• Aggressive behavior - dysfunction in the integrated functioning of brain circuits involving the amygdala

– Prefrontal cortex

• Decision-making circuits and socioemotional information processing circuits

– Frontoparietal regions

• Emotions and impulsive motivational urges


Social-Cognitive Factors

• Immature forms of thinking

• Cognitive deficiencies

• Cognitive distortions

• Deficits in facial expression recognition and eye contact

• Dodge and Pettit comprehensive socialcognitive framework model

– Cognitive and emotional processes are mediators


Steps In The Thinking And Behavior Of

Aggressive Children In Social Situations


Family Factors

• Severe forms of antisocial behavior

– Are associated with a combination of child risk factors and extreme deficits in family management skills

• Influence of family environment is complex

• Reciprocal influence

– Child’s behavior is influenced by and influences the behavior of others

• Child behaviors exert greater influence on parenting behavior than the reverse


Family Factors (cont’d.)

• Coercion theory

– Parent-child interactions provide a training ground for the development of antisocial behavior

– Four-step escape-conditioning sequence

• The child learns to use increasingly intense forms of noxious behavior to avoid unwanted parental demands (coercive parent-child interaction)

– Children with callous-unemotional traits display significant conduct problems regardless of parenting quality


Family Factors (cont’d.)

• Attachment theories

– Children with conduct problems have little internalization of parent and societal standards

– There is a relationship between insecure attachments and the development of antisocial behavior


Other Family Problems

• Family instability and stress

– High family stress may be both a cause and an outcome of child’s antisocial behavior

• Unemployment, low SES, multiple family transitions, instability, and disruptions in parenting practices are stressors

– Amplifier hypothesis

• Parental criminality and psychopathology

– Aggressive and antisocial tendencies run in families within and across generations


Societal Factors

• Individual and family factors interact with the larger societal and cultural context in determining conduct problems

• Social disorganization theories

• Adverse contextual factors are associated with poor parenting

• Neighborhood and school

– Social selection hypothesis

• Media


Cultural Factors

• Across cultures, socialization of children for aggression is one of the strongest predictors of aggressive acts

• Rates of antisocial behavior vary widely across and within cultures

• Antisocial behavior is associated with minority status in the U.S.

– Likely due to low SES


Treatment and Prevention

• Some treatments are not very effective

– Office-based individual counseling and family therapy

– Group treatments can worsen the problem

– Restrictive approaches (residential treatment, inpatient hospitalization, incarceration)


Treatment and Prevention (cont ’d.)

• Comprehensive two-pronged approach includes

– Early intervention/prevention programs

– Ongoing interventions


Effective Treatments For Children With

Conduct Problems


Parent Management Training (PMT)

• Teaches parents to change the child’s behavior in the home and in other settings using contingency management techniques

• Focus is on:

– Improving parent-child interactions

– Promoting positive behavior

– Decreasing antisocial behavior

• Makes numerous demands on parents


Problem-Solving Skills Training (PSST)

• Focuses on cognitive deficiencies and distortions in interpersonal situations

• Five problem-solving steps are used to:

– Identify thoughts, feelings, and behaviors in problem social situations


Problem-Solving Skills Training (PSST)

(cont ’d.)

• Children learn to:

– Appraise the situation

– Identify self-statements and reactions

– Alter their attributions about others’ motivations

– Learn to be more sensitive to others


Multisystemic Therapy (MST)

• Intensive family- and community-based approach

– For teens with severe conduct problems who are at risk for out-of-home placement

• Attempts to empower caregivers to improve youth and family functioning

• Effective in reducing long-term rates of criminal behavior

– Reduces association with deviant peers


Preventive Interventions

• Main assumptions

– Conduct problems can be treated more easily and effectively in younger than older children

– Counteracting risk factors/strengthening protective factors at young age limits/prevents escalation of problem behaviors

– Costs to educational, criminal justice, health, and mental health systems are reduced


Preventive Interventions (cont ’d.)

• Incredible Years intensive multifaceted early-intervention program for parents and teachers

– Support for effectiveness of early interventions in reducing later conduct problems and maintaining positive outcomes

• Fast Track program to prevent development of antisocial behavior in highrisk children, using five components


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