Conduct Disorders

Conduct Disorders • Conduct problems—age-inappropriate actions and attitudes of a child that violate family expectations, societal norms, and the personal or property rights of others • Context—most kids do this stuff (some of it) sometimes • 80% of teens have tried alcohol • 60% have tried cigarettes • 50% have tried marijuana • Most of these beh appear and then decline • 50% of parents of preschoolers report that they lie, steal, disobey, destroy property—but 10% of parents of young adolescents • Aggression is pretty stable over time ---.7 –same as IQ • Social and economic costs • About 5% of kids, but these kids are responsible for about 50% of all crime and 30-50% of clinic referrals • More teens die from firearms than all diseases combined • Figure 6.2—cost of one lost youth—drop out due to life of crime—about $2 Million

Oppositional Defiant Disorder • Defiant, oppositional, hostile, negative beh for at least 6 mos • Must be beyond what is expected for age and gender • At least 4 of • Loses temper • Argues with adults • Blames others • Angry or resentful • Actively defies reasonable requests • Deliberately annoys • Touchy or irritable • Spiteful or vindictive • Can’t be comorbid with CD • Prevalence 2-16% of kids • Higher rates in adopted kids (20%), especially those with preadoption abuse or neglect • More common in boys before puberty, = after, probably because boys move to CD • Low SES more at risk, 75% of clinic referred preschoolers are low income

Conduct Disorder • At least 3 of 15 • Initiates physical fights • Bullies, threatens, intimidates • Stealing • Fire setting • B&E • Runs away overnight • Physically cruel to animals • Physically cruel to people • Sexual coercion • Destruction of property • Lies frequently • Truant

Two Types of CD • Childhood onset (life course persistent) • More severe, more likely to persist into adulthood, more likely to begin with early problems in infant temperament and with early troubles in parent-child relationships • Adolescent onset or limited • More likely to be associated with troubled peers; may go until 20s • Other important distinctions: • Socialized/unsocialized • Degree of callous-unemotional traits—lack of guilt or remorse—low empathy • Lack of behavioral inhibition—this subtype has more freq contact with police, stronger parental hx of ADHD

Associated Characteristics • Oppositional attitudes toward parents, teachers, authority figures • Academic problems—early dropout, failing classes • Peer rejection • Substance use • Early, risky sexual behavior • Increased risk for ADHD

Cognitive, Verbal and Academic Deficits in CD • 8 pts lower on IQ tests (15 pts lower in childhood onset) • Performance > verbal • Children with both verbal impairments and family adversity have 4x as much aggression as kids with only one of these • School and learning problems—increased levels of special education, retention, dropout, suspension, expulsion • Underachievement in language and reading, but this goes away when we control for ADHD

Self-Esteem and Peer Relationships • Self-esteem • Inflated, unstable, tentative view of self • Overestimate acceptance by other kids • Peer problems • Social rejection in elementary school is a strong risk factor for adolescent conduct problems • Able to make friends by often like-minded antisocial friends • Deviant peers—strong predictor of substance use, delinquent behavior, violence (group tx may be damaging---deviancy training) • Overestimate amount of aggression directed at them (hostile attributional bias) • Underestimate their own aggression and its negative impact

CD and ODD • Much debate over whether these are separate or not • ODD emerges 2-3 yrs earlier than CD (6 vs 9) • But most don’t progress to CD • About 25% move to CD • About 25% sx remit and no longer have ODD • About 50% hold at ODD • Possible that CD criteria aren’t sensitive enough for younger kids—same requirement for number of sx, but fewer opportunities

CD and APD • 40-50% dev APD as adults • APD may also show psychopathy—callous, manipulative, deceitful, remorseless • Less is known about psychopathy in kids, but some 3-5 yo have been found to have a lack of conscience

Family Problems in CD • Among the strongest and most consistent correlates of antisocial behavior • 2 types— • General family disruptions—parental psychopathology, family hx of ASB, marital discord, limited resources, antisocial family values • Specific disturbances in parenting practices and family functioning—harsh discipline, lack of supervision, lack of emotional support and involvement, parental disagreement about discipline • These 2 are interrelated • High levels of conflict—common • Poor parenting practices—ineffective discipline, negative control, inappropriate punish and reward, lack of involvement and child rearing • Parents may show similar social-cognitive deficits • Especially high levels of conflict in CD kids and their sibs

