Conduct Disorder and Oppositional Defiant Disorder PDF

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Professor Mc Leod's Child Psychopathology Class Notes...

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Conduct Disorder and Oppositional Defiant Disorder Thursday, March 15, 2018

8:00 PM

Conduct Disorder: DSM-5 • • •

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Repetitive and persistent pattern of severely aggressive and antisocial acts Generally in older kids At least 3 symptoms in the past 12 months, with 1 present in the past 6 months: ○ Aggression to people & animals ○ Destruction of property ○ Deceitfulness or theft ○ Serious violation of rules Specifiers: ○ Specify onset: § Childhood-onset type (one symptom prior to age 10) § Adolescent-onset type (no symptom prior to age 10) § Unspecified onset ( not enough information to determine onset) ○ Specify if with limited prosocial emotions § Lack of remorse or guilt § Callous-lack of empathy § Unconcerned about performance § Shallow or deficient affect - not smiling a whole lot, lack of facial expression ○ Specify severity § Mild: few (if any) conduct problems in excess of those needed to make diagnosis, conduct causes relatively minor harm (e.g. lying, truancy) § Moderate: Number of problems lie between mild and severe § Severe: many conduct problems in excess of those required for diagnosis, conduct causes grave harm (e.g. rape, mugging)

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(ODD) DSM 5

Oppositional Defiant Disorder (ODD): DSM-5 • • •

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Age inappropriate and persistent display of stubborn, hostile, disobedient, and defiant behavior which lasts at least 6 months. Usually appears by age 8 Must evidence at least 4 of the symptoms: ○ Losing temper, arguing with adults, active defiance, refusal to comply, deliberately annoying others, blaming others for mistakes or misbehavior, easily annoyed, spitefulness, vindictiveness. Specifiers: severity ○ Mild: confined to one setting ○ Moderate: symptoms present in at least 2 settings ○ Severe: symptoms present in 3 or more settlings. Distress in individual or social context (e.g. family), or impacts negatively on social, academic, or occupational functioning.

Antisocial Personality Disorder: DSM-5 •

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Antisocial Personality Disorder (APD): Pervasive pattern of disregard for, and violation of, the rights of others ○ Illegal behaviors, deceitfulness, failure to plan ahead, fights/assaults, reckless disregard, failure to sustain work behavior, lack of remorse. 40% of youth with CD will develop APD

Perspectives on Conduct Disorders •

Beliefs about conduct disorders ○ Most future offenders can be identified during early childhood ○ Child abuse and neglect inevitably lead to violent behavior later in life ○ African American and Hispanic youths are more likely to become involved in violence than other racial or ethnic groups ○ Getting tough with juvenile offenders by trying them in adult criminal courts reduces the likelihood that they will commit more crimes ○ All of these are FALSE.

When is conduct a problem? •

Conduct and antisocial problems: ○ Age-inappropriate actions and attitudes

Violate family expectations, societal norms, and the personal or property rights of others In normal development, antisocial behaviors: ○ Vary in severity ○ Some behaviors decrease with age while others increase ○ More common in boys than in girls in childhood, but the difference narrows in adolescence ○

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Multidisciplinary perspectives on conduct disorders • • • •

Legal ○ Delinquent or criminal acts Psychiatric ○ DSM-5: disruptive behavior disorders Public Health ○ Prevention and invention Psychological ○ Continuous dimension of externalizing behavior

Typologies of conduct disorders • • • •

Destructive - cruelty to others, assault Nondestructive - swearing, breaking rules Overt - hitting, fighting, bullying Covert - lying, stealing

Prevalence of Conduct Disorders + Comorbidity • •

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ODD is more prevalent than CD in childhood ○ But by adolescence, they are equal Lifetime prevalence estimates: ○ 12% for ODD - 13% males, 11% females ○ 8% for CD - 9% males, 6% females Rates of prevalence are similar across cultures Rates are NOT similar across genders ○ Gender disparity increases throughout childhood, then narrows in early adolescence Early symptoms - girls (sexual misbehaviors) and boys (aggression & theft) Girls more likely to use relational aggression Boys are more likely to have earlier onset & greater persistence

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Comorbidities: ○ Across conduct disorders - 25% of youth with ODD will develop CD ○ ADHD - >50% of children with CD have ADHD, ADHD may increase risk for CDs ○ Learning Disabilities - ODD + ADHD risk of LDs increases

CD versus ODD •

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Developmental Trends ○ ODD persists in 50%, ODD remits in 25%, ODD becomes more serious in 25%, Early intervention may prevent more problematic disturbances ODD - limited to parents/home, emerges earlier, majority don't develop CD, does not include violation of basic rights, overt, nondestructive CD - violation of basic rights or societal norms, extend outside the home, overt, destructive, convert destructive, covert nondestructive.

