Disruptive Behavior Disruptive Behavior DisordersDisordersHealth Education

Mr. Dan KingEscalon High School

Attention-Deficit Attention-Deficit Hyperactivity DisorderHyperactivity Disorder

History of ADHDHistory of ADHDMid-1800s: Minimal Brain DamageMid 1900s: Minimal Brain Dysfunction1960s: Hyperkinesia1980: Attention-Deficit Disorder

With or Without Hyperactivity

1987: Attention Deficit Hyperactivity Disorder

1994-present: ADHD Primarily Inattentive Primarily Hyperactive Combined Type

ADHD StatisticsADHD Statistics

3-5% of all U.S. school-age children are estimated to have this disorder.

5-10% of the entire U.S. population

Males are 3 to 6 times more likely to have ADHD than are females.

At least 50% of ADHD sufferers have another diagnosable mental disorder.

Symptoms of ADHD: DSM-IVSymptoms of ADHD: DSM-IV

Inattentiveness:

Has a minimum of 6 symptoms regularly for the past six months.

Symptoms are present at abnormal levels for stage of development

Lacks attention to detail; makes careless mistakes

has difficulty sustaining attention

doesn’t seem to listen fails to follow

through/fails to finish projects

has difficulty organizing tasks

avoids tasks requiring mental effort

often loses items necessary for completing a task

easily distracted is forgetful in daily

activities

Symptoms of ADHD: DSM-Symptoms of ADHD: DSM-IVIV

Hyperactivity/ Impulsivity:

Fidgets or squirms excessively

leaves seat when inappropriate

runs about/climbs extensively when inappropriate

has difficulty playing quietly

often “on the go” or “driven by a motor”

talks excessively blurts out answers

before question is finished

cannot await turn interrupts or intrudes

on others

Has a minimum of 6 symptoms regularly for the past six months.

Symptoms are present at abnormal levels for stage of development

ADHD and the BrainADHD and the BrainDiminished arousal

of the Nervous System

Decreased blood flow to prefrontal cortex and pathways connecting to limbic system (caudate nucleus and striatum)

PET scan shows decreased glucose metabolism throughout brain

Comparison of normal brain (left) and brain of ADHD patient.

What causes ADHD?What causes ADHD?Underlying cause of these differences is

still unknown; there is much conflicting data between studies

Strong evidence of genetic componentPredominant theory: Catecholamine

neurotransmitter dysfunction or imbalance decreased dopamine and/or

norepinephrine uptake in brain theory supported by positive response

to stimulant treatment Recent study indicates possible lack of

serotonin as a factor in mice

OutcomeOutcomeADHD can persist into adulthood, but

usually symptoms gradually diminishWhen it persists into adulthood, it usually

requires ongoing treatment and counselingmost will develop another disorder

(especially learning disability, ODD, depression, and/or conduct disorder)

Without treatment:antisocial and deviant behavior increased rates of divorce, moving

violations, incarceration, and institutionalization

Post-traumatic Stress Disorder

Children and adolescents can also have PTSD as a result of experiencing:– Physical violence, including witnessing

violence – Major loss (death, divorce, removal from

home)

– Abuse– More

Post-traumatic Stress Post-traumatic Stress DisorderDisorder

Definition: A psychological reaction that occurs after experiencing a highly stressing event such as:• Physical violence • Wartime combat • Natural disaster

Post-traumatic Stress Post-traumatic Stress DisorderDisorder

Symptoms• Depression• Anxiety • Flashbacks• Repeating nightmares

Posttraumatic Stress Posttraumatic Stress DisorderDisorder

Symptoms• Avoidance of reminders of event• Emotionally numb, especially with

people once close

Identification and Identification and Characteristics ofCharacteristics of

Disruptive Behavior Disruptive Behavior DisordersDisorders

“DBDs are the most common mental health disorder among children with a rate of 4-9% of

all children from birth to 18 years old.”1 (Journal of the American Academy of Child &

Adolescent Psychiatry, Official Action, Jan 2007)

Learner ObjectivesLearner Objectives

Participants in this lecture will be able to:

• Identify symptoms and characteristics of disruptive behavior disorders (DBDs)

• Recognize the potential causes of DBDs

• Describe risk and protective factors for DBDs.

