What We Know About Acting Out Teens

1. What We Know About Acting Out Teens Diagnosis, etiology, risk assessment, the role of the Department of Juvenile Services, and treatment

2. Conduct Disorder Diagnosis

3. Conduct Disorder: What is it? • A repetitive and persistent pattern in which the basic rights of others or major age-appropriate societal norms or rules are violated, 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: • Aggression to people and animals • Often bullies, threatens, or intimidates others • Often initiates physical fights • Has used a weapon that can cause serious harm to others • Has been physically cruel to people • Has been physically cruel to animals • Has stolen while confronting a victim • Has forced someone into sexual activity

4. Conduct Disorder: What is it?(Continued) • Destruction of property • Has deliberately engaged in fire setting with the intention of causing serious damage • Has deliberately destroyed other’s property (other than by fire setting) • Deceitfulness or theft • Has broken into someone else’s house, building or car. • Often lies to obtain goods or favors or to avoid obligations • Has stolen items of nontrivial value without confronting a victim • Serious violations of rules • Often stays out at night despite parental prohibitions, beginning before age 13 years. • Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy time). • Is often truant from school, beginning before age 13 years.

5. Diagnostic Mistakes • Symptoms cause harm to others, so clinicians don’t ask about symptoms • Don’t get outside sources of data • Diagnosing someone with Conduct Disorder labels them as “bad” and “untreatable” • They have experienced trauma, so it’s just PTSD • They have an “underlying” depression, so it’s not Conduct Disorder

6. Conduct Disorder: A Serious Problem • Cost to the Individual: • Difficulties in relationships • Difficulties at school and work • Most common treatment referral (1/3) • Boys:Girls (5:1) • 1 to 4% of 9-17 year olds • Costs to Society • Violence • Property Loss • Cost of Incarceration • As adults: • High risk for becoming career criminals-35 to 40% • Substance abuse • Vocational Difficulties/Financial difficulties • Inability to sustain relationships • Child abuse and neglect

7. Conduct Disorder Etiology

8. What causes Conduct Disorder? • Genetics/Temperament • Environmental Factors • Family • Peers • Neighborhood

9. Genetic Predisposition • Temperament (Lahey, 2003) • Negative Emotionality • Daring • Lack of Prosociality • Cognitive Problems • Low Verbal IQ • Executive Deficits

10. Negative Emotionality • They experience negative emotions frequently, intensely, and with little provocation • Aggression • Low frustration tolerance • Can’t delay gratification • Frequent temper tantrums • Overwhelmed by normal demands of life • Can’t handle disappointments • Poor coping skills • DSM-V may call this Temper Dysregulation Syndrome with Dysphoria

11. Daring • Sensation-seeking behaviors • Low harm avoidance • Autonomic nervous system doesn’t respond to punishment • Lack of anxiety • Head injuries • Impulsivity

12. Lack Of Prosociality • Less sympathy and concern for others • Don’t share • Don’t help • Unkind behaviors • Lack of guilt or remorse

13. Environmental Factors • Parents poor behavior as youths • Born to teenage parent • Physical abuse and neglect • Absence of same sex role model • Witnessed violence • Access to other antisocial kids • Lack of monitoring • Antisocial or alcoholic parents • Lower SES • Family hostility

14. Genetic-Environment Correlations • Passive-the same genes that give the kid a bad temperament account for the bad parenting • Evocative-genes that create the temperament lead to behavior that evokes bad parenting, which then increases the likelihood of conduct disorder • Active-genes lead kid to seek out antisocial social environment

15. The Path to Conduct Disorder • Aggressive kids gets lots of negative feedback • School failure • Physical abuse • Peer rejection • Sometimes aggressive behaviors get reinforced • Parents give in to intense kid • Allowed to bully other kids in places where there is poor monitoring

16. The Path To Conduct Disorder • Constant negative feedback from parents, teachers, and peers intensifies the kids anger • At puberty, he finds other antisocial kids • Suddenly, he’s popular • Behavior problems worsen

17. Life Course-Persistent Versus Adolescent-Limited Conduct Disorder • Adolescent-Limited-well-behaved child becomes rebellious teen with unconventional values and connects with antisocial peers. • Life Course-Persistent-chronically aggressive child becomes antisocial teen

18. Longitudinal Studies of Conduct Disordered kids • Life-Course Persistent Conduct Disorder • Weak bonds with family • Callous-unemotional • Impulsive • Negative emotionality • Aggressive • Adolescent-Limited Conduct Disorder • Unconventional values • Were well-behaved as children

