Disruptive behaviour disorders Flashcards
(22 cards)
Core Features
Age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal or property rights of othersproblems in the self-control of emotions and behaviors2 diagnoses: Oppositional Defiant Disorder (ODD), Conduct Disorder (CD)
Oppositional Defiant Disorder (ODD
A) A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, andexhibited during interaction with a least one individual who is not a sibling.Negative affect (Angry/irritable mood)(1) Often loses temper(2) Is often touchy or easily annoyed(3) Is often angry or resentfulDefiant/headstrong behavior(4) Often argues with adults/ authority figures(5) Often actively defies or refuses to comply with requests from adults or with rules(6) Often deliberately annoys others(7) Often blames others for his or her mistakes or misbehaviorHurtful Behavior (Vindictiveness)(8) Has been spiteful or vindictive at least twice in the last 6 months
Four of the behaviors are presentFor children younger than 5-years-of age, behavior should beoccurring on most days for a period of a least six monthsFor children older than 5-years-of-age or older, the behavior should be occurring at least once a week for a period of six monthsNote that child has tobe engaging in behavior more than is normative for children of their developmental level, gender, & cultureMild –occurs in only one settingModerate –some symptoms presentin at least 2 settings(90% of kids = moderate or severe)Severe –Some symptoms present in three more settings
A Brief Aside about SiblingsFighting between siblings is commonDuring the preschool years, siblings fight once every 10 minutesBut there is mounting evidence that sibling aggression is harmfulSibling conflict, hostility, and negativity uniquely predict greater emotional and behavioral problems over timeConflict with siblings made lead to maladaptive behavior problems in other relationships
Assessment of ODD
Interviews and ChecklistsObservationDisruptive Behavior Diagnostic Observation Schedule (DB-DOS)Preschoolers interacting in 3 contextsWith an interactive examinerWith a busy examinerWith their parent“Presses” for disruptive behaviorComplianceFrustrationRule-breaking
Conduct Disorder (CD)
A repetitive and persistent pattern of violating basic rightsof others and/or age-appropriate societal norms or rules, including:Aggression to people and animals Destruction of property Deceitfulness or theftSerious violations of rules
15 symptoms (need 3 in past year 1 in past 6 months) See slide
SpecifiersOnsetchildhood-onsetOnset of at least one symptom before age 10adolescent-onsetMild–few if any symptoms in excess ofthose required to meet diagnostic criteria, symptoms are causing mild impairment and harm to others (e.g., lying, truancy)Moderate–number of conduct problems and impact on others is in between mild and severe (e.g., vandalism, stealing without confronting a victim)Severe–many conduct problems in excess ofthose required to make a diagnosis are present, or the behaviors are causing serious harm (e.g., forcing someone into sexual activity, use of a weapon)
Note that, per diagnostic criteria,there are many possible combinations of symptomsOften bullies, threatens or intimidates others, initiates physical fights, truant from school beginning before 13 years of agePhysically cruel to animals, forced someone into sexual activity, used a weapon that can cause serious physical harm^ What do you notice when comparing these 2 different kids with CD?