What is a Disruptive What is a Disruptive Behavior Disorder?Behavior Disorder?

The main category in the DSM-IV-TR that Disruptive Behavior Disorders fall into is:

Attention-Deficit Disorder and Disruptive Behavior Disorders

Disruptive Behavior disorders are split into three more specific diagnoses:

• Oppositional Defiant Disorder

• Conduct Disorder

• Disruptive Behavior Disorder (NOS)

Oppositional Defiant Disorder Oppositional Defiant Disorder (ODD)(ODD)

DSM-IV-TR DefinitionDSM-IV-TR Definition22

“A pattern of negativistic, hostile, disobedient and defiant behaviors. Children display four or more of these behaviors for more than 6 months

• Loses Temper Easily• Argues with Adults• Actively Defies Adults Requests or Rules• Deliberately Tries to Annoy Others• Blame others for their own misbehavior and

mistakes• Seems touchy or is annoyed easily • Angry and resentful• Spiteful or Vindictive”

Oppositional Defiant Oppositional Defiant DisorderDisorder

• Average age of onset is 6 years old, symptoms can be seen in children as early as 3 years old3

• Symptoms usually manifests by 8 years old, with most children diagnosed during preadolesence1

• Children with ODD have a significantly higher rate of having more that one psychiatric disorder4

• Most children, 67%, will ultimately exit from the diagnosis after a 3-year follow-up5

• Early onset of ODD is more likely to persist and lead to subsequent development of CD6

Conduct Disorder (CD)Conduct Disorder (CD) DSM-IV-TR Definition DSM-IV-TR Definition11

“Repetitive and persistent pattern of behaviors in which the basic rights of others or rules of society are violated. Three or more of the following behavior will have occurred within the last 12 months.

 

• Aggression Toward People and Animals

• Destruction of Property

• Deceitfulness or Theft

• Serious Violation of the Rules”

Conduct DisorderConduct DisorderChildhood-onset vs. Adolesent-onset7

Childhood-onset – - Average age is 9 years old- Males more likely to be affected- Prognosis is poor as the earlier the age

of CD syptom onset, the more severe the disorder is likely to be

Adolescent-onset – - Usually less severe- Tends to coincide with family or peer

problems. - Aggression may or may not be present. - Males = females for prevalence rates. - Adolescent-onset of CD has a much

better progonsis

Disruptive Behavior Disruptive Behavior Disorder Disorder

Not Otherwise SpecifiedNot Otherwise Specified (DBD NOS), DSM-IV (DBD NOS), DSM-IV

DefinitionDefinition11

This category of DBD was created for children who demonstrate similar behaviors as children with ODD or CD but do not display the same frequency /severity and only met one or two of the behavior criteria for this disorder.

Like ODD and CD, this disorder causes significant impairment in the child’s life.

How many children are How many children are diagnosed with DBDs?diagnosed with DBDs?

• A summary of 34 studies suggested the prevelance rate for children 4 – 18 years old is:8

ODD – range 3% to 22.5% with median of 3.2%CD – range 0% to 11.9% with a median of 2.0%

• Another study indicated that ODD has a wide range of prevelance from 1% -16% of children, depending on which criteria and assessment methods are used9

• Research presents evidence that the prevelence and the severity of this disorder are increasing10

Overlapping of disorders Overlapping of disorders It is rare for ODD/CD to occur outside the

context of other psychiatric disorders11

- Most common is ADHD 65% of children diagnosed with ADHD also had ODD 80% of children diagnosed with ODD also had ADHD

- Anxiety disorders 45% of children diagnosed with an anxiety disorder also had ODD

- Severe depression 70% of children diagnosed with severe depression also had ODD

- Bipolar 85% of children diagnosed with bipolar disorder also had ODD

- Language processing disorder (LPD)55% of children diagnosed with LPD also have ODD

What causes What causes Disruptive Behavior Disruptive Behavior

Disorders?Disorders?• It is thought that children with severe

behavior disorders may be more influenced by neurological and genetic factors12

• However mild to moderate DBDs are believed to appear in children who have an accumulation of a high number of risk factors and a low number of protective factors in all contexts of their lives7

• This imbalance of risk to protective factors may determines the presence and severity of a child’s DBD. 5 6 7

Risk FactorsRisk Factors

A risk factor is a characteristic within the individual or a circumstance of the individual that increases the probability of a Disruptive Behavior Disorder.

