Disruptive Behavior Disorders

Disruptive Behavior Disorders Gregg Selke, Ph.D. PSY 4930 September 19, 2006

Disruptive Behavior Disorders • DSM-IV • 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 coerciveor oppositional • To more severe, that represent a greater threat to those around them and/or may lead to juvenile justice system

Prevalence:Diagnosable Behavior Problems • One of the most common referrals (1/3-2/3 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 CriteriaOppositional 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 CriteriaOppositional 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- year-olds." 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 CriteriaConduct Disorder A. "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” • 4 Symptom Domains • 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 CriteriaConduct 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 CriteriaConduct Disorder • 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 CriteriaConduct Disorder 4. Serious rule violationsm) 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 CriteriaConduct 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: • Failure to conform to social norms (behaviors warranting arrest) • Deceitfulness (lying, conning, deceit) • Impulsivity • Irritability and aggressiveness • Reckless disregard for safety of others or self • Consistent irresponsibility • 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 2/3 of children with ODD do not go on to develop CD Typical Child Behavior Problems Oppositional Defiant Disorder Conduct Disorder Antisocial Personality Disorder Almost half of children with CD also meet criteria for a diagnosis of ODD

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 • “Covert – Overt” • “Destructive –Nondestructive”

Disruptive Behavior Classification Frick, et al., (1993) Covert Overt Aggression Oppositionality Stealing Substance Abuse

Disruptive Behavior Classification Destructive vandalism fighting Nondestructive truancy arguing

Destructive Covert Overt Nondestructive Classification – Age Progression CD - Property/Deceit Stealing, fire setting, vandalism, lying (3rd) CD – Aggression Cruelty, assault, fighting, bullying, spite, animal cruelty (2nd) ODD (1st) Tantrums, arguing, noncompliance, Defiance, annoying CD – status offenses Truancy, substance abuse, running away, curfew violations (4th)

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) • 90% adult psychopaths have APD (Lynam, 1998) • Only 25% of APD are psychopaths • Grandiose, Impulsive, Manipulative, Lack Empathy, Callous, Selfish, Shallow, Parasitic, Irresponsible, Glib, Dishonest, Boredom Susceptible, Criminal Acts • Adult Psychopath Criminals • ↑ 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 (P-ChIPS); 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 Parent-Child Interaction Therapy, that is designed to modify oppositional/defiant behavior and the aggressiveness sometimes seen in ODD children, as well as improve parent-child 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

Disruptive Behavior Disorders