Disruptive Behaviour Disorders

Question 1

Oppositional Defiant Disorder (ODD) criteria

Answer 1

(A) pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least 4 symptoms from any of the following categories (angry/irritable mood, argumentative/defiant bx, vindictiveness), and exhibited during interaction with a least one individual who is not a sibling
(A8) persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months. For individuals 5 years or older the behavior should occur at least once per week for 6 months. Other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture.
(B) he disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.
(C) The behaviors do not occur exclusively during the course of a psychotic, substance-use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood disorder.

Question 2

ODD angry/irritable mood

Answer 2

• loses temper
• touchy or easily annoyed
• angry or resentful

Question 3

ODD argumentative/defiant bx

Answer 3

• argues with authority figures or, for children and adolescents, with adults
• actively defies or refuses to comply with requests from authority figures or with rules
• deliberately annoys others
• blames others for his or her mistakes or misbehavior

Question 4

ODD vindictiveness

Answer 4

• Has been spiteful or vindictive at least twice within the past 6 months

Question 5

ODD severity specifiers

Answer 5

• mild: sx are confined to one setting
• moderate: some sx occur in at least two settings
• severe: some sx are present in at least three settings

Question 6

conduct disorder (CD) criteria

Answer 6

(A) repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months
categories: aggression to people/animals, destruction of property, deceitfulness or theft, serious violations of rules
(B) The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
(C) If the individual is 18 years or older, criteria are not met for Antisocial Personality Disorder

Question 7

CD aggression to people/animals

Answer 7

• bullies, threatens, or intimidates others
• initiates physical fights
• has used a weapon that can cause serious physical harm to others
• Has been physically cruel to people.
• has been physically cruel to animals
• Has stolen while confronting a victim (mugging, extortion)
• Has forced someone into sexual activity

Question 8

CD destruction of property

Answer 8

• Has deliberately engaged in fire setting, with the intention of causing serious damage.
• Has deliberately destroyed others’ property (other than by fire setting)

Question 9

CD deceitfulness or theft

Answer 9

• Has broken into someone else’s house, building, or car.
• lies to obtain goods or favors or to avoid obligations (‘cons’ others)
• Has stolen items of nontrivial value without confronting a victim (shoplifting, forgery)

Question 10

CD serious violations of rules

Answer 10

• 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 period.
• Is often truant from school, beginning before age 13 years

Question 11

CD specifiers

Answer 11

• childhood-onset: at least one sx is present before age 10
• adolescent-onset: no sx were present before age 10
• with limited prosocial emotions: individual must have displayed at least 2 of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider reports by others who have known the individual for extended periods of time

Question 12

CD with limited prosocial emotions sx

Answer 12

• at least 2 of the following present in the past 12 months in many interactions
• lack of remorse or guilt: does not feel guilty when they do something wrong (excludes remorse only expressed when caught), general lack of concern about negative consequences of their actions
• callous-lack of empathy: disregards/is unconcerned about the feelings of others, described as ‘cold and uncaring’, more concerned about the effects of their actions of themselves (even when they result in substantial harm to others)
• unconcerned about performance: doesn’t show concern about poor/problematic performance at school/work/activities, doesn’t put in the effort required even when expectations are clear, often blames others for their poor performance
• shallow/deficient affect: does not express feeling/show emotions to others except in ways that feel insincere, shallow, superficial (actions contradict emotions displayed, can turn emotions ‘on’ or ‘off’), or emotional expressions are used for gain (to manipulate/intimidate)

Question 13

CD severity specifiers

Answer 13

• mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to other (lying, truancy)
• moderate: The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe” (stealing, vandalism)
• severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (forced sex, physical cruelty)

Question 14

two dimensions of disruptive behaviour

Answer 14

• overt-covert:
• destructive-nondestructive
• aggression is overt and destructive *more at risk for later bx problems
• property violations are covert and destructive
• status violations (truancy, substance use, runaway) are covert and nondestructive
• oppositional bx (stubborn, touchy, argues) is overt and nondestructive

Question 15

research about sibling fighting

Answer 15

• very common, cannot be used to diagnose ODD
• sibling conflict, hostility, and negativity predicts greater emotional and bx problems over time
• can lead to maladaptive bx problems in other relationships