19. Features of Life-Course Persistent Conduct Disorder (Moffitt, et. al., 2001) • Individual Risk factors • Under controlled temperament at age 3 • Neurological abnormalities and delayed motor development at age 3 • Low intellectual abilities • Reading difficulties • Poor memory • Hyperactivity • Slow heart rate • Parenting Risk Factors • Teenage single parent • Mothers with poor mental health • Harsh or neglectful mothers • Family conflict • Changes in caretaker • Low SES • Rejection by peers • Childhood onset antisocial behavior nearly always predicts poor adult adjustment

20. Are Two Groups Enough? Possible Third Groups • Substance abuse driven conduct disorder • Antisocial behaviors are non-aggressive and revolve around substance use • Low level chronic offenders • Socially isolated-less contact with antisocials • Anxious • Unmarried, unemployed, mental health needs

21. Gray’s Biobehavioral Theory of Brain Function • Behavioral Activating System • Activates when there are signals for rewards • Escape from punishment • Instrumental aggression • Hope and relief • Behavioral Inhibiting System • Inhibits behavior when signals of punishment, frustration, or novelty • Anxiety and apprehension • Conduct Disordered kids have overactive BAS and underactive BIS

22. Support for Gray’s Theory • Daugherty and Quay, 1991 • Computerized card game • Subjects get money for correct responses, but lose money for incorrect. • As the game goes on, the probability of correct responses decreases. • Most subjects stop playing. Conduct Disordered kids keep playing. • Conduct Disordered kids are reward dominant

23. Support for Gray’s Theory • Walker, et. Al., 1991 • Conduct Disordered youth with co-occurring anxiety disorder-less deviant and less aggressive • Kerr, Tremblay, Pagani, and Vitaro, 1997 • Followed kids in high crime urban area. • Kids who showed anxiety in new situations were protected against the later development of antisocial behaviors

24. Support for Gray’s Theory • Raine, Venables, and Williams, 1995 • 14 year longitudinal study of CD kids • Measured electrodermal activity (measure of ANS arousal) • Kids with higher ANS arousal ceased their antisocial behaviors • Sequin, Pihl, Boulerice, Tremblay, and Harden, 1996 • Measured sensitivity to pain at age five and followed kids • Persistently aggressive teens had least sensitivity to pain at age five

25. Other Problems Associated with CD • ADHD • Learning Disabilities • Substance Abuse • Trauma and Abuse Issues • Unstable self-esteem • Anger Management

26. Deficits related to Conduct Disorder • Low IQ (especially Verbal)-language processing and communication • Executive functions • Social skills • Emotion regulation • Cognitive flexibility

27. Low IQ • Moffitt (1993)-reviewed 47 studies. CD kids score 8 points lower, even after you control for other risk factors. Persistently aggressive kids score 17 points lower. • Kids can’t express feelings • Language development helps us regulate emotions • Kids have difficulty listening to and comprehending instructions • Kids can’t express their point of view in a conflict situation • Language development may play a role in the development of empathy • Sets them up for social interactions full of tension

28. Executive Functions • Self-regulation • Maintaining a problem-solving mental set in pursuit of a goal • Inhibition • Planning • Interference control • Allocation of attention • Lack of persistence • Initiation • Abstraction • Cognitive flexibility

29. Emotion Regulation • Grouchy, irritable • Difficulty being calm enough to think clearly when frustrated • Get upset and stay upset-minor things can ruin their day • Over-react, making their coping efforts ineffective

30. Social Skills and Conduct Disorder • Difficulty collaborating • Refusal to ask for help • Unable to be in a non-dominant role • Difficulty accepting limits • Unaware of others/ surprised by their response • Inaccurate self-perception • Difficulty taking the others point of view • Afraid they will be perceived as “soft” • Egocentric • Examples • Youth who doesn’t want to sit near another kid in class • Youth on an outing from a facility expects to be able to walk around without escort

31. Cognitive Inflexibility • All-or-none thinking • Problems with ambiguity, uncertainty • Insistence on sticking with the original plan • Can’t take another’s perspective • Problems with transitions

32. Families and Conduct Disorder

33. Families of Conduct Disordered Kids • Lack of monitoring • Lack of family rituals • Lack of affection • Don’t comfort distress-lock kids out • Lack of mirroring • Violence • Coercive family environment (Patterson)

34. Coercive Family Environment • Parents don’t reinforce prosocial behaviors, they use negative reactions to exert influence on kids • Parents are inconsistent in addressing antisocial behaviors • Children use aversive behaviors to terminate intrusions by family members • Irritable fathers have explosive reactions • Mothers chronic nagging

35. Families of Conduct Disordered Kids • Absent father-insecure mother • Create closed system • Hide the dysfunction • Teens need to go through phase of devaluing parents, who don’t respond by rejecting • Us against the world • “I won’t hold you accountable for your behavior, if you don’t hold me accountable for mine.” • Moms don’t cooperate with authorities-threatened by kids acting up • CD Kids-”mom’s always been there for me.” • CD Moms-”He’s always been good for me.”