Biological Risk FactorsBiological Risk Factors• Difficult Temperament at birth – irritable, easily

frustrated, angry and hard to soothe13

• Aggression is highly influenced by genetic factors in boys and girls.12

• In severe cases of DBDs neurological factors may cause the brain to function differently compared to how an average child’s brain may function.12

• Children diagnosed with both ODD/CD and ADHD (ADHD being highly genetic) are likely to have greater symptom severity and increased risk of future disorders11

Individual Risk FactorsIndividual Risk Factors

• Underdeveloped emotional regulation skills

• Low tolerance of frustration• Little to no problem solving capabilities• Inability to adapt to new situations• Language development impairment11

Family Risk FactorsFamily Risk Factors• Young age of the mother at birth of

first child

• Insecure Parental Attachment

• Coercive parent – child interactionsParental behaviors include inconsistent/harsh discipline,

poor monitoring/ supervision, low levels of warmth/nurturance, high numbers of negative verbalizations towards the child.

• Depressed or “distressed” mother

• High levels of substance abuse and antisocial behaviors in parents7 14

Contextual Risk FactorsContextual Risk Factors• Living in urban, low-socioeconomic

settings.As the magnitude of poverty increases, so too does the severity of aggression and conduct problems7

• Living in a disadvantaged neighborhood Characterized by dilapidated housing, high crime rates, isolation, lack of economic resources and unsafe conditions.15

• Witness of violence or being the victim of violence or abuse7

• Stressful live events16

School Risk FactorsSchool Risk Factors• Zero-tolerance discipline which is highly punitive

and erratic, escalating with little or no attention to students’ good behaviors or efforts to achieve10 17

• Negative interactions with adults, typical school experience for these students is highly negative10

• Discipline including punishments that takes students away from the academic environment17

• Deficits in social skills lead to rejection by prosocial peers7

• Affiliation with “deviant” peers7 10

Non – FactorsNon – Factors

• No significant evidence has been found that demonstrates increased occurrence of DBDs in relation to race and ethnicity 7 18 19

• Although controversial, most researchers have concluded that there are no IQ differences between children with and without CD.7 19

Protective FactorsProtective Factors

Protective factors reduce the likelihood of children confronted with risk factors to develop maladaptive behaviors

associated with Disruptive Behavior

Disorders.

Resilience in ChildhoodResilience in Childhood

Resilience, a positive adjustment occurring in children at-risk, seems to result from a combination of internal and external resources that function as protective factors.7

Child Protective FactorsChild Protective Factors

• Easy Temperament• Good intellectual functioning• Self-confidence• Empathy• Talents3 7

Family Protective FactorsFamily Protective Factors• Good supportive relationship with

a parent• Close supervision by parents

when not in school• Positive parent-child relationships:

warmth, structure, high expectations

• Connection to extended supportive family networks 5 7 8

School Protective FactorsSchool Protective Factors• Children with ODD/CD who had a

positive teacher-child relationship showed a decrease in aggression.20

• Friendship with prosocial peers7

• Bonds to prosocial adults outside the family7 17

• Attending effective school3

InterventionsInterventions

Interventions will be more successful if they not only reduce the risk factors, but also promote the protective factors observed in resilient

children.7

WhatWhat is Bipolar Disorder ?is Bipolar Disorder ?

• It is a spectrum of affective episodes including:• Major depressive

episode• Manic episode• Mixed episode• Rapid cycling• Hypomanic

episode

• The DSM-IV categorizes it into:

• Bipolar I Disorder• Bipolar II Disorder• Cyclothymia• Bipolar N.O.S.