Health Related Problems • Premature death (before 30) is 3-4x higher in boys with CPs • Homicide, suicide, accidental poisoning, traffic accident, overdose • Associated with early onset and persistence of risky sex behavior • Associated with illicit drug use • Commit more than 50% of all felony assaults and thefts

Prevalence of CD • 1-4 million in North America • 1-10-26% (6-16% boys, 2-9% girls) • Boys: more confrontational, aggressive beh • Girls: more nonconfrontational—running away, skipping school, abusing substances—onset is also later—gender diff is evident by age 4 • Gender diff is much greater (10:1) for chronic rather than transient (2:1) • Gender diff has decreased over past 50 yrs by more than 50% • More prevalent in low SES • 40-50% will grow up to have APD—fairly stable over time • 35-75% of clinic referrals

Comorbidity • 50-90% also meet criteria for ADHD • Why the overlap?—common underlying factor such as impulsivity, poor self-regulation, temperament may lead to both • ADHD may be a catalyst for CD—contributes to persistence and escalation • ADHD may lead to childhood onset CD • But—2 distinct disorders—ADHD is more likely to be associated with cognitive impairment, neurodevelopmental abnormalities, increased accidental injuries, increased inattention in class • Both are worse than either alone • Internalizing disorders common in girls • 1/3 meet criteria for depression or anxiety • Most girls with CD will develop depression or anxiety by early adulthood • More severe ASB, more severe mood/anxiety dis • CD is also a risk factor for suicide • Substance abuse—common

Course of the Disorder • Begins with difficult temperament • Aggression in kindergarten predicts years later • Earlier and later aggression--.6 to .9 corr—comparable to IQ • Tends to decrease gradually—less severe before more severe; diversification of behavior over time • More stability over time (& a progression from ODDCDAPD) is assoc with • Parental hx of APD or criminal involvement • Problematic family environments • Low ses • Early onset • Severe aggression • Comorbidity with ADHD • Low IQ • High #s and large variability in conduct problems

Adult Outcome • By early 20s, # of active offenders decreases by 1/2. By late 20s, 85% of former offenders have stopped • But-coercive interpersonal styles, family, health, and work difficulties may persist • LCP (childhood onset)—as adults • Lower skill attainment—erratic work hx • Difficulty getting along with coworkers • More violent marriages • Increased rates of divorce • More likely to select partners with similar backgrounds

Causes of CD • Multiple causes that operate in a transactional way • Genetic influences— • More minor physical anomalies and allergies—like ADHD • CPs are not inherited, but difficulty temperament, hyperactivity-impulsivity, lack of fear in the face of danger are • Multiple studies have shown a link between temperament and externalizing problems • Age 3—restless, impulsive, risk-taking, emotionally labileincr ASB in adolescence • Adoption and twin studies—about 50% inherited • LCP pattern—2x genetic risk of AL pattern • Aggressive—more heritable than non-aggressive in childhood but genes and environ are = in adolescent onset

Biological Pathways • Temperament, impulsivity, insensitivity to punishment, etc. can create antisocial propensity • Such factors may increase likelihood that a child will be exposed to other risk factors-divorce, maltreatment, etc. • Genotype may moderate sensitivity to environment • Prenatal and birth complications • Malnutrition • Lead poisoning • Mother’s use of marijuana, alcohol, nicotine • Neurobiological factors • Gray 1987—two subsystems of the brain, each with its own region and neurotransmitters • BAS-stimulates beh in response to reward or nonpunishment • BIS-produces fear and inhibits ongoing beh • Proposed that CD kids have overactive BAS, underactive BIS • Early onset—decreased cortical arousal, low autonomic reactivity—may lead to fearless, stimulus seeking temperament—may lead to lack of necessary anticipatory fear

