Evidence-Based Psychosocial Evidence-Based Psychosocial Treatment of Disruptive Treatment of Disruptive

Behavior Disorder - OverviewBehavior Disorder - Overview

Developed by the Center for School Mental Health with support Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the provided in part from grant 1R01MH71015-01A1 from the

National Institute of Mental Health and Project # U45 MC00174 National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health from the Office of Adolescent Health, Maternal, and Child Health

Bureau, Health Resources and Services Administration, Bureau, Health Resources and Services Administration, Department of Health and Human ServicesDepartment of Health and Human Services

Defining Disruptive Defining Disruptive BehaviorsBehaviors

Two main types of Disruptive Behavior Two main types of Disruptive Behavior Disorders (DBD):Disorders (DBD): Oppositional Defiant Disorder (ODD) – loses Oppositional Defiant Disorder (ODD) – loses

temper, argues with adults, easily annoyed, temper, argues with adults, easily annoyed, actively defies or refuses to comply with actively defies or refuses to comply with adults. adults.

Conduct Disorder (CD) – aggression toward Conduct Disorder (CD) – aggression toward peers, destruction of property, deceitfulness peers, destruction of property, deceitfulness or theft, and serious violation of rules.or theft, and serious violation of rules.

Oppositional Defiant Oppositional Defiant DisorderDisorder

A pattern of negativistic, hostile and defiant A pattern of negativistic, hostile and defiant behavior lasting greater than 6 months of behavior lasting greater than 6 months of which you have 4 or more of the following:which you have 4 or more of the following:

Loses temperLoses temper Argues with adults Argues with adults Actively defies or refuses to comply with rulesActively defies or refuses to comply with rules Often deliberately annoys people Often deliberately annoys people Blames others for his/her mistakesBlames others for his/her mistakes Often touchy or easily annoyed with othersOften touchy or easily annoyed with others Often angry and resentfulOften angry and resentful Often spiteful or vindictiveOften spiteful or vindictive

Oppositional Defiant Oppositional Defiant DisorderDisorder

(ODD)(ODD) Prevalence-3-10%Prevalence-3-10% Male to female -2-3:1Male to female -2-3:1 Outcome-in one study, Outcome-in one study,

44% of 7-12 year old 44% of 7-12 year old boys with ODD boys with ODD developed into CDdeveloped into CD

Evaluation-Look for Evaluation-Look for comorbid ADHD, comorbid ADHD, depression, anxiety depression, anxiety &LD/MR&LD/MR

Conduct DisorderConduct Disorder(CD)(CD)

Aggression Aggression toward people toward people or animalsor animals

Deceitfulness or Deceitfulness or TheftTheft

Destruction of Destruction of propertyproperty

Serious violation Serious violation of rulesof rules

Conduct DisorderConduct Disorder(CD)(CD)

Prevalence-1.5-3.4%Prevalence-1.5-3.4% Boys greatly Boys greatly

outnumber girls (3-outnumber girls (3-5:1)5:1)

Co-morbid ADHD in Co-morbid ADHD in 50%, common to 50%, common to have LDhave LD

Course-remits by Course-remits by adulthood in 2/3. adulthood in 2/3. Others become Others become Antisocial Antisocial Personality DisorderPersonality Disorder

Conduct DisorderConduct Disorder

“You left your D_MN car in the driveway again!”

Disruptive Behavior Disorder Disruptive Behavior Disorder NOSNOS

Disorders characterized by conduct Disorders characterized by conduct or oppositional defiant behaviors that or oppositional defiant behaviors that do not meet criteria for ODD or CDdo not meet criteria for ODD or CD

Still must have impairment in Still must have impairment in functioningfunctioning

MH interventions shown to be MH interventions shown to be EFFECTIVE for Disruptive EFFECTIVE for Disruptive

behavior and Willful behavior and Willful misconduct problemsmisconduct problems

““Parent Training in behavior Parent Training in behavior management has the clearest management has the clearest support for its efficacy, having been support for its efficacy, having been evaluated in 24 controlled tests…”evaluated in 24 controlled tests…”

What is Parent Training?What is Parent Training? Why children misbehave – correcting Why children misbehave – correcting

misperceptionsmisperceptions Identifying and removing barriers to Identifying and removing barriers to

effective child managementeffective child management Paying attention to and reinforcing Paying attention to and reinforcing

child’s good behavior (improving child’s good behavior (improving emotional relationship)emotional relationship)

Issuing effective commands Issuing effective commands (compliance training)(compliance training)

Use of time-outUse of time-out Reinforcement and response cost Reinforcement and response cost

system (tokens or points) for system (tokens or points) for appropriate/inappropriate behaviorsappropriate/inappropriate behaviors

Extension to school and public settings - Extension to school and public settings - behavior report card behavior report card

ODD/CD: Practice ODD/CD: Practice ComponentsComponents

54

68

70

73

89

0 20 40 60 80 100

Problem Solving

Parent Priase

Time Out

Commands/LimitSetting

Tangible Rewards

% of EBP w/PracticeComponent

What works for DBD?What works for DBD?

