disruptive behavior disorders gregg selke, ph.d. psy 4930 september 19, 2006

Disruptive Behavior Disorders

Gregg Selke, Ph.D.

PSY 4930

September 19, 2006

Disruptive Behavior Disorders

DSM-IVDSM-IV1.1. Oppositional Defiant DisorderOppositional Defiant Disorder

2.2. Conduct DisorderConduct Disorder

3.3. Disruptive Behavior Disorder Not Otherwise Disruptive Behavior Disorder Not Otherwise SpecifiedSpecified

Juvenile Delinquency Acting-out Externalizing Antisocial Noncompliant

Disruptive Behavior Disorders Children who display a broad range of behaviors that

bring them into conflict with their environment Heterogeneous

Including behaviors described as coercivecoercive or oppositionaloppositional To more severe, that represent a greater threatgreater threat to those around

them and/or may lead to juvenile justice systemjuvenile justice system

Noncompliance Tantrums Disruptions Verbal Abuse Running Away

Aggression Property Destruction Stealing Lying Fire-setting

Prevalence:Diagnosable Behavior Problems

One of the most common referrals (1/3-2/3 of all child referrals)

Epidemiological studies of children displaying more general conduct disordered features have suggested that somewhere between 3.2 and 6.9% of the general child/adolescent population may be affected

8-12% of children meet specific DSM criteria for diagnosis of ODD and CD

Prevalence:General Disruptive Behavior

60% of teenagers engage in more than one type of delinquent behavior

50% of preschoolers display disobedience 26% of preschoolers destroy property

Referrals for males outnumber females anywhere from 4:1 to 6:1

Oppositional Defiant Disorder (ODD)

http://www.fox.com/nanny911/ Janice and Kerry Delaney

Prevalence rates 2.1 – 15.4 % in epidemiological studies (Loeber et al., 2000)

DSM-IV CriteriaOppositional Defiant Disorder

A recurrent “pattern of negativistic, hostile, and defiant behavior”

Lasting > 6 months During which > 4 of the following are present: a) often loses temper b) often argues with adults c) often actively defies or refuses to comply with adults' requests

or rules d) often deliberately annoys people e) often blames others for his or her mistakes or misbehavior f) is often touchy or easily annoyed by others g) is often angry and resentful h) is often spiteful or vindictive

DSM-IV CriteriaOppositional Defiant Disorder

Criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

The symptoms cause clinically important distress or impair work, school or social functioning

The symptoms do not occur in the course of a Mood or Psychotic Disorder

The symptoms do not fulfill criteria for Conduct Disorder If older than age 18, the patient does not meet criteria

for Antisocial Personality Disorder

Oppositional Defiant Disorder

Characteristics should occur more often than expected for age and developmental level

Developmental considerations Toddlers Preschool Middle childhood Adolescence

ODD – Development

Average Age of Emergence (NYU Child Study Center)

Age 3 – Child acts stubborn Age 5 – Defies adults, temper tantrums Age 6 – Irritable, argumentative, blames

others Age 7 – Annoys others, spiteful & angry

Case Examples (NYU Study Center)

Brandon's teachers in the daycare center report that he is the "terrorist of the 4- year-olds." He punches or bites children and pushes them off the swings in the playground without provocation. He swings the class pet rabbit by the tail in spite of being told how it hurts the animal. His parents report that he has been difficult to manage since he was an infant. What is different from ODD?


Eleven-year-old Paul, known as The Prankster in his family, was suspended from school after leaving half-eaten candy bars in all the girls' lockers. He had previously been suspended for leaving poison pills for the frogs in the biology class lab. What is different from ODD?


Robin, l6: "When I was 13, that summer was a blast. One time we picked up some older guys in a bar and tried a new kind of speed. We got really wild and we smashed in some car windows and somebody called the police. My mother freaked out and tried to punish me by locking me in my room, but I would just skip out on her through the window.“ What is different from ODD?

Conduct Disorder (CD)

6-16% of males & 2-9% of females under the age of 18

1.3 – 4 million children & adolescents –U.S.

http://www.fox.com/nanny911/ The Arilotta Family Possible precursors to CD??