Question 16

assessment of ODD

Answer 16

• interviews and checklists
• Disruptive Behaviour Diagnostic Observation Schedule: watching preschoolers interact with an interactive examiner, a busy examiner, with their parent (pressing for disruptive behaviour by testing their compliance, frustration, rule-breaking) - also used for CD
• complementing a parent report

Question 17

callous-unemotional (CU) traits

Answer 17

• ‘with limited prosocial emotions’ specifier
• 2-6% of kids with CD have CU traits - when they do = earlier onset, aggression is more severe and instrumental
• CU associated with insensitivity to punishment (harder to treat)

Question 18

instrumental aggression

Answer 18

using aggression to get something out of it, to get what you want

Question 19

how to assess limited prosocial emotions

Answer 19

• Clinical Assessment of Prosocial Emotions (CAPE1.1) semistructured interview
• need multiple information sources

Question 20

CD and ODD comorbidity

Answer 20

• in DSM-IV, a more severe presentation of ODD was qualified as CD
• in DSM-5, you can have both diagnoses at the same time
• ODD tends to start presenting at age 6, CD around age 9 (ODD developmentally precedes CD, but not in all cases)
• some kids will have ODD that never evolves into CD
• some kids will be diagnosed with CD without ever having had an ODD diagnosis

Question 21

prevalence rates ODD and CD

Answer 21

• lifetime: ODD: 12%, CD: 8%
• 6-month: ODD: 7.5%, CD: 1.3%
• cultural and contextual differences
• strongly associated with poverty, exposure to violence
• if disruptive bx only occurs in a negative environment where it is adaptive/protective, it shouldn’t be diagnosed
• only when disruptive bx occurs without negative environmental demands is it functionally impairing

Question 22

social causation

Answer 22

• stress of poverty leads to an increase in childhood psychopathology (strong exposure to stressors)
• predicts more problem bx in low SES environments

Question 23

social selection

Answer 23

• families with genetic predispositions drift down towards poverty
• disruptive behaviours aren’t rewarded in our society (getting expelled, unable to hold a job)
• predicts more problem bs in low SES environments

Question 24

Great Smoky Mountains study

Answer 24

• longitudinal study of epidemiology of childhood disorders
• positive association between pverty and disruptive bx
• sample included many Indigenous youth living on a reservation
• when a casino opened on the reservation, they gave the Indigenous families a stipend (more income which led to 4 groups: persistently poor, ex-poor, never poor, newly poor)
• showed support for social causation theory (ex-poor kids reduced disruptive bx)
• if social selection was true, the added income wouldn’t have had an impact on disruptive bx
• full mediator: increased income = improved parental supervision = fewer disruptive bx problems

Question 25

gender differences in disruptive bx

Answer 25

• conduct problems are 2-4x more common in boys
• gender gap reduces in early teens
• early-onset persistent CD: 10:1 ratio
• adolescent-limited CD: 2:1 ratio
• girls start to engage in more covert nonaggressive bx (lying, truancy)

Question 26

types of aggression in males/females

Answer 26

• physical aggression is more common in boys than girls
• relational aggression is more common than physical in girls
• the gender difference in relational aggression is small and not meaningful (girls engage in slightly more relational)
• boys disruptive bx is more overt = noticed earlier

Question 27

relational aggression

Answer 27

targeting social relationships

Question 28

comorbidities with ODD/CD

Answer 28

• 35% of youth with ODD have ADHD
• 50% of youth with CD have ADHD
• 50% of youth with ODD/CD have depression or anxiety

Question 29

correlates of ODD/CD

Answer 29

• cognitive/verbal challenges (not associated with intellectual impairment, may have specific verbal deficits)
• academic functioning (underachievement, grade retention, dropout, suspension, expulsion, may lead to depression/anxiety in adulthood)
• family functioning (high conflict, lack of family cohesion and emotional support)
• peer problems (engage in aggression, likely to be rejected, form friendships with other antisocial peers which is associated with health risks like injury, substance abuse, STIs)
• boys with conduct problems are 3-4x more likely to die before age 30 (more accidental deaths like overdoses)
• relational aggression may be predictive of popularity with peers instead of aggression

Question 30

conduct problems in infants

Answer 30

• difficult temperament
• fussy, irritable, hard to soothe
• higher in negative affectivity, lower in positive affectivity, lower in surgency
• may be linked to later ODD in boys

