Development of Disruptive Behavior Disorders: Implications

for Prevention & Treatment

Marcia Jensen, Ph.D., NCSP

3/2/2010

jens0692@umn.edu

Plan for Presentation

What are Disruptive Behavior Disorders?Why are DBD problematic?What causes DBD?Who has DBD?What are implications for prevention &

treatment of DBD?

What are Disruptive Behavior Disorders?

Attention-Deficit/Hyperactivity DisorderOppositional Defiant DisorderConduct DisorderDisruptive Behavior Disorder, NOS

Attention-Deficit/Hyperactivity Disorder (ADHD) ADHD-I: > 6 symptoms of inattention occurring

often for 6+ months causing significant impairment in social, academic, or occupational fxning

ADHD-H-I: > 6 symptoms of hyperactivity-impulsivity for 6+ months causing significant impairment

ADHD-C: > 6 symptoms of inattention & > 6 symptoms of hyperactivity-impulsivity with impairment

Below developmental level and some symptoms before age 7

Oppositional Defiant Disorder (ODD)

> 4 criteria occurring often for 6+ months causing significant impairment in social, academic, or occupational fxning Loses temper Argues with adults Actively defies/refuses to comply with adults’ requests/rules Deliberately annoys people Blames others for own mistakes/behavior Touchy/easily annoyed by others Angry/resentful Spiteful/vindictive

Conduct Disorder (CD)

> 3 criteria occurring in 12 months, > 1 in past 6 months causing significant impairment in social, academic, or occupational fxning

Aggression to people/animals Often bullies, threatens, or intimidates others Often initiates physical fights Used a weapon than can cause serious physical harm to others Has been physically cruel to people Has been physically cruel to animals Stolen with confrontation Forced someone into sexual activity

Destruction of property Fire setting with intent to cause serious damage Destruction of property other than fire setting

Deceitfulness or theft Broken into someone’s house, building, or car Often lies to obtain goods/favors (i.e., cons others) Stolen items of nontrivial value without confrontation

Serious violations of rules Stays out all night despite parent prohibition (before age 13) Run away from home overnight > twice or once for lengthy period Often truant (before age 13)

Childhood onset if > 1 symptom prior to age 10; Adolescent onset if no criteria before 10; Unspecified if age of onset unknown

Why are DBD problematic?

High association with comorbid psychiatric diagnosis

High association with negative life course outcomes

Comorbidity of DBD

DSM-IV-TR Diagnosis

Comorbid Conditions (%)

ADHD Internalizing (13-51)

Externalizing (43-93)

ODD ADHD (35); Anxiety (62); Mood (46)

Conduct Disorder ADHD (80); Anxiety (40);

Depression (50)

Ollendick et al., 2008

Life Course Outcomes of DBD

Higher rates of violence, arrest/conviction, substance abuse/dependence, unemployment

Poor school performance, low educational attainment

Problems with peers, social isolation Mental & physical health problems Violent, coercive parenting Children with problem behaviors

De Genna et al., 2007; Farrington, 1991; Jaffee et al., 2006; Offord & Bennett, 1994; Offord, Boyle, & Racine, 1991; Temcheff et al., 2008

What Causes DBD?

Physiological influences Genes Temperament Neurological functioning

Environmental influences Risk factors Protective factors

Developmental Trajectory of Self-Control

Age Typical AggressiveInfant/Toddler Easy temperament

Manageable negative behaviors

Irritable, fussy, unresponsive to parent

Tantrums/whines

Preschool Obeys most caregiver directions

Follows rules

Disobeys caregiver directions

Fails to follow rules

Continued tantrums

Elementary School Usually reflective & thinks before acting

Can calm down when upset

Often impulsive & acts before thinking

Gets upset & overreacts to stress

Adolescence Copes with strong emotions

Aware of behavior & impacts on others

Frequent intense anger outbursts

Unaware of behavior & impact on others

Theories on Developmental Trajectory of Aggressive Behavior 2 pathways to later criminality

Early onset; life-course persistent Later onset; adolescence-limited

Patterson, DeBaryshe, Ramsey, 1989; Moffitt, 1993

5 pathways 2 life-course persistent groups

Early onset w/ ADHD Middle childhood onset w/o ADHD

2 limited duration aggression groups High aggression subsides in middle childhood ‘’ late teens

1 late onset group Loeber & Stouthamer-Loeber, 1998

Developmental Trajectory & Outcomes

Schaeffer et al., 2003

Trajectory Juvenile Arrest %

Adult Arrest %

CD % ASPD %

Nonaggressive 12 9 16 9

Moderate 42 26 20 16

Increasing 72 46 69 62

Chronic High 73 48 74 71

Genetic Biomarkers of DBD?