Most of the evidence-based practice elements Most of the evidence-based practice elements used for Disruptive Behavior Disorders have used for Disruptive Behavior Disorders have their basis in Clinical Behavior Therapy.their basis in Clinical Behavior Therapy. We covered the basic premises behind behavior We covered the basic premises behind behavior

therapy in the first unit.therapy in the first unit. We will cover the specifics of effective interventions We will cover the specifics of effective interventions

for DBD in this unit.for DBD in this unit. Problem-solving is also effective for treating Problem-solving is also effective for treating

students with Disruptive Behavior Disorders. students with Disruptive Behavior Disorders.

What doesn’t work for DBD?What doesn’t work for DBD?

Treatments with little or no evidence of Treatments with little or no evidence of effectiveness includeeffectiveness include Special elimination dietsSpecial elimination diets Vitamins or other health food remediesVitamins or other health food remedies Psychotherapy or psychoanalysisPsychotherapy or psychoanalysis BiofeedbackBiofeedback Play therapyPlay therapy Chiropractic treatmentChiropractic treatment Sensory integration trainingSensory integration training Social skills trainingSocial skills training Self-control trainingSelf-control training

Clinical Behavior Therapy: Clinical Behavior Therapy: TheoryTheory

Proposed Mechanism:Proposed Mechanism: Individuals with Individuals with ODD/CD have difficulty understanding ODD/CD have difficulty understanding the consequences of their actions.the consequences of their actions.

Approach:Approach: Application of the principles of Application of the principles of social learning theorysocial learning theory to modify to modify children’s behavior by training parents children’s behavior by training parents and teachers to manipulate and teachers to manipulate environmental antecedents, environmental antecedents, consequences and contingencies. consequences and contingencies.

The ABC ModelThe ABC Model

Behavior

Consequences

Antecedents

Contingencies

An example: The ABC ModelAn example: The ABC Model

BehaviorStudent ignoresbell while rest of

class takes out mathbooks

ConsequencesTeacher yells at

student

Antecedent9:30 bell signals

beginningof math period

The ABC ModelThe ABC Model

BehaviorStudent takes out

math book

ConsequenceTeacher smiles

at student

Antecedent9:30 bell signals

beginningof math period

Contingencies

Teacher makes eye contact with student, says, “Take out your math books.”

Specific interventions to help Specific interventions to help the ODD/CD studentthe ODD/CD student

Parent praiseParent praise Commands/limit settingCommands/limit setting Tangible rewardsTangible rewards Response costResponse cost Parent monitoringParent monitoring Time outTime out Psycho-education with parentPsycho-education with parent Problem solvingProblem solving

ResourcesResources

Several empirically-supported Several empirically-supported protocols exist:protocols exist: Defiant Children/Defiant Teens Defiant Children/Defiant Teens

(Russell Barkley)(Russell Barkley) Helping the Noncompliant Child (Rex Helping the Noncompliant Child (Rex

Forehand)Forehand) Videotape Parent Modeling (Carolyn Videotape Parent Modeling (Carolyn

Webster-Stratton)Webster-Stratton)

ResourcesResources

Parent/Teacher DBD Rating ScaleParent/Teacher DBD Rating Scale

http://ctadd.net/ctadd/PDFs_CTADD/DBD.phttp://ctadd.net/ctadd/PDFs_CTADD/DBD.pdfdf

Vanderbilt Assessment ScalesVanderbilt Assessment Scaleshttp://www.nichq.org/nichqhttp://www.nichq.org/nichq

ResourcesResources

The University of Buffalo Center for The University of Buffalo Center for Children and FamiliesChildren and Families http://http://wings.buffalo.edu/adhdwings.buffalo.edu/adhd// Free resources on disruptive behavior Free resources on disruptive behavior

disorders:disorders: Parent handoutsParent handouts Teacher handoutsTeacher handouts Assessment toolsAssessment tools