Bipolar I or II Disorder ?Bipolar I or II Disorder ?What is the difference?What is the difference?

• Bipolar I

• 1+ manic or mixed episodes

• May have other mood episodes

• Bipolar II

• 1 + major depressive episodes AND

• 1 + hypomanic episodes

• Never manic or mixed episode

Prevalence Rates and Prevalence Rates and CourseCourse

• Bipolar I• Lifetime: .4-1.6%• = in men and women• Men>manic episodes• Women>dep episodes• Women>rapid cycling• Ave. age onset = 20• Recurrent • 60-70% of manic episodes occur before or

after a depressive episode

Prevalence Rates and Prevalence Rates and CourseCourse

• Bipolar II• Lifetime: .5%• May be more common in women than men• Men>hypomanic than depressive episodes• Women>depressive than hypomanic episodes• Women>rapid cycling• 60-70%of hypomanic episodes occur before or

after a depressive episode• Interval between episodes decrease with age• Less data overall

Bipolar Disorder N.O.S.Bipolar Disorder N.O.S.

• Rapid cycling (days) between manic and depressive symptoms

• Recurrent hypomanic episodes without intercurrent depressive symptoms

• Hypomanic episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis

Etiological FactorsEtiological Factors

• Hereditary Factors• Biochemical Hypothesis• Stressful Life Events• Cognitive Styles as Vulnerabilities

Hereditary FactorsHereditary Factors

• 1st degree relatives have significantly higher rates

• Twin and adoption studies indicate genetic vulnerability

• May reflect environmental factors

Biochemical HypothesisBiochemical Hypothesis

• Deficiency in norepinephrine

• Dopamine implicated in the study of mania and psychotic symptoms

• Serotonin levels have also been implicated

StressfulStressful Life EventsLife Events

• Linkage between significant life events and affective abnormalities

• Negative, traumatic life events trigger mania

• Low social support, low self-esteem trigger depressive

Bipolar Disorder-Bipolar Disorder-Major Public Health IssueMajor Public Health Issue

• Overall economic burden is estimated at $45 billion dollars annually

• Costs of treatment for an individual exceed $17,000 per year

• 1 in 3 people with bipolar disorder fail to comply with medications

• Non-adherence to treatment often results in hospitalization and suicide

B.D. is often comorbid with B.D. is often comorbid with other disorders. Differential other disorders. Differential

diagnosis should also be diagnosis should also be considered. Specifically with:considered. Specifically with:• Bipolar vs. unipolar• ADHD• Schizophrenia• Substance abuse• Axis II

Substance Abuse and Bipolar Substance Abuse and Bipolar DisorderDisorder

• B. D. is the highest Axis I disorder comorbid/concurrent with substance abuse

• 21-61% of people with B.D. abuse or are addicted to substances as compared to 3-13% in the general population

• B.D. is second to antisocial personality disorder in terms of concurrent substance abuse

• Substance use adversely effects medication, produces earlier onset of symptoms and often leads to hospitalization

Bipolar Disorder and Bipolar Disorder and Personality DisordersPersonality Disorders

• Approximately 50% of all Bipolar patients also meet criteria for a personality disorder

• The most common comorbid conditions are in cluster B and C

• The most common Cluster B disorders include Antisocial, Borderline, Histrionic, Narcissistic

• The most common Cluster C disorders include Avoidant and Obsessive-Compulsive

Major Issues that Impede Major Issues that Impede Diagnosis and Recognition of Diagnosis and Recognition of

B.D.B.D.• Lack of reliable assessment tools for Bipolar

Disorder• Misdiagnosed as unipolar depression• Children, adolescents and young adults are often

diagnosed with ADHD• People often do not have clear cut, discrete mood episodes• Mania if often unrecognized or considered irritability/

aggression• Psychotic features are often mistaken for Schizophrenia• Unwillingness of the client to seek treatment• Lack of insight from client in mood episodes• Clinicians are not looking for manic/hypomanic episodes-

and reliance on self-reports

SUICIDE RISK SUICIDE RISK Must Be Continually Must Be Continually

MonitoredMonitored• Suicide completion rates in

patients with B.D. 10-15%• Presence of suicidal or homicidal

ideation, intent, plans• Access to means• Psychotic features, severe anxiety• Substance abuse• History of previous attempts• Family history or recent exposure

School-wide InterventionsSchool-wide Interventions• Create a positive school climate • Define behavioral expectations

- Small set of general expectations and specific expectations for different locations in the school

• Support positive behavior- Monitor behavior especially during common problem

times, acknowledge and reward positive behavior, use reminders and review of behavior expectations.