Genetic studies evaluate main effects of genes (G), environment (E), and GxE interactions

Conclusive evidence of main effects for E Some evidence of main effects for G

Within serotonin & dopamine transmitting systems, but far from definitive markers to reliably diagnose or predict treatment outcomes

Some evidence of interaction effects for GxE Polymorphism on MAOA gene moderates impact of

childhood maltreatmentMoffitt et al., 2008

Gender Differences in DBD

Few differences in rate of conduct problems during infancy/toddlerhood

Males exhibit more conduct problems than females between the ages of 4 & 13 and post-puberty

Smaller differences between males & females around puberty

Males more likely to be on LCP trajectory; similar prevalence for AL trajectory Lahey et al., 2006

Gender Differences in DBD

Differences in early childhood conduct problems may be result of differential socializing responses from adults Keenan & Shaw, 1997

Differential response patterns by males & females to same experience

Girls shift from physical to relational aggression Crick & Zahn-Waxler, 2003

Insufficient evidence to create female-specific diagnostic criteria for CD Moffitt et al., 2008

Synthesis of Developmental Models

DBD associated with increased risk for negative life-course outcomes

LCP = psychopathology & is relatively uncommon (3-16%)

Worst prognosis for high stable aggression, problems associated with low & moderate stable aggression

LCP vs. AL model applies to males and females, but DBD & LCP more prevalent in males

Trajectory determined by a combination of genetic & environmental influences

There may be both main effects & interaction effects for G & E influences

Bronfenbrenner’s Ecological Theory

Risk & Protective Factors

Protective Factors

Risk Factors

Child Behavioral/emotional regulation

Social skills

> Average IQ

Academic skills

Behavioral/emotional dysregulation/problems

Poor social skills

Low IQ

Academic difficulties

Parent/family Close relationship w/ stable adult

Supportive, authoritative parenting

Predictable routines/rituals

Positive parent-child interactions

Positive/stable family environment

Middle/high SES

Problems w/ parent-child attachment

Permissive, inconsistent parenting

Family lacks routines/rituals

Coercive parent-child interactions

Family problems/instability

Parent personal problems

Low SES

Risk & Protective Factors

Protective Factors

Risk Factors

Social/Peer Group

Acceptance by positive peer role models

Associations/acceptance by positive-influence peers

Rejection by positive peer role models

Associations/acceptance by negative-influence peers

Community Attending effective school

Safe, organized neighborhood

Opportunities of positive influence: school, religious, community activities

Nonviolent media influences

Attending ineffective school

Neighborhood problems

Community violence & crime

Poverty

Violent media influences

Bloomquist & Schnell, 2002

Social Information Processing Theory

Encoding of Cues

Interpretation of Cues

Clarification of Goals

Response Evaluation

Response Search

Behavioral Enactment

Database

PEER EVALUATION & RESPONSE

Adapted from Crick & Dodge, 1994

Social Info Processing & Aggression

Hostile attribution bias: aggressive children more likely to attribute hostile intent to neutral interactions; linked to reactive aggression

Deficits in response selection: aggressive children generate fewer responses, have & choose more aggressive & less prosocial responses

≈ 40% of children have SIP problems, boys and African Americans at greater risk Lansford et al., 2006

Who has DBD?

Children of delinquent parents Children of substance abusing parents Low SES associated with increased risk for DBD Racial/ethnic differences not observed when

SES controlled More prevalent in boys than girls; boys age 14-

17 have steeper increase in delinquent behavior than girls

Girls may manifest in different ways (e.g., relational aggression)Note: These statements are summarized from data presented across many studies.

Prevention & Treatment

Universal Entire population prior to onset; $

Selected At-risk population; $$

Indicated/Intensive High risk individuals showing early warning signs; $$$

Treatment/recurrence prevention Individuals who have already demonstrated problem to

reduce symptoms/recurrence; $$$$

Effective Prevention Strategies

Should be based on theory about developmental course of a condition

Analyze problemDevelop intervention to enhance protective

factors or minimize risk factorsTest, evaluate, & refine

Dumka et al., 1995

Why DBD are a good candidate for prevention?