DSM-IV CriteriaConduct Disorder

A. "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated”

4 Symptom Domains1. aggressive behaviors

2. behaviors that result in property loss or damage

3. deceitfulness or theft

4. other serious rule violations (e.g., running away from home, truancy)


As manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

1. Aggression to people and animals a) often bullies, threatens, or intimidates othersb) often initiates physical fights c) has used a weapon that can cause serious physical harm to

others (e.g., a bat, brick, broken bottle, knife, gun)d) has been physically cruel to people e) has been physically cruel to animals f) has stolen while confronting a victim (e.g., mugging, purse

snatching, extortion, armed robbery) g) has forced someone into sexual activity


2. Destruction of property h) has deliberately engaged in fire setting with the intention of causing serious damage

i) has deliberately destroyed others' property (other than by fire setting)

3. Deceitfulness or theft j) has broken into someone else's house, building, or

car k) often lies to obtain goods or favors or to avoid

obligations (i.e., "cons" others) l) has stolen items of nontrivial value without

confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)


4. Serious rule violationsm) often stays out at night despite parental prohibitions, beginning before age 13 years

n) 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)

o) is often truant from school, beginning before age 13 years

B. These symptoms cause clinically important job, school or social impairment

C. If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder


Childhood-Onset Type: 1+ problem with conduct before age 10

Adolescent-Onset Type: no problems before age 10 Severity:

Mild (both are required): 3-4 endorsements and behavior causes minor harm

Moderate: number and effect of conduct problems is between Mild and Severe

Severe: 10 endorsements and/or behavior causes considerable harm

Emotional Deficits in CD

They may……. Lack empathy & feelings of guilt Little concern for feelings & well-being of

others Misperceive the intentions of others in

ambiguous situations as more hostile and threatening

Fail to inhibit antisocial behavior regardless of knowledge of potential punishment

CD – Etiology & Correlates(may also be risk factors for ODD)

Child Risk Factors Inappropriate early aggression Hyperactivity Impulsivity – sensation seeking Difficult temperament Neuropsychological deficits – learning deficits Male gender Association with delinquent peer group Poor interpersonal problem-solving skills

CD – Etiology & Correlates

Family Risk Factors Inconsistent parenting Authoritarian or harsh parenting Parent conflict – divorce Use of physical aggression Little involvement in child’s activities

http://www.fox.com/nanny911/ Heidi & Craig Morris Family Longairc-Green Family Family dynamics: Interaction of cause and effect

Family Risk Factors Poverty

↑ parent stress Single parent households ↓ financial and community resources ↑ community dangers, e.g., gangs,

drugs Negative peer influences

Family Risk Factors History of parental

Alcohol dependence Mental illness ADHD Conduct Disorder Antisocial Personality Disorder

CD – Etiology & Correlates

CD – Correlates

Neurologic Correlates: Limited evidence for for ↓ right temporal lobe frontal lobe abnormalities

Physiologic Correlates: Underaroused ↓ resting heart rate ↓ heart rate reactivity ↓ skin conductance reactivity ↓ startle response to victimization pictures

CD – Etiology

Multiple interacting etiologies in the development of CD

No one factor has been determined to be “the cause”

Rather than finding a single etiological factor, it seems more likely that there are numerous possible combinations of contributing variables that can result in the clinical manifestations of CD and ODD

CD – Development & Course Typically, mild delinquent behaviors emerge 1st followed

by more severe behaviors gradually surfacing later Average Age of Emergence of CD symptoms

(NYU Child Study Center)

Age 8 – Lies, fights Age 9 – Bullies, fire setting, weapon use Age 10 – Vandalizes Age 11 – Physical cruelty Age 12 – Steals, runs away from home, truant,

breaks and enters Age 13 – Forced sexual activity

CD – Course, Outcomes, & Future Risks

Early onset of Drinking Smoking Sexual behavior illegal drug use

Increased risk for future Criminal behavior Incarceration Alcohol abuse Marital discord Occupation impairment Social impairment Up to 40% of children with CD will meet criteria for Up to 40% of children with CD will meet criteria for

Antisocial Personality Disorder in AdulthoodAntisocial Personality Disorder in Adulthood

Antisocial Personality Disorder

“pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood”

Must have history of some CD symptoms before age 15

Antisocial Personality Disorder

Three or more of the following:1. Failure to conform to social norms (behaviors

warranting arrest)2. Deceitfulness (lying, conning, deceit)3. Impulsivity4. Irritability and aggressiveness5. Reckless disregard for safety of others or self6. Consistent irresponsibility7. Lack of remorse (indifference or rationalization)