Questioning 3 Symptom Cutoff –Lindheimet al., 2015Each diamond is a different symptom combinationThere are certain combinations of 2 symptoms that are more severe than certain combinations of 3 symptomsIfcutoff stays 3, we might be missing some high severity people who happen to be right below the cutoff
Additional Specifier(‘new’ to DSM5With ‘limited prosocial emotions’ specifierTwo of the following characteristics persistently present over the last 12 months, and in multiple relationships and settingsLack of remorse or guiltCallous, lack of empathyUnconcerned about performanceShallow or deficient affectWe refer to these characteristics collectively as callous and unemotional (CU) traits
CU Traits2% to 6% of youth with Conduct Disorder have significant CU traitsWhen youth have CU traits, CD is earlier onset, aggression is more severe and more instrumentalCU associated with insensitivity to punishmentHarder to treat
Inventory of Callous-Unemotional Traits –Frick, 2004
Limited Prosocial Emotions –interview measureClinical Assessment of Prosocial Emotions (CAPE1.1) –2020PDF of manualSemi-structured interviewNeed multiple information sources Sample items from manual →
Conduct Disorder and ODD
In DSM-IV, CD subsumed ODD
In DSM-5, they can be diagnosed at the same timeNearly half of all children with CD have not been diagnosed with ODD~50% of children with ODD do not progress to more severe CDSome do –may start with ODD diagnosis then add CD dx with age
Summary so far
Disruptive behavior disorders are characterized by age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal or property rights of othersRange from mild behaviors to severe behaviorsTwo diagnoses: ODD and CDAssessment typically done with interviews and rating scalesMay be necessary to use observation with younger children in order todifferentiate normative from clinically concerning disruptive behavior
Prevalence of CD and ODD
Lifetime prevalenceODD –12%(13% males 11% females –so very similar)CD –8%(9% males 6% females –also very similar)Ontario Child Health Study Sequel6 monthprevalence of ODD is 7.5%6 monthprevalence of CD is 1.3%
Cultural and contextual differencesStrongly associated with povertyStrongly associated with exposure to violence“Concerns have been raised that the Conduct Disorder diagnosis may at times be misapplied to individuals in settings where patterns of undesirable behavior are sometimes viewed as protective(e.g., threatening, impoverished, high crime) . . . a Conduct Disorder diagnosis should only be applied whenthe behaviorin question is. . . not simply a reaction to the immediate social context” DSM-IV-TR
Poverty and Disruptive Behavior Disorder
Social causationStress of poverty leads to an increase in childhood psychopathologySocial selectionFamilies with genetic predisposition drift down towards povertyGreat Smoky Mountains StudyLongitudinal study of epidemiology of childhood psychiatric disorderSignificant positive association between poverty and disruptive behaviorSample included a significant number of Indigenous youth, many of whom lived on a reservationCostello, Compton, Keeler, & Angold, 2003
Partway through the study, a casino opened on the reservationAll indigenous participants’ families got a stipendLed to four groupsPersistently poor Ex-poorNever poorNewly poor (excluded because of small number)Naturally-occurring experiment allowed for test of 2 competing theoriesSocial causation theoryIncrease in income should reduce children’s symptomsSocial selection theoryIncrease in income should have no effect on children’s symptoms
Youth whose families were no longer poor due to the stipend from the casino reported decrease in disruptive behaviorsResults support social causation theory
Why is Poverty Associated with Disruptive Behavior Problems?Follow-up analysis examined possible mediators of the association between increase in income and decrease in behavioral symptomsFound that increased parental supervision fully mediated relationship
Gender and Disruptive Behavior Disorders
Conduct problems are 2-4 times more common in male childrenSmaller differences in early teensEarly-onset persistent CD 10 male: 1 female ratioAdolescent-limited CD2 male: 1 female or no gender differenc
In general,
Boys are more physically aggressive than are girls, across the lifespanRelational aggressionAmong girls, this is more common than physical aggressionAvailable evidence suggests that girls engage in slightly more relational aggression than do boys, but the difference is small and not meaningfulBoys’ antisocial behavior is more overt, may get them noticed at an early age
ODD/CD & Comorbid Psychopathology
ADHD35%+ of youth with ODD also have ADHD More than 50% of children with CD also have ADHD Depression and anxietyAbout 50% of children with ODD and CD also have depression or anxiety
Correlates:
Cognitive and verbal challengesCD and ODD are not associated with intellectual impairmentSpecific verbal deficits may be presentAcademic functioningUnderachievement, grade retention, dropout, suspension, expulsionMay lead to anxiety or depression in young adulthoodAntisocial Personality Disorder-Up to 40% of kids with CD develop APD as adultsFamily functioning➢High levels of conflict➢Lack of family cohesion and emotional supportPeer problems➢Children with ODD/CD many engage in aggressive behavior with peers➢Often rejected by peers, although some are popular➢Form friendships with other antisocial peersCD is associated with significant health risks*Personal injury, substance abuse, sexually transmitted infectionsBoys with conduct problems are 3 to 4 times more likely to die before the age of 30