We have a lot of information about developmental trajectories, risk, & protective factors

Largely influenced by environmental factors

Many, expensive, negative life-course outcomes associated with DBD

 

 

Degree of Unresponsiveness to InterventionLOW HIGH

HIGH

Inte

nsi

ty o

f T

reat

men

t

Level I

Universal Interventions

Level II

Selected Interventions

Level III

Intensive Interventions

Level IV

Special Education IEP Determination

Prevention of DBD through RTI Logic

Targeted/Intensive

(High-risk students)Individual Interventions

(3-5%)

Selected(At-risk Students)

Classroom & Small Group Strategies

(10-20% of students)

Universal(All Students)

Schoolwide, Culturally Relevant Systems of Support (75-85% of students)

Adapted from:

Sprague & Walker, 2004

Multiple Tiers of Behavior Support

Targeted/Intensive

(High-risk students)Individual Interventions

(3-5%)

Selected(At-risk Students)

Classroom & Small Group Strategies

(10-20% of students)

Universal(All Students)

School/classwide, Culturally Relevant Systems of Support (75-85% of students)

Tier 3 Menu:•Assessment-based Behavior Intervention Plan•Replacement Behavior Training

Tier 2 Menu:•Behavioral Contracting•Self Monitoring•School-Home Note•Mentor-Based Program•Differential Reinforcement•Positive Peer Reporting

Tier I Menu:•Schoolwide PBS•SEL Curriculum•Good Behavior Game•Proactive Classroom Management

IN AN IDEAL WORLD:Menu of a continuum of evidence-based supports

Tier 1 for All: Recommended Complementary Services

Schoolwide Positive Behavior Support Teach, model, and reinforce behavioral expectations in all settings

Social Emotional Learning Curriculum Teach self-regulatory behaviors and expose students to big picture

concepts

Peer Mediation Program Teach students to reduce interpersonal conflict through mediation

strategies

Proactive Classroom Management Seating, rules, instructional activities, transitions, proactive strategy

Good Behavior Game Classroom-based behavior management system

Good Behavior Game as “Behavioral Vaccine”

Provides an inoculation against the development of physical, mental or behavior disorders e.g., antiseptic hand washing to reduce childbed

fever

High need for low-cost, widespread strategy as simple as antiseptic hand washing

Little time and effort = high likelihood of use

Embry, 2002

Good Behavior Game

Short term benefits: Improved discipline practices by teacher, decreased discipline problems, more behavioral success

Longer term benefits: Decreased smoking, substance abuse/dependence, reduced risk of development of mental health problems & later arrest

Practical considerations: Need for adoption by school personnel; monitoring & mentoring to insure effective delivery & positive outcomes; cost per child/year ≈ $200 Estimated cost/year to deliver to all 1st & 2nd graders in WY:

$1,000,000 Anticipated savings due to reduced special education

placements (5%), legal problems (2%), substance use (4%): $15-20,000,000

Tier 2 for Some: Evidence-Based Interventions

Behavioral contracting Self-monitoring Systematic school-home note system Mentor-based support (e.g., Check & Connect; BEP) Differential reinforcement procedures Positive peer reporting Group contingencies Social skills training Multicomponent prevention program: Early Risers

Early Risers

Description: Program implemented in multiple settings Child Skills: Weekly group to develop social skills & reading

enrichment Child Monitoring & Mentoring: Systematic monitoring of child’s

academic/school functioning, goal setting/attainment strategies, reading enrichment, teacher consultation, & facilitating involvement of parents around school issues

Family Skills: Parent-focused education & skills training to enhance parent’s knowledge of child development and effective parenting strategies with special parent-child “bonding” activities

Family Support: Tailored monitoring of family functioning, goal setting/attainment strategies, assisting families in accessing community services, & intensive parent skills training

Early Risers

Short-term benefits: Child improvements on academic and social/behavioral

measures (greatest for most aggressive youth) Parent improvements in disciplinary practices

Longer-term benefits: Fewer symptoms of ODD for ER participants

Practical considerations: Requires extensive training, technical assistance, oversight,

and resources Parent participation & level of treatment fidelity must be

sufficient to achieve positive outcomes. Cost per child/year ≈ $1750 (w/out cost of training & technical

assistance included)