Family Factors in CD • Lots of factors implicated, nature of causal role is still debated • Family difficulties are more related to CD than ODD and more to LCP than AL • Reciprocal influence—child’s beh both influences and is influenced by the beh of others • Coercion theory—Gerald Patterson—parent-child interactions set stage for ASB • Reinforcement trap • Attachment theories • Increased stress is assoc with – beh in the home • Poverty is a strong predictor of CD and high rates of crime • Costello et al • Amplifier hypothesis—stress amplifies the maladaptive predispositions of the parents, disrupting their family management and ability to be supportive • Parent criminality and psychopathology

Societal Factors • Neighborhood and school—increased rates in poor neighborhoods with criminal subculture. Antisocial people select neighborhoods with those like them—social selection hypothesis. • Poor schools increase risk, positive schools decrease risk • Media • By grade 6—have seen 8000 murders on tv and 100,000acts of violence • Can be short term precipitating factor and a long term predisposing factor • Wingood et al 2003—hip hop videos • Huesmann et al 2003—tracked 329 adults originally studied in late 1970s at age 6-9 • Appears causal, debate persists • Cultural factors—rates vary widely around the world

Treatment and Prevention • Restrictive approaches—residential tx, inpatient tx, incarceration • Expensive and not terribly effective. • Deviancy training. • Boot camps, wilderness programs, etc. • Also not effective • Office-based individual tx is cheap, but not effective • So what works? • Two-pronged approach • Ongoing interventions for older youth and parents • Early intervention/prevention for young kids just starting out • Parent management training— • Teaches parents to change beh at home—specific new skills • Can be individual or group, clinic or home • Minimal or no intervention of therapist with child • Parents learn to promote + beh, decrease ASB • Sessions cover use of commands, rule setting, praise, tangible rewards, use of mild punishment, etc. • Need to address parents’ beliefs about why beh is occurring

Treatment and Prevention II • Problem-Solving Social Skills training • Focus on cognitive deficiencies and distortions • Steps to solve problems • Multisystemic Treatment (MST) • Family and community based—work with parents, schools, peers, juvenile justice staff, etc • Uses PMT, PSST, marital tx, spec ed if necessary, etc • Long term benefits, which make it cost effective • Prevention • Easier to prevent than to treat • More cost effective • Webster-Stratton—2-8 yo or at risk for CPs • Teaches child management skills • Personal self-control strategies for parents • Teachers taught to improve relationships with students, to teach social skills, improve anger management • Effective for 2/3 of kids whose parents are involved • Other programs exist that work with the kids themselves

Anxiety Disorders • JPSP Dec 2000—two meta-analyses • Trait anxiety—both studies—1 of 40,192 college students and the other of 12,056 kids aged 9-17—found evidence of large increase in anxiety levels such that normal children today report more anxiety than child psychiatric pts in 1950s. • Anxiety disorders general characteristics • Presence of anxiety • Unacceptability of sx to the sufferer • Relative intactness of reality testing • Sx do not actively violate social norms • Approx ½ of adult sx originate before age 15 • Anxiety disorders in childhood increase risk of later problems

Separation Anxiety Disorder • Characterized by extreme, developmentally inappropriate worry that child will get hurt or caregiver will get hurt if not with child • Somatic complaints are common • Considered abnormal only when it occurs after the normal period • Common after stress • Onset is often sudden • Progresses from mild to severe • More common in girls or = depending on the study • School avoidance in ¾ • 1/3 meet criteria for depression • Course is variable—from spontaneous remission to chronic • Chronicity assoc with later onset, psychopathology in the family, and comorbidity • Prevalence about 4-10% • Peak onset between 7 and 9; age of referral 10-11

School Refusal • AKA school phobia—no actual dx • Can be part of other disorders; not the same as SAD • 17/1000 kids • Not truants • Big difference—refusers want to be home with parents • Somatic sx disappear within an hour of being allowed to stay home • Unrelated to IQ • Huge secondary gains from being allowed to stay home • Berg—3 yr follow-up—1/3 little improved, 1/3 quite a bit. 1/3 remitted • ½ were still unable to go to school some of the time • In HS may be prodromal sign of schizophrenia • Ok in non-school settings • Older onset than SAD • More males • Tx—warmly but firmly send kid to school