Summary again
Prevalence of ODD is 12% and CD is 8%Strongly associated with poverty and there is evidence that poverty worsens symptomsBoys more likely to be diagnosed with a disruptive behavior disorder than are girlsCo-morbid with other psychological disordersAssociated with significant impairment, including health risks
Developmental Course
InfantsDifficult temperamentFussy, irritable, hard to sootheSome evidence that this is linked to later ODD in boysPreschoolersTwo diagnostic challengesImpossible or improbable symptomsTruancy, staying out at all night
But…. see article
PreschoolersNormative misbehaviorNoncompliance, temper loss, and aggression are commonChildren’s physical aggression increases until 27 months of age40% of girls and 50% of boys are reported by their parents to hit, kick, and bite occasionally75% of preschoolers have temper tantrumsFor many preschoolers, some misbehavior is normativeand will decrease as they grow olderFor some, misbehavior is an indicator of significant behavioral and emotional dysregulation that will escalate with time if left untreated (top group in graph to right) →10,000 children; Cote et al., 2006
DBD in Preschoolers: Diagnostic ChallengesHow do we distinguish “typical” misbehavior from that representing a significant problemFrequencySeverityFlexibilityExpectabilityPervasivenes
Developmental CourseEarly-onset/life-course consistent pathwayat least one symptom before age 1010:1 male to female ratio 50% persist in antisocial behavior into adulthoodAggression in childhoodLess serious nonaggressive antisocial behavior in middle childhoodMore serious delinquency in adolescenceDiversificationLate-onset pathway / ‘adolescent-limited’Onset in adolescence, frequently with social changePeer influences2:1 or 1:1 male to female ratioLess extreme antisocial behaviorLess likely to commit violent offensesLess likely to persistSnaresOutcomes of antisocial behavior that put people on a problematic pathUnplanned pregnancy, dropping out of school, drug addiction
Summary again
Disruptive behavior disorders may manifest in infancy as difficult temperamentIn the preschool years (ages 3 to 5) it is difficult to disentangle normative from clinically concerning misbehaviorTwo pathways of conduct problems: early-onset/life course persistence and adolescent limitedPrognosis is poorer for early-onset, but adolescent limited may be associated with significant negative outcomes
Heritability of Disruptive Behavior Problems
Adoption and twin studies indicate that 50% or more of the variance in antisocial behavior is hereditar
Prenatal Factors and Birth ComplicationsPregnancy and birth factorsLow birth weightMalnutrition (possible protein deficiency) during pregnancyLead poisoningMother’s use of nicotine, marijuana, and other substances during pregnancyMaternal alcohol use during pregnancy
Genotype x Maltreatment Interaction in the Development of Antisocial BehaviorChildhood maltreatment is universal risk factor for antisocial behaviorBut most people who are maltreated do not develop severe anti-social behaviorIt may be that vulnerability to adversities is conditional, depending on genetic factorsMAOA is an enzyme that metabolizes neurotransmitters such as dopamine and norepinephrine (makes them inactive)Caspiet al., 2002
A Caspiet al. Science 2002;297:851-854INTERACTION/ MODERATION -relationship between maltreatment and antisocial behavior is STRONGER for those with low MAOA activit
Parenting and Disruptive Behavior Problems
Caspiet al. examined associations between maltreatment and antisocial behaviorMaltreatment is a risk factor for disruptive behavior problemsand other types of psychopathologyNegative parenting behaviors that do not constitute abuse are also associated with disruptive behavior problems
Operant conditioning
Coercion Theory (conditioning principles)Cycle of increasingly negative interactionsDelay/escape strategies and demands by childInconsistency and explosions from parentManages to be “reinforcing” to allParenting behaviors are associated with an increase in disruptive behavior problemsKey target for interventions
Summary again
Conduct problems are heritable (approximately 50% of the variance)Genetic factors interact with environmental factorsGenotype x maltreatment interactionParenting behavior can contribute to the escalation of disruptive behavior problems and is a key target for interventions
Cognition and Disruptive Behavior Problems
Social information processingA series of cognitive steps that take a person from situation to actionSocial information processing problemsWhat do I pay attention to? (encoding)What does it mean? (interpretation)What can I do? (response search)What will I do? (response decision)How well did I do it? (enactment)Crick and Dodge, 1994
Ex: You are getting ready for your turn on the monkey bars. You see two boys/girls playing catch with a baseball nearby. Just as you start across the bars, you get hit hard in the back with the baseball thrown by this kid.