Question 31

conduct problems in preschoolers

Answer 31

• can be difficult to diagnose due to improbable symptoms (truancy, staying out at night) so need to adapt to a younger age group
• noncompliance, temper loss (temper tantrums), aggression (kicking, biting) are common (aggression increases until 27 months then should level out)
• low desisters: start with low misbehaviour, and misbehaviour decreases even more
• moderate desisters: start with moderate misbehaviour, but decreases at age 11
• high stable: lack of a normative decrease (higher risk for ODD and CD), significant behavioural and emotional dysregulation that will escalate if left untreated

Question 32

early-onset/life-course consistent pathway

Answer 32

• at least 1 sx before age 10
• 10:1 male to female
• 50% persist into antisocial bx in adulthood
• aggression in childhood
• nonaggressive antisocial bx in middle childhood
• serious delinquency in adolescence
• diversification: adding more serious disruptive bx with age

Question 33

late-onset pathway/adolescent-limited

Answer 33

• onset in adolescence, frequently with social change (peer influence)
• 2:1 or 1:1 male to female
• less extreme antisocial bx
• less likely to commit violent offenses
• less likely to persist into adulthood
• snares: outcomes of antisocial bx that put people on problematic paths (unplanned pregnancy, dropping out of school, drug addiction) and could move you to the life-course pathway

Question 34

how do we distinguish typical misbehaviour from a problem, especially in preschoolers

Answer 34

• frequency (and whether you can shape the behaviour with reinforcement)
• severity
• flexibility
• predictability (is Bx occurring when expected i.e. when a situation is overwhelming for a child or is it unexpected and random)
• pervasiveness (in many settings)

Question 35

heritability of disruptive disorders

Answer 35

• adoption and twin studies: about 50%
• but there are occasional cases in which behaviour seems to come out nowhere (no parent psychopathology, siblings are fine)
• strongest biological evidence for early-onset pathway

Question 36

prenatal factors and birth complications

Answer 36

• low birth weight
• malnutrition (protein deficiency) during pregnancy
• lead poisoning
• mother’s use of nicotine, marijuana, alcohol during pregnancy

Question 37

genotype x maltreatment interaction

Answer 37

• childhood maltreatment is a universal risk factor for psychopathology & most people don’t develop severe antisocial bx
• low MAOA activity is linked to aggression (not metabolizing NTs like dopamine and norepinephrine) and a gene on the X chromosome
• there’s a main effect of childhood maltreatment (it increases = so does antisocial)
• no main effect of low/high MAOA activity
• significant interaction effect: relationship between childhood maltreatment and antisocial bx is moderated by your level of MAOA activity (lower MAOA = higher antisocial), childhood activity produces an even bigger risk with this vulnerability
• there are other types of negative parenting that also contribute to psychopathology, not just maltreatment

Question 38

coercion theory

Answer 38

• cycle of increasingly negative parent-child interactions (delay/escape strategies and demands by the child + inconsistencies from parent are reinforcing to all)
• adult makes a request = child reacts with hostility = parent withdraws request or becomes reactive/hostile = child doesn’t do what was asked
• negative reinforcement: child learns that the parent’s demands are withdrawn when they throw tantrums so they don’t have to do what they don’t want to do
• positive punishment: parent’s demands are constantly met with hostile behaviour (acts as the punishment) which decreases the likelihood of making more demands

Question 39

social information processing

Answer 39

• various steps in going from perception of a situation to interpretation and action
• encoding: what to pay attention to
• interpretation: what does it mean
• response search: options for actions
• response decision: what will I do
• enactment: how well did I do it

Question 40

social information processing deficits in kids with disruptive disorders

Answer 40

• encoding: not much is known
• interpretation: hostile attribution bias
• response search: generate fewer responses overall, but more of them will be aggressive and less of them will be prosocial
• response decision: outcome expectancy (believe they will get what they want) and self-efficacy (believe they will be good at implementing the aggressive response), they choose the aggressive option
• enactment: not much is known (they’re selecting the aggressive options and doing them, but unclear if they’re actually good at them)

Question 41

hostile attribution bias

Answer 41

assuming negative intentions in neutral situations (impaired in the interpretation phase)

Question 42

how do social information processes become impaired

Answer 42

• parents: mothers show the hostile attribution bias, parents may unintentionally or outwardly approve of aggressive behaviours (see aggression as an appropriate response to a peer provocation)
• peers may be reinforcing (kids think aggression works, probably because it usually does and they get what they want)