Generalized Anxiety Disorder • Formerly overanxious disorder of childhood • Excessive and uncontrollable anxiety and worry about many events or activities on most days • Apprehensive expectation • Worry about everything; future • 95% worry all the time • Seems to be chronic • 3-6% prevalence (some estimates as high as 19%) • = in boys and girls; more common in girls in adolescence and adulthood • Average onset 10-14 • Sx diminish with age

Fears and Phobias • Fear—normal reaction to an environmental threat • Most research is on fears • 1935—Jersid & Holmes—kids age 2-6 had between 2 and 4 fears • Parents report fewer fears in kids than kids do • Most fears are transient and disappear in 3 mos • Most research shows more fears in girls than boys, but it may be more acceptable for girls to report them • Both # and intensity of fears decline with age • Morris and Kratchowill (89)—ages of fears Toddler—separation, animals, dark Preschool—strangers, toddler fears, bodily harm School age—being alone, imaginary beings, violence, death, dark, injury, storms, peer teasing Teens—peer rejection, achievement, family problems, global issues • Starting in childhood and declining—doctors, injections, darkness, strangers • Declining slowly—specific animals, heights, storms, enclosed spaces • Some fears persist into adulthood—crowds, death, injury, illness

Specific Phobias • Marked and persistent fear of a specific situation or object that is excessive and unreasonable • Inappropriate for age • Almost immediate anxiety response when exposed • Adults and adolescents must acknowledge that fear is unreasonable but this criterion doesn’t hold for kids • Subtypes • Prevalence—2-4% (2.5% of kids, 3.5% adolescents) in general population meet criteria, but few are referred for tx—parents my not view these as harmful to dev • Not a lot of conclusive data on gender diff—some are more common in girls (blood) • Most common comorbid dx is another anxiety dx, but comorbidity rates are somewhat lower for phobias than for other dx • Age of onset—typically begin 7-9 for animals, blood, darkness, injury • Likely to decline with age, though less so than other fears • Stable for about 5-15% of kids • Peak 10-13

Social Phobia • Marked fear of acting in an embarrassing or humiliating way • Occurs when exposed to unfamiliar people or to scrutiny by others • Must be demonstrated that kids actually have social skills • Cannot occur just with adults • Many social phobics meet criteria for depression (20%) or other anxiety disorders • Hard to distinguish from GAD • Common fears—public speaking, taking tests, performing in front of others, having a test returned, writing on the board, reading a report out loud, being called on in class • Not as many negative cognitions in kids • Occurs in 1-3 % of kids, increases with age (self-conscious teens)—most often dev after puberty. Rare under 10 • May be overlooked because shyness is common and these kids don’t call attention to themselves • Average onset 11-12 • Girls>boys

Selective Mutism • Formerly known as elective mutism • When children fail to speak in 1 or more situations when they can speak in other situations • Typical—speaks home but not at school or away from home • High anxiety—not oppositional • Shy! • 90% meet criteria for social phobia • .5% of kids • > in younger kids • > in girls

Obsessive-Compulsive Disorder • Obsessions vs. compulsions • Prevalence by adolescence is about 1%, <1% under 10 yo. Some estimates are 2-3%, • Many try to keep it a secret • Gender is about =, but boys > before puberty, girls>after • Onset 9-12—two peaks—early childhood and early adolescence • 20-30% have first degree relatives with sx • ½-1/3 have comorbid dx • Likely to be chronic—up to 50% may continue to have problems into adulthood • Washing, repeating, and checking are the most common rituals • Fear of contamination and concerns about hurting oneself or a family member are most common obsessions • Some kids with OCD may be starting a psychosis

Panic • Sudden, overwhelming period of intense fear or discomfort • 10-30 min or a few hrs • Extremely rare in young kids • 3-4% of teens have panic attacks • Panic disorder is less common • Females>males • ½ of those with PD have no other dx. • Onset 15-19 • 95% are postpubertal