August et al., 2002; Bernat et al., 2007; Bloomquist et al., 2008

Tier 3 for a Few: Functional Behavior Assessment (FBA) -Based Supports

Examination of progress monitoring dataFBA-based support

Conduct FBA to identify variables maintaining problem behavior

Alter environmental contingencies surrounding problem behavior

Weekly Replacement Behavior Training

Off the Pyramid, Tier 3 and Beyond: Specialized Supports for Persistent Non-responders

Special Education evaluationWraparound services pursuedIncrease intensity of services

Treatments for DBD

Parent and family skills trainingMultisystemic therapyResidential TreatmentJail

Parent & Family Skills Training

Description: Parent training about effective commands,

contingent reinforcement, differential attention, & time out; persistent & consistent implementation improve outcomes

Use modeling, role play, practice, & feedback in session

Specific CBT for youth targeting maladaptive social cognitive processes, improving anger control, social skills, & problem solving

Parent & Family Skills Training

Short-term benefits: Reduce coercive interactions between parent & child Consistent & effective responses to child’s behaviors

Longer-term benefits: Reduced aggression/conduct problems Lower parent stress & increased parental sense of self-efficacy

Practical considerations: Need to establish good relationship with family & provide

structure when teaching skills Harder to engage families with higher number of problems May need to begin with motivational interviewing > $1500 for 10 sessions of therapy

Bloomquist & Schnell, 2002; Offord & Bennett, 1994

Parent & Family Skills Training Topics

Child Behavioral Development Teaching a child to obey Teaching a child to follow rules Teaching a child to avoid dishonest behavior

Child Social Development Teaching a child social behavior skills Teaching a child social problem solving skills Teaching a child to cope with bullies Promoting positive peer affiliations

Parent & Family Skills Training Topics

Child Emotional Development Teaching a child to understand & express feelings Teaching a child to think helpful thoughts Teaching a child to deal with stress Promoting a child’s self-esteem

Child Academic Development Helping a child appreciate and enjoy reading Teaching a child self-directed academic behavior skills Being involved in your child’s schooling

Parent & Family Skills Training Topics

Parent Well-Being Improving parent stress management

techniques Staying calm with a stressful child Changing unhelpful parent thoughts

Family Relationships Improving the parent-child bond Improving family interactions Developing family routings & rituals

Bloomquist, 2006, 2010

References

August, G. J., Hektner, J. M., Egan, E. A., Realmuto, G. M., & Bloomquist, M. L. (2002). The early risers longitudinal prevention trial: Examination of 3-year outcomes in aggressive children with intent-to-treat and as-intended analyses. Psychology of Addictive Behaviors, 16, 27-39.

Baker, L.A., Raine, A., Liu, J., & Jacobson, K.C. (2008). Differential genetic and environmental influences on reactive and proactive aggression in children. Journal of Abnormal Child Psychology, 36, 1265-1278.

Bernat, D., August, G.J., Hektner, J.M., & Bloomquist, M.L. (2007). The Early Risers preventive intervention: Six year outcomes and mediational processes. Journal of Abnormal Child Psychology, 35(4), 605-617.

Bloomquist, M.L. (2006). Skills training for children with behavior problems: A parent and practitioner guidebook (Rev. ed.). New York : Guilford Press.

Bloomquist, M.L., August, G. J., Horowitz, J., Lee, S.S., & Jensen, C. (2008). Moving from science to practice: Transposing and sustaining the “Early Risers” conduct problems prevention program in a community service system. The Journal of Primary Prevention.

Bloomquist, M.L., & Schnell, S.V. (2002). Helping Children with Aggression and Conduct Problems: Best Practices for Intervention. New York: Guilford Press.

Campbell, S.B., Spieker, S., Burchinal, M., Poe, M.D., & the NICHD Early Child Care Research Network (2006). Trajectories of aggression from toddlerhood to age 9 predict academic and social functioning through age 12. Journal of Child Psychology and Psychiatry, 47, 791-800.

Crick, N.R., & Dodge, K.A. (1994). A review and reformulation of social information-processing mechanisms in children’s social adjustment. Psychological Bulletin, 115, 74-101.

Crick, N.R., & Zahn-Waxler, C. (2003). The development of psychopathology in females and males: Current progress and future challenges. Development and Psychopathology, 15, 719-742.

References

Dumka, L.E., Roosa, M.W., Michaels, M.L., & Suh, K.W. (1995). Using research and theory to develop prevention programs for high-risk families. Family Relations, 44, 78-86.