ODD – CD Relationship Persistent ODD symptoms often precede and

predict early onset of CD (Loeber et al., 2000) ODD and CD generally emerge at different ages Achenbach and Edelbrock (1981) study of 2,600

children (4- 16 yrs) Data collected from mothers on symptoms at different ages Youngest children tended to display oppositional behaviors At later ages, behaviors such as stealing and fire setting

increased Other serious conduct disordered behaviors such as truancy,

vandalism, and involvement in substance abuse developed later

Disruptive Behavior: A Continuum

2/3 of children with ODD do not go on to develop CD

Typical Child Behavior Problems

OppositionalDefiant Disorder

Conduct Disorder

Antisocial PersonalityDisorder

Almost half of children with CD also meet criteria for a diagnosis of ODD

ODD – CD Relationship

Some scientists have questioned whether CD and ODD are truly distinct disorders or whether a new classification system is needed ODD with aggression versus ODD without aggression ODD with aggressive CD symptoms versus

Nonaggressive CD behaviors

Empirical Dimensions of Disruptive Behavior Disorders

Frick et al. 1993: meta-analysis of 60 factor analytic studies 228,401 children/adolescents with conduct

problems Conclusions: Most Conduct Problems could be

classified by 2 orthogonal dimensions

1.1. ““Covert – Overt”Covert – Overt”

2.2. ““Destructive –Nondestructive”Destructive –Nondestructive”

Disruptive Behavior Classification

Frick, et al., (1993)

Aggression

Oppositionality

Stealing

Substance Abuse


vandalism fighting

truancy arguing

Classification – Age Progression

CD - Property/Deceit

Stealing, fire setting, vandalism, lying (3rd)

CD – Aggression Cruelty, assault, fighting, bullying, spite, animal cruelty (2nd)

CD – status offenses

Truancy, substance abuse, running away, curfew violations (4th)

ODD (1st)

Tantrums, arguing, noncompliance,

Defiance, annoying


4 categories appear to correspond to categories of antisocial behavior often used by the Juvenile Justice system

Consistent with other systems for classifying conduct disordered and delinquent behavior (e.g., oppositional behavior, aggressive behavior, property violations, status offenses)

Psychopathy- Another way to classify

Personality Type Related but unique from APD (behaviorally- based)

90% adult psychopaths have APD (Lynam, 1998) Only 25% of APD are psychopaths

Grandiose, Impulsive, Manipulative, Lack Empathy, Callous, Selfish, Shallow, Parasitic, Irresponsible, Glib, Dishonest, Boredom Susceptible, Criminal Acts

Adult Psychopath Criminals ↑ violent, ↑ crimes, ↑ recidivism than non-psychopathic criminals

““Future Psychopathic Adult” Future Psychopathic Adult” (Lynam, 1996, 1997, 1998)(Lynam, 1996, 1997, 1998)

Children with CD + ADHD may be at greatest risk

Common Comorbid Disorders with ODD & CD

Between 34.7 and 48 % of children and adolescents with ODD/CD also show evidence of ADHD

~ 25% of children with ADHD diagnosed with CD Compared to CD and ADHD alone

ADHD/CD more serious and earlier onset of antisocial behaviors, traffic offenses, failing a grade, school suspension & expulsion

ADHD/CD ↑ Antisocial Personality Disorder (APD) in adulthood

Common Comorbid Disorders with ODD & CD

Comorbidity estimates ranging from 12-18% have been found for depressive disorders

As many as 19% of children/adolescents with ODD/CD qualify for a diagnosis of anxiety disorder

Assessment of Disruptive Behaviors

Use of parent-report questionnaires: Eyberg Child Behavior Inventory (ECBI): parents

endorse the frequency and intensity of child behavior problems

Behavior Assessment System for Children (BASC): parents rate frequency of child behavior problems and other issues

Assessment of Disruptive Behavior Disorders

Interview: should include both parents and the child Important to ask about the child’s misbehavior

and strengths Parenting styles and strategies Semi-Structured Diagnostic Interviews

Children’s Interview for Psychiatric Syndromes-Parent Version (P-ChIPS); Structured Clinical Interview for DSM-IV-TR (KID-SCID)