Encoding (what to pay attention to)Relatively little is known about encoding and aggressive behaviorsInterpretationHostile attribution biasVery robust evidence linking hostile attribution bias and aggressive behaviorChildren with aggressive behavior problems are more likely to think the other child did it on purpose
Response Search (What could I do?)Response Decision (Evaluate response on different dimensions)Outcome expectancies –what will happen if I do this?Self-efficacy –how well can I carry out this response?Children who are aggressive perceive themselves as being very able to carry out those behaviorsResponse Decision (What will I actually do?)Children who are aggressive pick aggressive strategi
Enactment(Carry out the response)How well can you actually doit?Can children with aggressive behavior problems carry out other types of responses?Very little work examining this issue
How Do These Patterns Develop?ParentsMothers of aggressive boys also show the hostile attribution biasParents may reinforce or approve of behaviorsMay see aggression as a competent response to peer provocationPeersMay be reinforcing behaviorsChildren with aggressive behavior problems think aggression works, probably because it often does
Summary again
Genes and biologySome evidence of genetic diathesisSeem to be gene(s) x environmentinteraction (maltreatment)Strongest biological evidence for early-onset pathwayParenting and environmental factorsStrong correlationsMay interact with biological factorsCognitive and learning factorsDifficult to establish that information processing comes firstLikely involved in maintaining problems over tim
Treatment of DBD: Problem-solving Skills Training and Parent Management Training
See table
Bronfenbrenner’s Ecological Model of Human Development
Problem Solving-Skills TrainingWork with the child to reduce behavior problemsTargeting cognitive processes upstreamUnderlying theory: Social-information processingEncodingAttentionInterpretationHostile attribution biasResponse SearchGenerationResponse SelectionEvaluation along different dimension
S say what the problem isT think of solutionsE examine each onePpick one and try it outS see if it workedEncoding and InterpretationResponse SearchResponse SelectionResponse Decision and Enactment
Anger Coping Program Treatment for aggressive behavior designed by John Lochmanand colleaguesFocuses on specific cognitive biases:Interpretation (i.e., Hostile attribution bias)Distorted perceptions of aggressivenessFaulty emotional identificationResponse search and selectionRely heavily on direct action rather than verbal solutionsMaladaptive outcome expectancies
Three critical stepsChildren taught:1)To inhibit early angry and aggressive reactions2)To cognitively re-label stimuli perceived as threatening3)To solve problems by generating alternative coping responses and choosing adaptive, nonaggressive alternativesGoal: To inhibit early angry and aggressive reactionsSample Activities:❖Building domino towers while being verbally distracted by peers❖Learn to identify bodily cues that signal angry arousal and identify thoughts that contribute to greater or reduced anger❖“Stop! Think! What should I do?”
Problem-Solving Skills Training (incl anger coping)Generallywork well, but may not be enoughin certain situations (especially when severity is more moderate or severe)Why?In the real world, problematic behaviors may be reinforcedChildren are unlikely to change such behaviorsMay need to intervene on other levels of ecological system outside just individualE.g., parents in the microsyste
Bronfenbrenner’s Ecological Model of Human DevelopmentProblem-Solving Skills TrainingParent-Management TrainingMultisystemic Therapy
Problem Solving-Skills TrainingWork with the child to reduce behavior problemsTargeting cognitive processes upstreamUnderlying theory: Social-information processingEncodingAttentionInterpretationHostile attribution biasResponse SearchGenerationResponse SelectionEvaluation along different dimensionsI’m having trouble with a friend of mine. Well, she used to be a friend, but now she is saying all kinds of things behind my back and giving me a bad reputation in school. I don’t know why she is being so horrible. Last summer we spent tons of time together, and we were still friends at the beginning of the year. We didn’t hang out so much after I started going out with my boyfriend. I guess she could be mad that I got caught up in being with my guy, but she could just talk to me about it. I don’t know what to do. If she keeps spreading rumors about me, I might lose other friends. My boyfriend could break up with me, too, if he believes what she’s saying. Maybe I should tell everyone what a total liar she is. And, I know things about her that I don’t think she’d want me saying to people. I could give her a taste of her own medicine. What do you think I should do?
Problem-Solving Skills TrainingSTEPS for Solving ProblemsS say what the problem isT think of solutionsE examine each onePpick one and try it outS see if it workedEncoding and InterpretationResponse SearchResponse SelectionResponse Decision and Enactment
Anger Coping Program Treatment for aggressive behavior designed by John Lochmanand colleaguesFocuses on specific cognitive biases:Interpretation (i.e., Hostile attribution bias)Distorted perceptions of aggressivenessFaulty emotional identificationResponse search and selectionRely heavily on direct action rather than verbal solutionsMaladaptive outcome expectancies
Anger Coping ProgramThree critical stepsChildren taught:1)To inhibit early angry and aggressive reactions2)To cognitively re-label stimuli perceived as threatening3)To solve problems by generating alternative coping responses and choosing adaptive, nonaggressive alternativesGoal: To inhibit early angry and aggressive reactionsSample Activities:❖Building domino towers while being verbally distracted by peers❖Learn to identify bodily cues that signal angry arousal and identify thoughts that contribute to greater or reduced anger❖“Stop! Think! What should I do?”