Post-Traumatic Stress Disorder • 3.7% boys, 6.3% girls 12-17 • 75% comorbid depression or substance abuse • Maybe 30-40% of those exposed to trauma • Often see them replaying what happened • Intense distress—may be clingy • Hallucinations or flashbacks • Distancing, social withdrawal • Regress or stop developmentally • Restricted affect, hypervigilance • May occur after kids become able to cog understand what happened • More likely if child is immediately present • Subjective experience of threat • More severe if parents are compromised and unable to offer help • May be chronic, relapse and remit, or improve

All Anxiety Disorders • No relation to IQ • Selectively attend to potentially threatening info • Cognitive errors in interpretation • Comorbidity is quite common—most common between two anxiety disorders or mood disorders • E.g., 30-50% of those with SAD also meet criteria for depression • Disorder in childhood increases risk for problems in adulthood

Theories and Causes • Genetic—family and twin studies indicate bio vulnerability, but link isn’t to specific disorders. • Perhaps 1/3 of variance • Heritability may be greater for girls than boys. • Bio/neurobio—Abnormalities (larger volume) in brain regions assoc with social info processing and fear conditioning • Amygdala and superior temporal gyrus in GAD • PTSD-overactive behavior inhibition system. • Family functioning • Parenting practices or rejection, overcontrol, overprotection, modeling of anxious beh • Overinvolved, instrusive, or limiting of independence • Expectations that child will be upset • Insecure attachment may be a risk

Theories and Causes • Behavioral models • Classical conditioning of Little Albert • Two-factor theory—phobia is put in place initially by classical conditioning and maintained by operant conditioning • Social learning theory

Treatment • Behavior tx • Exposure—75% of kids with anx are helped by this • Graded exposure • Flooding • Response prevention • CBT-skills training • Improvement in 71% • Meds—typically in combo with CBT or when CBT has failed • If severe, kids may need meds first • OCD-results positive, but results are inconsistent in other disorders

Mood Disorders • Historical views • Through the 1960s, analysts believed that kids couldn’t show depression because their personality structure was too • Anaclitic depression-1940s-term for infants who lost primary caregiver or whose caregiver was abusive • Related concept—failure to thrive—Bowlby • Masked depression—late 60s-early 70s • Any negative behavior was a sign of child warding off feelings of depression • Problem: very hard to put into practice—highly inferential—but other disorders like aggression are highly comorbid. • Masked is a misnomer—if someone looked at these kids, depression could be found

Problems in Using Adult Criteria • Developmental research that shows little depression in children and higher rates in adolescence • Change in sex ratio at puberty • Cognitive diff • Ability to feel shame doesn’t emerge until around 7 or 8 • Young kids don’t understand guilt/failure • Problems in the ability to report sx • Children have more somatic complaints, SAD, phobias, hallucinations, psychomotor agitation • Adolescents—helpless/hopeless, anhedonia, hypersomnia, drugs and alcohol • In depressed kids—depressed appearance, low s-e, somatic complaints decrease with age • Somatic complaints and social withdrawal so common in children that some propose including them as criteria in this age group

Major Depressive Disorder • More than just feeling blue • Can be a single episode or recurrent • Prevalence rates—2-8% of children and adolescents at any one time--<1% in preschool, 2% in school age • 10-50% of kids in in or outpatient facilities experience MDD • Increases with age. • Before puberty, = between boys and girls or boys greater • After puberty, girls>boys 2:1 • Why the gender diff? Girls are more likely to ruminate. In girls, negative cognitions are more salient.

Comorbidity • Depression is often found in kids who meet criteria for other dx • Anxiety—one study found 75% comorbidity of anxiety in kids with depression • Especially high in girls • One study found that 97% of adolescents with depression met criteria for another dx • Commonly: SAD, CD, ODD, social phobia, substance use

Course of the Disorder • Preschoolers—more likely to be irritated and have somatic sx than dysphoria or hopelessness • Older kids—more sleep problems, decreased self-esteem, hopelessness, report of depressed mood • Average length of episode—16-36 weeks • Recovery is high, but so is relapse. • One study showed recurrence of MDD in 54% after 3 yrs. • Different study—69% in 2 yrs. 25% in one yr, 70% in 5 yrs