• Respond to problem behavior consistently and effectively- Use consistent procedures in responding to minor and

serious problem behaviors. Institute procedures for problems solving meetings.

Classroom InterventionsClassroom Interventions• Establish and teach the classroom rules and

procedures- Classroom rules and procedures need to be established and

clearly stated, explicitly taught, closely monitored and consistently followed.

• Manage common problem times: transition, seat work, other unstructured times of the day

• Promote social and emotional functioning• Use rewards effectively• Use mild punishment effectively• Manage angry/acting out behavior

Three-level: Triangle Three-level: Triangle ApproachApproach

School-Based School-Based InterventionsInterventions

Green-Zone

Positive behavior support interventions that are school-wide will support all children. This foundational level is sufficient for promoting positive behavior for approximately 80% of students

Red-Zone

Comprehensive and individualized interventions that focuses on 5% of children with significant difficulties

Yellow-Zone

Early interventions for children at risk, will affect 15% of children

Individual InterventionsIndividual Interventions• Consistently reinforce good behavior• Use of proactive and instructive

teaching strategies to teach adaptive behaviors and problem solve with the student

• Train student to self-monitor disruptive behaviors

• Use positive reinforcement when students reaches behavior goals.

IDEA Classification IDEA Classification Special Education Special Education

InterventionsInterventions• If a student with DBDs is labeled “emotionally disturbed” they are included under and given all protections under the Individuals with Disabilities Education Act (IDEA)

• But, if a student with DBDs is labeled “socially maladjusted but not emotionally disturbed”, they are denied any protection under IDEA and special education services10

Piecing it all together: Piecing it all together: What does all of this mean What does all of this mean

for a teacher?for a teacher?

Parent InvolvementParent Involvement• Home-school collaboration has the

potential to significantly increase academic success for students with DBDs

• Teacher and parent use a “partnership approach” to child’s success in school

• Send daily report card home about the student’s behavior

• Encourage positive parental reinforcement of specific desired behaviors

What teachers should What teachers should avoidavoid

• Use of only reactive behavioral strategies

• Model antisocial behaviors by yelling or insulting student, instead teachers should model prosocial or problem solving behaviors.

• Use of harsh punishment• Only coercive interactions

with student

What teachers should doWhat teachers should do

• Understand that teaching children with DBDs may take a “superhuman tolerance for interpersonal nastiness” 10

• Directly teach adaptive behavior strategies• Model and teach prosocial skills, problem

solving, empathy and self-control• Use individual interventions for

students with DBDs• Understand the teacher-student

conflict cycle and how to avoid it

The Conflict CycleThe Conflict Cycle

Retrieved from: http://cecp.air.org/interact/authoronline/april98/3.htm

Questions?Questions?

Glossary Glossary • DSM IV - DSM-IV (Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition)   An official manual of mental health problems developed by the American Psychiatric Association. Psychiatrists, psychologists, social workers, and other health and mental health care providers use this reference book to understand and diagnose mental health problems. Insurance companies and health care providers also use the terms and explanations in this book when discussing mental health problems. (site is the

• Prosocial behavior -The term prosocial behavior describes acts that demonstrate a sense of empathy, caring, and ethics, including sharing, cooperating, helping others, generosity, praising, complying, telling the truth, defending others, supporting others with warmth and affection, nurturing and guiding.

• Antisocial behavior – The term anitsocial behavior describes behaviors that are unacceptable in our society. Examples are acts of aggression or malice, over-reactive displays of anger, inability to work or get along with others, disrespectful towards others, and abusive towards others.

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