Question 43

which levels in Bronfenbrenner’s model do various treatments target

Answer 43

• PSST: microsystem (the individual)
• PMT: agents within the microsystem (mesosystem)
• MST: multiple levels

Question 44

Problem-Solving Skills Training (PSST)

Answer 44

• targets cognitive processes upstream to change disruptive behaviour
• underlying theory: social information processing
• targets attentional biases (encoding), hostile attribution bias (interpretation), how well you generate and evaluate response options (response search and decision)

Question 45

STEPS for solving problems

Answer 45

• PSST technique: train them to think of more solutions, how to examine them in role-playing/pros and cons, try new options even if you think they might not work (then kids get better results from using prosocial response which gets reinforced)
• Say what the problem is
• Think of solutions
• Examine each one
• Pick one and try it out
• See if it works

Question 46

Anger coping program

Answer 46

• focuses on cognitive biases
• hostile attribution
• distortion in perceptions of aggressiveness: kids underestimate how aggressive they are and overestimate how aggressive other people are
• faulty emotional identification: tendency to mislabel any high arousal (like anxiety) as anger, which leads them to react accordingly - gain emotional insight to label appropriately
• response search/selection: teaching to focus on verbal solutions instead of direct action (aggressive kids tend to think prosocial options aren’t likely to have good outcomes)
• has some good evidence, but also critiqued

Question 46

steps for anger coping program

Answer 46

• inhibit early angry and aggressive responses
• cognitively re-label stimuli perceived as threatening (change hostile attribution)
• solve problems by generating alternative coping responses and choosing non-aggressive responses instead

Question 47

critiques of PSST and anger coping

Answer 47

• may not be enough because in the real world, problematic behaviours can be reinforced (outside the therapy setting)
• these only target the individual, but there’s a whole system they go home to that may promote unhelpful behaviours
• may need to intervene at other levels than the microsystem (like parents)

Question 48

Parent Management Training overview

Answer 48

• gold standard
• reset the parent-child relationship: create opportunities to start feeling good around each other (instead of constant frustration)
• since parents tend to only react to negative behaviours and miss the positive - try to motivate the kids to get attention from positive bx (reinforce small behaviours then work your way up to the ideal)
• may not be as effective in kids with CU traits
• stronger effects for preschoolers and elementary-schoolers than adolescents (teens show more impairment and people besides parents are reinforcing behaviours)

Question 49

PMT principles

Answer 49

• operant conditioning: consequences of a bx determine the likelihood of it re-occurring
• education: help parents establish realistic expectations of their child’s behaviour (normative bx for kids that age), behaviour tends to get worse before it gets better when doing therapy
• communication: give clear instructions to kids, setting clear and firm boundaries, set immediate and doable consequences for bad bx (there should be a rationale for punishment)
• ABC model: change contingencies by modifying environments/antecedents, observe behaviours and their contexts, modify consequences

Question 50

controversy about time-outs

Answer 50

• removal of positive reinforcement/negative punishment/omission training
• 1min per year of age - highly recommended strategy
• has been shown to decrease detrimental bx in youths despite the general outcry against them in media
• robust lack of association between time-outs and adverse outcomes in short-term and long-term
• emerging studies about positive effects on well-being

Question 51

Multisystemic Therapy

Answer 51

• fit assessment: figure out what is driving the behaviour, which drivers/behaviours to target first
• considers context in which bx is occurring to produce long-lasting change
• integration of multiple evidence-based practices (because serious clinical problems arise from many interacting factors)
• PSST, PMT, global reinforcement context (association with deviant peers)
• intensive services: access to therapist 24/7, services in home and other settings, about 4 months of Tx
• used with most severe cases (chronic juvenile offenders, violent bx, substance use)

Question 52

MST efficacy

Answer 52

• difference is clinically significant in people’s lives: school performance, relationships, living skills (functional outcomes, not just statistical significance)
• but mixed evidence for MST vs. other treatments (may not improve some functional outcomes like peer relations, academics but works for delinquency and family functioning)
• strong theoretical basis for the therapy, but unclear if it’s working better than other Tx (could be because it’s only used in more severe cases)

Question 53

mediator in MST

Answer 53

• family functioning drives the effects of MST