Etiology • Bio influences • Genetic—children of depressed parents are more likely to be depressed, even if raised by nondepressed adoptive parents • MZ twins have higher concordance than DZ or sibs • Rutter et al 1999—estimates that 50% of variance in development of depression is due to genetics • Some differences in hormones and neurotransmitters may also play a role • Cognitive-behavioral perspective • Like adults, show maladaptive cogs—internal, global, stable attributions for – events • Coyne 1976—interpersonal theory—individuals who seek excessive reassurance tend to be rejected by others. This is linked to increased feelings of depression

Etiology II • Family environment and functioning • Less supportiveness, more conflict • Higher levels of critical EE • Also high rates of loss among kids referred for tx • Maternal depression—kids are at increased risk of depression • Depression in mothers is related to other psychological problems and to interpersonal problems. • Assortative mating • Tiffany Field 1992—children of depressed moms already have a depressive mood style by 8 mos that carries over to other adults. • In preschool—kids of depressed moms exhibit more negative behaviors • Related to lower self-esteem in 8 yo • Maternal depression is most strongly related in middle childhood and before—then declines in importance • Why? • Peers—neglected or rejected kids show increased rates of depression.

Treatment and Prevention • Treatment— • No standard tx for all • Medication—evidence is not as compelling as for adults • Several studies have not shown that SSRIs or tricyclics work better than placebo. Two are approved. • Rate was increasing before suicide ideation scare. Trend unclear now. • Tx that focus on cognitive-behavioral techniques work well • Family tx—effective at reducing conflict • Prevention • Social-problem solving • Improving parenting skills • Improving coping skills

Dysthymic Disorder • Inability to experience joy • Must last at least one year • 1-5% prevalence • Average length—3.9 years • Double depression—70% will have depressive episode • Not much research • Lasts longer in kids with comorbid dx • Onset around 11 or 12

Bipolar Disorder • Rare in young kids • 20% with bipolar have onset in adolescence-- age 15-19 • Prevalence of .4-1.2% in older adolescents • Recovery and relapse are high • 63% of adolescents with bipolar have one first degree relative with dx • Often misdiagnosed as schizophrenia or ADHD • Stimulants can worse bipolar • 20% are comorbid with CD or ODD

Suicide • 2,000-2,500 adolescents per year • 3rd leading cause of death in 15-24 after accidents and homicide • 6-10% of adolescents report attempting suicide • Rate tripled from 1957 (4.0/100,000) to 1977 (13.3/100,000). Has leveled off around 13.0/100,000. • Rates for whites have always been higher than for other groups—but is increasing for African Americans, Hispanics, Native Americans • Males outnumber females 5:1

Suicide • 70% occur in the home • Most common method for males and females: firearms and explosives. 2nd—males—hanging; females—drugs. • Suicidal adolescents with access to guns are 75x more likely to kill themselves than suicidal adolescents with no guns • Not all suicides are depression related • Overall—79-96% met criteria for something • Rare but increasing in children and preadolescents

Suicide Attempters • Rate of attempts to completion 10:1 • Most important variable is hopelessness • Deficit in interpersonal problem solving • Feelings preceding attempt: anger, feeling lonely and unwanted, worried about the future, sorry and ashamed, hopeless • Adolinks 1987—reasons given • Relief from intolerable state of mind, escape from an impossible situation • Making people see how desperate they were • Making people sorry for the way they’ve been treated/getting back at someone • Trying to get someone to change his/her mind • Showing someone how much he/she cared seeing if someone really cared • Seeking help • Only ½ said they wanted to die. 40% said that they didn’t care if they lived or died • Little premeditation • Many cases—done where it would be discovered • Majority improve in a month • 1/3 subsequently experience major difficulties—increased psych and phys dis etc • 1/10 will repeat the attempt

Suicide Completers • High intention, high lethality • Drug and alcohol abuse in15-33% • Intent increases after use • 70% exhibit some antisocial behavior from shoplifting to prostitution • Primary risk factor—impulsivity—only ¼-1/3 show evidence of planning. Other risk factors—low frustration tolerance, alienation, imitation, poor family relationships with little affection • 83% of completers told someone the week before

Conduct Disorders