Disruptive Behavior Disorders Disruptive Behavior Disorders DSM-IV 1. 2. 3. Oppositional Defiant Disorder Conduct Disorder Disruptive Behavior Disorder Not Otherwise Specified Juvenile Delinquency Antisocial Personality Noncompliance Disruptive Behavior Disorders Children who display a broad range of behaviors that bring them into conflict with their environment Age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal property rights of others Heterogeneous Behaviors fall along a continuous dimension of externalizing behavior, which includes a pattern of Impulsivity Over-activity Defiance Aggressiveness Delinquency (*legal term) Prevalence: General Disruptive Behavior 50% of preschoolers display disobedience 26% of preschoolers destroy property 60% of teenagers engage in more than one type of delinquent behavior Referrals for males outnumber females anywhere from 4:1 to 6:1 Prevalence: Diagnosable Behavior Problems One of the most common referrals (1/32/3 of all child referrals) 8-12% of children meet specific DSM criteria for diagnosis of ODD and/or CD 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 Video Clip ODD – Development and Key Features 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 Extreme negative impact on parent-child interactions Oppositional Defiant Disorder Characteristics should occur more often than expected for age and developmental level Developmental considerations Toddlers: difficult temperament, frustration with novelty Preschool: discipline problems Middle childhood: poor peer relationships, diversification of negative overt behaviors Adolescence: association with deviant peers, covert conduct problems, delinquency Case Examples 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 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 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? 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 CD: Key Features Severe behavior Experience accompanying problems E.g., Poor school adjustment E.g., Poor peer relationships Parents feel helpless Families often have own problems Marital discord, unemployment, psychological problems DSM-IV Criteria Conduct Disorder Childhood-Onset Type: 1+ problem with conduct before age 10 Adolescent-Onset Type: no problems before age 10 More likely male More likely aggressive PERSISTS Linked to neurological deficits that interfere with development of language, memory, and self-control Equal male/female Less likely to commit violent offenses Less likely to persist over time Linked to temporary situational factors Severity: Mild (minor harm) to Severe: (considerable harm) Video Clip Deficits in CD Emotional Moral Little concern for feelings & well-being of others Cognitive Lack empathy & feelings of guilt Misperceive the intentions of others in ambiguous situations as more hostile and threatening Behavioral Fail to inhibit antisocial behavior regardless of knowledge of potential punishment 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: Associated Features Cognitive and verbal deficits School and learning problems Rejection Family problems Inflated, unstable Peer problems Underachievement, grade retention, dropout Self-esteem deficits Lower IQ Discord, instability, harsh discipline, conflict Health-related problems Risky- behaviors (drug use, sexual promiscuity) Adult CD Outcomes Unplanned parenthood School dropout Substance abuse Disabling injuries Unemployment Difficulty forming lasting relationships Divorce Criminal behavior Imprisonment Poor parenting 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 Less social More resentful More anxious More irritable Low social support High family conflict 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) ***HIGH RISK CD – status offenses Truancy, substance abuse, running away, curfew violations (4th) ODD (1st) Tantrums, arguing, noncompliance, Defiance, annoying Etiology Etiology of Disruptive Behavior Disorders Biological influences Genetic contribution ~50% of variance Difficult temperament Reward deficiency syndrome Neurobiological factors Overactive behavioral activation system: stimulate behavior in response to reward/punishment Underactive behavioral inhibition system: produces anxiety and inhibits behavior Testosterone levels Etiology of Disruptive Behavior Disorders Social cognitive factors: egocentrism and lack of perspective taking Encoding: Seek less information before acting Interpretation: attribute hostile intentions to ambiguous situations Response Search: generate fewer and more aggressive responses Response Decision: choose aggressive solution Enactment: poor verbal communication; strike out physically Etiology of Disruptive Behavior Disorders Family Factors Poor disciplinary practices Lack of parental supervision Family conflict and violence Coercion theory (Patterson) Box 6.5 Child learns to use increasingly intense forms of aversive behavior to escape and avoid unwanted parental demands Poor attachment/bond to parents – thought to lead to association with deviant peers Family instability and stress Etiology of Disruptive Behavior Disorders Peer influences Rejection Association with deviant peers Etiology of Disruptive Behavior Disorders Societal Factors Poverty Neighborhood crime Family disruption Media: TV violence 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 ODD – CD Relationship Persistent ODD symptoms often precede and predict early onset of CD (Loeber et al., 2000) 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 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 Risk factor for psychopathy 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) Comorbidity Common Comorbid Disorders Between 34.7 and 48 % of children and adolescents with ODD/CD also show evidence of ADHD Common factors: impulsivity and poor self regulation ~ 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 Comorbidity estimates ranging from 12-18% have been found for depressive disorders Increased risk for suicide As many as 19% of children/adolescents with ODD/CD qualify for a diagnosis of anxiety disorder Substance Use Assessment Assessment of Disruptive Behaviors Use of parent-report questionnaires: Specific Behavior Problems Eyberg Child Behavior Inventory (ECBI): parents endorse the frequency and intensity of problems Broad Measures: frequency ratings Behavior Assessment System for Children (BASC) Child Behavior Checklist (CBCL) 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 discipline strategies Semi-Structured Diagnostic Interviews Children’s Interview for Psychiatric Syndromes-Parent Version (P-ChIPS); Structured Clinical Interview for DSM-IVTR (KID-SCID) Assessment of Disruptive Behaviors Observation of parent-child interaction (DPICS) Child-directed and parent-directed interaction + clean-up Record parent’s and child’s Negative behaviors Parent: commands, questions, criticisms Child: non compliance Positive behaviors Parents: reflection, praise, description, affection Child: non compliance, aggression Treatment Treatment of Disruptive Behavior Disorders Most promising: EARLY and PARENT/TEACHER INVOLVEMENT Most popular approach is behavioral in nature Treatment Parent Management Training (PMT) Psychoeducation Contingency management techniques Reinforcement of prosocial behavior Praise/Acknowledgement/Recognition Tangible Rewards (e.g., Token economy system) Punishment of antisocial behavior Time-out Removal of privileges Focus on Communications Monitoring/Supervision Treatment of Disruptive Behavior Disorders Parent-Child Interaction Therapy Treatment of Oppositional Defiant and Conduct Disorders Problem-Solving Skills Training (PSST) Effective problem solving skills Identify problem Brainstorm possible solutions Evaluate solutions Choose a solution Evaluate outcome Modification of cognitions Hostile attribution bias Maladaptive self statements Treatment of Oppositional Defiant and Conduct Disorders Multisystemic Treatment Intensive approach Involves external systems School, family, juvenile justice etc Involves: PMT, PSST, Marital Therapy, Specialized academic interventions Home visits Addresses hypothesized etiological factors 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 legal term “delinquency” is applicable to such children and adolescents Juvenile Delinquency 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 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