Observation of parent-child interaction (DPICS) Child-directed and parent-directed interaction + clean-up Record parents commands, questions, criticisms, and

positive play skills

Treatment of Disruptive Behavior Disorders

Most popular approach is behavioral in nature The work of Patterson and colleagues is most

representative of this basic approach parents pinpoint problem behaviors (e.g.

aggressive responses, noncompliant responses)

Monitor more appropriate responses as well utilize various child behavior management

techniques to decrease problem behavior and increase desirable behavior


Other behavioral procedures: reinforcement of appropriate behaviors extinction (withdrawal of reinforcement) time out procedures for dealing with undesirable

behaviors School personnel may be involved in order to deal

with the child's behavior in that setting as well This multifaceted behavioral approach has been

shown to be highly effective in treating a range of conduct problems

See: http://www.effectivechildtherapy.com


Other behavioral approaches have been used to deal with specific behaviors (or classes of behaviors) displayed by behavior disordered children

One example involves Videotaped Parent Training developed by Carolyn Webster-Stratton at Washington and the work of Forehand & McMahon with non-compliant children at Georgia

Of special note is the work of Eyberg and Boggs with Parent-Child Interaction Therapy, that is designed to modify oppositional/defiant behavior and the aggressiveness sometimes seen in ODD children, as well as improve parent-child attachment. Guest lecture in future

Treatment of Oppositional Defiant and Conduct Disorders

Kazdin (1993) has also developed another more cognitively oriented approach, Problem-Solving Skills Training

This approach focuses on the modification of cognitions such as attributions of hostile intent, which may precipitate aggressive behavior, and maladaptive self-statements which may mediate other expressions of antisocial behavior

An additional focus is on helping the child learn and use effective problem solving skills in dealing with problematic interpersonal situations he/she may encounter

Treatment of Oppositional Defiant and Conduct Disorders

While such cognitive-behavioral procedures have been shown to be somewhat effective in dealing with older conduct disordered children, questions still remain regarding the clinical significance of observed treatment effects and the precise nature of those variables that contribute to effectiveness

Juvenile Delinquency

Some children not only show oppositional defiant behavior and features of conduct disorder – they also come into conflict with the juvenile justice system.

The term “delinquency” is applicable to such children and adolescents

Juvenile Delinquency Delinquency is a legal term rather than a

psychological construct. It refers to a juvenile (usually under 18 years) who

is brought to the attention of the juvenile justice system for committing a criminal act or displaying a variety of other behaviors not allowed under the law

These "other behaviors" are usually referred to as status offenses: truancy, curfew violations, running away, the use of

alcohol These are only violations of the law due to the

child's age and his/her status as a minor

Juvenile Delinquency Considered within the context of DSM-IV, the

concept of delinquency overlaps with conduct disorders

While many delinquents do meet criteria for a diagnosis of conduct disorder, many youths who come into contact with the juvenile justice system do not show the pattern of seriously antisocial behavior associated with the diagnosis of conduct disorder

Likewise, many conduct disordered youth are never considered delinquent as their illegal behaviors escape detection


Given that juvenile delinquency is essentially a “legal” category used to designate those who have committed any of numerous offenses, delinquents represent a heterogeneous group

However, research studies have often focused on the causes, correlates, and treatment of delinquency without taking this variability into account.

This has often led to unreplicated findings and inconclusive results.


Due to the variability within this group, some researchers have considered that various dimensions of delinquency may exist

Quay (1964; 1987b): developed the most widely cited, empirically based, classification scheme for delineating dimensions of delinquent behavior


In this early research, factor analyses of ratings of behavioral traits obtained from the case histories of institutionalized male delinquents yielded four independent groupings:

1. socialized-subcultural delinquency

2. unsocialized-psychopathic delinquency

3. disturbed-neurotic delinquency

4. inadequate-immature delinquency


Socialized-subcultural - strong allegiance to selected peers, being accepted by delinquent subgroup, having bad companions, staying out late at night, and having low ratings on shyness and seclusiveness


Unsocialized-psychopathic –solitary rather than group-oriented; rated high on such traits as inability to profit from praise or punishment, defiance of authority, quarrelsomeness, irritability, verbal aggression, and assaultiveness


Disturbed-neurotic - unhappy, shy, timid and withdrawn, and prone to anxiety, worry, and guilt over their behavior