36. CD Families • Sexual and physical abuse • Neglect • Abandonment • Parents are burdened by kids needs • Teach kids feelings are unimportant • Secrets-hide our dysfunction, defensiveness • Difficult to address family’s faults-a task of adolescence • Out of touch with feelings • CD kids-skewed notion of what parenting is-leads to unwanted children

37. The Psychology of CD • Antisocial behaviors help person avoid helplessness. • Invulnerability. • Omnipotence. • Protect self-esteem. • Little tolerance for bad feelings. • Externalize blame. • Introspection is painful. • Impulsivity/immediacy. • Thrill-seeking-turn the volume up. • Hate boredom.

38. The Psychology of CD • Externalizing disorder • Moral judgment is impaired • Empathy feels like pity • Competitiveness • Self-esteem is bolstered by destroying others • Seems self-serving, but is self-destructive • Difficulty cooperating • Difficulty tolerating delays • Experience limits as excessive

39. Conduct Disorder and Social Cognition

40. Social Cognition • Human beings are social beings • We attend to important social stimuli. • We interpret those stimuli in meaningful ways • We use memory to associate these interpretations with possible behavioral responses • We evaluate those responses • We decide which response is best

41. Social Cognition • We selectively attend to certain aspects of the stimulus field. • We differ as to: • what we attend to • the attributions we make to other’s behavior • the goals we have • the responses we generate • the evaluations we make of our response. • Example-some people are hypervigilant to threat cues, whereas others interpret events in a way that maintains harmony.

42. Social Cognition Examples • Teacher yells at kids to “quiet down.” • One kid gets mildly irritated and sits quietly, thinking “Boy, she’s having a bad day.” • Another kid feels disrespected, and yells back at her, “You can’t talk to me that way.” • Another kid feels sorry for the teacher, and feels annoyed with the kids in the class who she sees as rude.

43. Social Cognition and Aggression • Aggressive kids have been found to: • Make hostile attributions regarding others intent • Attribute anger to teachers • Generate fewer potential responses in situations • Tend to evaluate aggressive responses favorably whatever the outcome (especially callous-unemotional kids) • Boys tend to make more hostile attributions and evaluate aggression favorably

44. What Causes Biased Social Information Processing? • Dodge (2001)-found kids exposed to early maltreatment had biased social information processing styles in kindergarten, and continued to have the same response pattern in grades 8 and 11. • Peer rejection may result from and lead to biased social information processing style. • Hostile attributional bias explains reactive aggression. It does not account for the aggression of the callous-unemotional.

45. Is This An Avenue For Intervention? • Several studies targeting hostile attributional bias have found that reducing it leads to less aggressive behavior. • Clinically, it’s important to understand the way your patient interprets situations. • We can offer non-hostile attributions (i.e., perhaps the teacher wasn’t trying to humiliate you, perhaps she told you to quiet down because she was frustrated with the class)

46. Is This An Avenue For Intervention? • We can get kids to reevaluate their goals in social situations (i.e., “does everyone have to respect you”, “some kids have no respect”) • We can help kids more critically evaluate their aggressive responses.

47. Aggression in Conduct Disorder

48. The Biology of Aggression • Testosterone levels are correlated with aggression. • Low cortisol levels are indicative of low autonomic nervous system arousal, and are correlated with increased aggression. • Aggressive kids have lower heart rates. • SSRI’s decrease cortisol levels.

49. The Development of Aggression • At 17 months (Tremblay, et. Al., 1999) • 50% of children push others • 25% kick others • 15% have bitten others • Aggression increases to age three or four and then declines • Aggression is a natural behavior that children learn to inhibit • Language helps kids problem solve non-aggressively • Middle class kids have thousands more words in their vocabulary than poor kids at age five. • Low Verbal IQ is associated with poor outcome among Conduct Disordered boys

50. Conduct Disorder and Aggression • The aggressive symptoms of the disorder concern us the most • Do the most harm • Create the most countertransference • Most useful predictor of outcome in boys • Least popular third grade boy is the most likely to be an adult offender • Aggression is fairly stable for boys from third grade on.