Associated Characteristics of Conduct Disorders •

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Cognitive and verbal deficits ○ Most have normal overall IQ ○ Verbal and executive functioning deficits § Lead to difficulties in emotion regulation and self-control § Difficulties with incentives and motivation School and learning problems ○ Academic underachievement, dropout, and suspension ○ Academic difficulties - CD Family problems ○ Strongest correlate of conduct problems § General family disturbances § Disturbances in parenting practices § Conflict between siblings Peer problems ○ Verbal and physical aggression towards others ○ Poor social skills § Reactive-aggressive - angry/defensive response § Proactive aggressive - lack of concern for others ○ Deviant friendships Self-esteem deficits - inflated unstable view of self allows them to

Self esteem deficits inflated, unstable view of self allows them to rationalize antisocial conduct • Health-related problems - high risk for injury, illness, STD's, substance abuse, and physical problems Development of Conduct Disorders - course and etiology • Developmental Course ○ Toddler/Preschool Years § Hyperactivity § Compositionality § Irritability § Fussiness § Stubbornness § Temper Tantrums ○ Early and Middle Childhood § ODD and ADHD symptoms increase risk § Poor academic performance § Covert conduct problems begin § At age 8-12 more overt behaviors begin § Risk for depression and anxiety § Low self-esteem § Poor peer relationships ○ Late Childhood and Adolescence § Increasing amounts of conduct problems § Greater association with deviant peers § Increased rates of arrest § Increase risk for anxiety, depression, suicide § Continued poor academic performance ○ Late Adolescence § Antisocial behaviors: substance dependence, unsafe sex, drunk driving § Criminal behavior § Psychiatric problems § Continued association with deviant peers § Higher divorce rate § Unemployment common ○ Pathways •

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Pathways § Life-course-persistent (LCP) - 10%, engage in aggression and antisocial behavior at an early age, neuropsychological deficits (vulnerable to environment leads to conduct problems) - occurs during the entirety of life, earlier symptomology § Adolescent-limited (AL) - antisocial behavior begins around puberty and may cease around young adulthood; have greater risk in childhood, but display antisocial behavior around adolescence; less severe, but still long-lasting Etiology: § Biological Causes: genetic influences - 50% of variance in antisocial disorder, GxE interaction □ Prenatal factors/birth complications - malnutrition, exposure to substances, correlated, rather than direct influence § Neurobiological Causes □ Gray's BIS/BAS Theory - Overactive behavioral activation system (BAS) □ Underactive behavioral inhibition system (BIS) □ Increased rates of neurodevelopmental risk factors: TBI (Traumatic Brain Injury) and birth complications □ Increased rates of lead exposure □ Perhaps as a result of the above: executive functioning deficits, lower verbal IQ § Social-Cognitive Causes □ Social-Cognitive Deficits (Crick & Dodge's Model) ® Encoding - seek less information before acting ® Interpretation - hostile attributions ® Response search - generate fewer & more aggressive solutions ® Response decision - more likely to choose aggressive solutions ® Enactment - poor verbal communication, strike out physically § Family Causes

Risk Factors ® Family instability, marital discord & stress ® Parent criminality ® Parent psychopathology □ Reciprocal influence - interplay between family influence & antisocial behavior □ Coercion theory: parent-child interactions are the training ground for antisocial behavior □ Attachment theory: quality of attachment will determine identification with values, belief, and standards. Societal Causes □ Society - neighborhood (crime/delinquency, low participation in community organizations), school (high risk school environment), media? □ Culture - socialization of children, US most violent of industrialized nations, no differences among race/ethnicity when controlling for SES and other demographics. Summary: □ Community/Social Influences - poverty, neighborhood violence, criminal subcultures, low social support □ Family functioning - harsh discipline, parental criticism & coerciveness lack of support & positive interactions □ Child functioning - predisposition, difficult temperament, increased risk for conduct problems □

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Treatment of Conduct Disorders •

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Parental Management Training - teaches to change child behavior at home and in other settings, implementation of behavioral modification techniques, enhancing positive parent-child interactions, enhancing parent's coping skills Evidence-based, especially for ODD Responding with praising, ignoring, setting firm, fair, limits. Parent-Child Interaction Therapy - PCIT is treatment for young children with behavioral disorders, improves parent-child relationship and interaction - where the therapist is in another room and parent is told

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what to say, kids under the age of 8 Problem-Solving Skills Training (PSST) - CBT that focuses on cognitive distortions and deficiencies - change distortions, problem-solving skills ○ What am I supposed to do? ○ I have to look at all my possibilities ○ Evaluate each possibility ○ Choose ○ Did it work? Multisystemic Therapy ○ For youth with severe conduct problems ○ Change pattern of transactions within or between social systems ○ Uses of variety of different techniques (PMT, PSST, marital therapy, special education, legal services) Prevention ○ Best prevention programs involve - parent training, CBT for children, academic assistance, teacher based interventions ○ Success of prevention program depends on severity of child's difficulties and magnitude of risk and protective factors....