Embry, D.D. (2002). The good behavior game: A best practice candidate as a universal behavioral vaccine. Clinical Child and Family Psychology Review, 5, 273-297.

Farrington, D.P. (1991). Childhood aggression and adult violence: Early precursors and later life outcomes. In D.J. Pepler & K.H. Rubin (Eds.), Development and Treatment of Childhood Aggression (pp.5-30). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

Jaffee, S.R., Belsky, J., Harrington, H., Caspi, A., Moffitt, T.E. (2006). When parents have a history of conduct disorder: How is the caregiving environment affected? Journal of Abnormal Psychology, 115, 309-319.

Kellam, S.G., Brown, C.H., Poduska, J.M., Ialongo, N.S., Wang, W., Toyinbo, P., Petras, et al. (2008). Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes. Drug and Alcohol Dependence, 95S, S5-S28.

Lahey, B.B., Van Hulle, C.A., Waldman, I.D., Rodgers, J.L, D’Onofrio, B.M., Pedlow, S., et al. (2006). Testing descriptive hypotheses regarding sex differences in the development of conduct problems and delinquency. Journal of Abnormal Child Psychology, 34, 737-755.

Lansford, J.E., Malone, P.S., Dodge, K.A., Crozier, J.C., Pettit, G.S., & Bates, J.E. (2006). A 12-year prospective study of patterns of social information processing problems and externalizing behaviors. Journal of Abnormal Child Psychology, 34, 715-724.

Moffitt, T.E. (1993). Adolescent-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100, 674-701.

References

Moffitt, T.E., Arseneault, L., Jaffee, S.R., Kim-Cohen, J., Koenen, K.C., Odgers, C.L., et al. (2008). Research review: DSM-V conduct disorder: Research needs for an evidence base. The Journal of Child Psychology and Psychiatry, 49, 3-33.

Offord, D.R., & Bennett, K.J. (1994). Conduct disorder: Long-term outcomes and intervention effectiveness. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 1069-1078.

Offord, D.R., Boyle, M.C., & Racine, Y.A. (1991). The epidemiology of antisocial behavior in childhood and adolescence. In D.J. Pepler & K.H. Rubin (Eds.), Development and Treatment of Childhood Aggression (pp.31-54). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

Ollendick, T.H., Jarrett, M.A., Grills-Taquechel, A.E., Hovey, L.D., & Wolff, J.C. (2008). Comorbidity as a predictor and moderator of treatment outcome in youth with anxiety, affective, attention deficit/hyperactivity, and oppositional/conduct disorders. Clinical Psychology Review, 28, 1447-1471.

Patterson, G.R., DeBaryshe, B.D., & Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44, 329-335.

Schaeffer, C.M., Petras, H., Ialongo, N., Poduska, J., & Kellam, S. (2003). Modeling growth in boys’ aggressive behavior across elementary school: Links to later criminal involvement, conduct disorder, and antisocial personality disorder. Developmental Psychology, 39, 1020-1035.

Sprague, J., Cook, C.R., Browning-Wright, D., & Sadler, C. (2008). Response to intervention for behavior: Integrating academic and behavior supports. Palm Beach: LRP Publications.

Temcheff, C.E., Serbin, L.A., Martin-Storey, A., Stack, D.M., Hodgins, S., Ledingham, J. et al. (2008). Continuity and pathways from aggression in childhood to family violence in adulthood: A 30-year longitudinal study. Journal of Family Violence, 23, 231-242.

Schoolwide PBS Programs

Building Effective Schools Together (BEST; Sprague, 2004)

Effective Behavior and Instructional Supports (EBIS; Sugai et al., 2006)

Florida Positive Behavior Support Project (Kincaid - http://flpbs.fmhi.usf.edu/)

OSEP Technical Assistance Center - Positive Behavior Interventions and Supports (http://pbis.org/)

Resources on Schoolwide SEL Programs

Collaborative for Academic, Social, and Emotional Learning (CASEL) at the University of Illinois at Chicago

www.casel.org/about/index.php

Behavior Education Program Manuals Crone, Horner, & Hawken (2004). Responding to

Problem Behavior in Schools: The Behavior Education Program. New York, NY: Guilford Press

Hawken, Pettersson, Mootz, & Anderson (2005). The Behavior Education Program: A Check-In, Check-Out Intervention for Students at Risk. New York, NY: Guilford Press.