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CONDUCT DISORDER

CONDUCT DISORDER. Jeanette E. Cueva, M.D. Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons; Adjunct Associate Professor of Clinical Psychiatry, New York Medical College. Normal Behavior (1) ( McFarland et. Al., 1970).

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CONDUCT DISORDER

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  1. CONDUCT DISORDER Jeanette E. Cueva, M.D. Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons; Adjunct Associate Professor of Clinical Psychiatry, New York Medical College

  2. Normal Behavior (1)(McFarland et. Al., 1970) • Longitudinal study: ages < 2 yo – 14 yo • lying at 6 yo: • boys 53%; girls 48% • lying at 11 yo: • boys 10%; girls 0%

  3. Normal Behavior (2)(Achenbach and Edelbrock, 1981) • Cross-sectional Study • age: 4 yo- 16 yo • disobedience, destruction of own property: • 50% and 26% at 4-5 yo • 20% and 0% at 16 yo

  4. Normal Behavior (3) • Antisocial behaviors are frequent at different points in normal development (toddler age; adolescence) • These behaviors decline over time • Stability of these behaviors over time = clinically significant departure from the normal pattern

  5. HUMAN AGGRESSION • Behaviors by one person intended to cause physical pain, damage or destruction to others

  6. Aggression in Animals (Moyer, 1971) Predatory Intramale Fear induced Irritable Territorial Maternal Instrumental

  7. Aggression Subtypes(Flynn et. al., 1970) • Predatory/covert: instrumental • Affective/overt: intermale, fear induced, irritable, territorial, maternal

  8. Overt Aggression • Overt/Affective: high autonomic arousal • Piloerection • Pupillary dilation • Threatening behaviors • Increase BP

  9. Covert Aggression • Covert/Predatory: Low autonomic arousal • Not associated with intense increase in BP e.g. Animals silently stalking prey

  10. CONDUCT DISORDER • RULE BREAKING AND ILLEGAL ACTIVITY • VIOLATION OF BASIC RIGHTS OF OTHERS • PRE- REQUISITE FOR ANTISOCIAL PERSONALITY DISORDER

  11. Areas to Consider • Pattern of antisocial behaviors • Degree of impairment • Degreeofunmanageability

  12. Prevalence and Epidemiology • ICD-9: (Esser et. al., 1990) prevalence of less than 1% in a study of 8 y.o. in Germany • DSM III: (Kashani et. al.,1987) prevalence of 8.7% in a group of teenagers • DSM IV: prevalence of 4-6% overall; 6-10% in males and 2-9% in females • Up to 75% of clinic referrals

  13. DSM IV CRITERIA (1994) • Aggression to people and animals • Destruction of property • Deceitfulness or theft • Serious violation of rules

  14. RISK FACTORS • CHILD FACTORS: temperament, neuropsychological functioning, academic/intellectual performance • PARENTAL FACTORS: pathology and criminal behavior, harsh disciplinary practices, marital discord • SCHOOL RELATED: setting, low teacher student ratio etc.

  15. ETIOLOGY • Biological: no clear genetic factors • Psycho physiological: low autonomic arousal; stimulation seekers • Learning: aggression is reinforced, modeling

  16. Kohlberg’s Moral Development • PREMORAL LEVEL; STAGE 1: FEAR OF PUNISHMENT STAGE 2: SATISFYING SELF-INTEREST REQUISITE FOR ANTISOCIAL PERSONALITY • UP TO APPROXIMATELY 14 YO

  17. KOHLBERG’S MORAL DEVELOPMENT • CONVENTIONAL LEVEL • Stage 3: Conforming to values of significant others • Stage 4: Conforming to social order and its maintenance for its own sake • Up to about 20 y.o.

  18. Kohlberg’s Moral Development • SELF ACCEPTED LEVEL • STAGE 5: balance between human rights and laws • STAGE 6: recognition of valid universal ethical principals to which a person can choose to commit himself or herself to • From age 20 and upward

  19. Diagnostic Evaluation • Clinical Interview • Family and developmental histories (exposure to drugs in utero) • History of physical or sexual abuse • Collateral information: include school functioning • Rating Scales: CBCL, K-SADS, OAS

  20. DIFFERENTIAL DIAGNOSIS • ADHD • BIPOLAR DISORDER • MAJOR DEPRESSION • PSYCHOTIC DISORDERS

  21. TREATMENT • Individual Psychotherapy • Group Therapy • Behavior Therapy • Problem-solving Skills Therapy • RTC • Family Therapy • Parent Management Training • Pharmacothrepy

  22. PHARMACOTHERAPY • LITHIUM: anti aggressive properties • CBZ • Beta-blockers • Neuroleptics • MEDICATION ALONE NOT SUFFICIENT

  23. COMBINATION OF INTERVENTIONS • INCLUDE INDIVIDUAL, FAMILY AND COMMUNITYH BASED TREATMENTS • MEDICATION SOMETIMES HELPFUL IN PARTICULAR FOR YOUTHS WITH OVERT AGGRESSION • TREATMENT NEEDS TO BE LONG-TERM • “BIG BROTHER” OR “BIG SISTER” FOUND TO BE VERY HELPFUL

  24. COMMUNITY BASED TREATMENT • “PROBLEM” YOUTH INTEGRATED WITH PROSICIAL PEERS • PROMOTES GROUP INFLUENCES FROM PROSOCIAL PEERS • DECREASES STIGMATIZATION • CAN BE DONE AT A LARGE SCALE

  25. IDENTIFY CHILDREN AT RISK

  26. PROGNOSIS DEPENDS ON MANY FACTORS HOWEVER CURRENTLY GUARDED OR POOR

  27. “Kevin” • Cc :Evaluated at 10 yo due to “poor progress at his current school setting” • H/o maladaptive and aggressive behaviors since toddlerhood • H/o of special education placement since 2nd grade due to LD (MIS IV); average cognitive functioning • Currently in an “emotionally disturbed” class setting (SIE VII) since 4th grade

  28. “Kevin” • Developmental History: exposed to crack in utero and born addicted • Milestones were normal • Adopted by foster family at 1 yo but has contact with biological mother • Adoptive family (consists of mother and two older adoptive sibs) overwhelmed: have 6 children under 19 yo overall • Poor supervision

  29. “Kevin” • Throws rocks from roof with and without other peers • Steals • Stays out late (until up to 11 pm or later) • Friends with older peers (16 yo and 18 yo) who are themselves delinquent • Suspected of smoking MJ and dealind in drugs

  30. TREATMENT AND PROGNOSIS

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