Inadequate-immature - not usually accepted by delinquent peers, passive and preoccupied, picked on by others, and easily frustrated, poorly developed behavioral repertoire

Treatment ofJuvenile Delinquency

Treatment of children has frequently been conducted in institutions or within community based programs

Research suggests that treatment within standard institutional programs is often unsuccessful, with as many as 70-80% being rearrested within a year or so after release

However, data suggests that the inclusion of well‑conceived behaviorally‑based programs can result in positive outcomes


Illustrative of such an approach is the Cascadia Project, conducted in Tacoma, Washington by Irwin Sarason and his colleagues at the University of Washington

In this program residents were provided with: modeling and role‑play/discussion experiences taught a variety of adaptive skills to decrease the

likelihood of future delinquent behaviors (e.g., learning how to resist temptation from peers, to delay gratification, to apply for a job, how to behave appropriately when stopped by police, etc.)


Gains were seen at post-treatment 5-year follow up data evidenced recidivism rates

for treated youths was less than half than that of those who did not receive treatment

Conclusion: skills‑based treatments that promote a pro-social lifestyle may be of value in decreasing the likelihood of future delinquency

Booster-sessions after release may maximize the durability of skills


Teaching Family Model (Achievement Place) from University of Kansas

Community-based program Residents live in a home‑like setting with 7-

8 other residents and 2 house parents trained in behavior management skills


Residents attend school and have a variety of work responsibilities

An extensive token economy program serves as the basic focus of treatment rewards for appropriate behaviors (e.g.,

completing homework assignments, increased academic performance, improving conversational skills with adults, modifying aggressive statements, improving problem solving skills with parents)

fined for showing inappropriate behaviors


Reinforcement is with points which can be cashed in for a wide variety of back‑up reinforcers (e.g., allowance, snacks, TV viewing)

Important treatment component: generalizing to the outside environment so that gains will maintain after release from the program

Some support for the general effectiveness of this program, although relapse rates are typically high


Another relatively new non-institutional approach to treatment is Multisystemic Therapy (MST), which is designed to address the role of multiple, interconnected systems in which the adolescent is embedded

This approach recognizes the effects of family, school, work, peer, community and cultural institutions on the adolescents functioning and in the initiation and maintenance of delinquent behavior

Intervention occurs on multiple levels


The length of MST averages between 13 and 17 sessions

Therapists employ empirically-based treatment techniques, including those used in structural family therapy and cognitive-behavioral therapy, to tailor interventions to the needs and strengths of each family member

9 treatment principles (e.g., “Focus on systemic strengths” “Interventions should be developmentally appropriate”)


MST has been shown to result in long-term reduction in delinquent activity

In a longitudinal investigation, MST improved family cohesion, reduced the number of incarcerations at a 59-week follow-up, and significantly reduced peer-related aggression

Re-arrest rates were also reduced at a 2-year follow-up


In another study, MST was found to reduce violent and criminal activity at a 4-year follow-up

Documented efficacy with ethnic minority populations

Cost-effectiveness in comparison to incarceration.

One of the most promising, empirically-supported treatment approaches for this population

Diagnostic criteria for Adjustment Disorders

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant as evidenced by either of the following: 1. marked distress that is in excess of what would be expected from exposure to the stressor 2. significant impairment in social or occupational (academic) functioning

C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

D. The symptoms do not represent Bereavement. E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than

an additional 6 months.Specify if: Acute: < than 6 months versus Chronic: > 6 months or longer Subtypes

309.0 With Depressed Mood 309.24 With Anxiety 309.28 With Mixed Anxiety and Depressed Mood 309.3 With Disturbance of Conduct309.3 With Disturbance of Conduct 309.4 With Mixed Disturbance of Emotions and Conduct309.4 With Mixed Disturbance of Emotions and Conduct 309.9 Unspecified

Intermittent Explosive Disorder (312.34)

Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.

The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors (little or no provocation).

The aggressive episodes are not better accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease).

V71.02 Child or Adolescent Antisocial Behavior

This category can be used when the focus of clinical attention is antisocial behavior in a child or adolescent that is not due to a mental disorder (e.g., Conduct Disorder or an Impulse-Control Disorder). Examples include isolated antisocial acts of children or adolescents (not a pattern of antisocial behavior).

disruptive behavior disorders gregg selke, ph.d. psy 4930 september 19, 2006

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