Problem-Solving Skills Training (incl anger coping)Generallywork well, but may not be enoughin certain situations (especially when severity is more moderate or severe)Why?In the real world, problematic behaviors may be reinforcedChildren are unlikely to change such behaviorsMay need to intervene on other levels of ecological system outside just individualE.g., parents in the microsystem
Parent Management Training (PMT)Also called behavioral parent training (BPT)https://youtu.be/EnkfW6H-QTM?si=5zol-0PPL-3CxbB8(2:08)
Parent Management Training (PMT)Operant conditioningConsequences of anbehavior will determine whether you get more or less of it in the futureEducationReasonable expectations for child’s behaviorBehavior will get worse before it gets betterCommunication“Say what you mean”“Mean what you say”Let children know what will happen if they continue their behaviorPick consequences that ar
Learn to observe your child’s behaviorABC model -Antecedent-Behavior-ConsequenceIn which situations does this behavior occur?What happens next?Modify the contingenciesMonitor changes in behaviors
Are time outs detrimental to children’s long-term development?Time out involves removal of positive reinforcement –toys, electronics, positive social interaction –for a brief period of time1 minute for every year of ageIt is one of the only discipline strategies recommended by the American Academy of PediatricsUse of time outs has been shown to decrease behavior problems in youthAlarmist claims in popular media that time outs are hurting childrenTime Magazine: “Time Outs are Hurting Your Child”
Hey! Aren’t time outs detrimental to children’s long-term development? NOTo support their claim, the authors of the Time Magazine article cited data showing that social exclusion activates similar areas of the brain as does physical painHowever, those data are based on work with adults, and it’s not clear that time out –when properly implemented –is comparable to the experiences that adults are havingThey also did not cite data documenting associations between time out and adverse outcomes for childrenThere is very limited work examining associations between time outs and children’s well-beingRecent study suggests no association between parental use of time outs at when children were 3 years of age and measures of children’s emotional and behavioral health when children were in Grade 5 (Klein et al., 2020).
Parent Management Training: EfficacyIn general, studies have shown that parent management training results in a significant reduction in problem behaviors, relative to no-treatment control groups and wait-list control groupsStronger effects for preschoolers and elementary-school aged children than adolescentsAdolescents tend to be showing more significant impairmentPeople besides parents may be reinforcing behaviors
Summary again
Effective treatments for disruptive behavior problems in children are problem-solving skills training, parent management training, and multisystemictherapyProblem-solving skills training involves working directly with youth to change maladaptive social cognitive patternsParent management training involves working with parents to help them learn how to shape children’s behavior using appropriate rewards and consequences
Multisystemic Therapy
Serious clinical problems result from the interplay of multiple factorsCaregivers are key to positive long-term outcomes for youthSustainabilityIntegration of evidence-based practiceProblem solving skills training Parent management trainingChange globalreinforcement contextAssociation with deviant peersIntensive services that overcome barriers to service accessTherapist available 24/7Services in home and directly other settingsTypically4 months of treatment
Evidence for EfficacyMST has been tested with youth presenting a wide range of problemsChronic and violent juvenile offendersSubstance using juvenile offendersYouth in psychiatric crisisMST has been shown to improve important variables Statistical versus clinical significanceFunctional outcomes
–systematic review + meta-analysis of Multisystemic Therapy for youth (10-17
23 studies reviewedMixed evidence for increased efficacy of MST versus other treatments :/ E.g., 1-yar reduction in child out-of-home placements only for trials in US but not in other countriesReduced self-reported delinquency and increases in family functioning but not other important outcomes (e.g., peer relations, academics)Family functioning is mediating mechanism shown to drive effects of MSTIs MST better than other studies? The literature says…. We don’t know, kind o
Summary
Evidence based treatments for DBD are problem-solving skills training, parent management training, and multisystemictherapyThere is evidence that MST leads to clinically meaningful change in serious conduct problemsMST may work primarily by improving family functionin
