Overview. Conduct Problems. Overview. Conduct Disorder. Dr. K. A. Korb, University of Jos 5/20/2013. Dr. K. A. Korb

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1 Overview Conduct Problems Dr. K. A. Korb Conduct problems and antisocial behavior in children are age-inappropriate actions and attitudes that violate family expectations, societal norms, and the personal or property rights of others Conduct behaviors range from complaining, swearing, temper outbursts, vandalism, theft, assault Many children with conduct problems grow up in dysfunctional families and neighborhoods with high rates of physical abuse, neglect, poverty, or exposure to criminal activity Overview Most youth engage in some antisocial behaviors Many children in nursery school are physically aggressive, steal, lie, disobey, and steal property However, by adolescence, the rate of antisocial behavior in a typical child declines Conduct disorder: Early, persistent, and extreme pattern of antisocial behavior that occurs in about 5% of children Antisocial behavior is the most expensive mental health problem in North America due to costs to the educational, health, criminal justice, and mental health systems 1

2 Oppositional Defiant Disorder Oppositional Defiant Disorder: Age inappropriate pattern of stubborn, hostile, and defiant behaviors Included in the DSM to capture antisocial and aggressive behavior by nursery and primary school children Source: Mash & Wolfe (2002) Oppositional Defiant Disorder (ODD) Diagnostic Criteria (DSM-IV-TR) A pattern of negativistic, hostile and defiant behavior lasting at least 6 months, during which four (or more) of the following are present; 1) often loses temper 2) often argues with adults 3) often actively defies or refuses to comply with adults request or rules. 4) often deliberately annoys people 5) often blames others for his or her mistakes or misbehavior 6) is often touchy or easily annoyed by others 7) is often angry or resentful 8) is often spiteful or vindictive Note: consider a criterion met only if the behavior occurs more frequently than typically observed in individuals of comparable age and development level. Note: ODD is not diagnosed when criteria for conduct disorder are met. : Children who display severe, aggressive and antisocial acts that inflict pain on others or interfere with others rights through physical and verbal aggression, stealing, or committing acts of vandalism 2

3 Diagnostic Criteria (DSM-IV-TR), Part 1 Presence of three (or more) of the following criteria in the past 12 months, with at least one criteria present in the past 6 months. Aggression to people and animals 1) often bullies, threatens, or intimidates others 2) often initiate physical fights 3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) 4) has been physical cruel to people 5) has been physical cruel to animals 6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) 7) has forced someone into sexual activity. Diagnostic Criteria (DSM-IV-TR), Part 2 Destruction of property 8) has deliberately engaged in fire setting, with the intention of causing serious damage 9) has deliberately destroyed others property (other than by fire setting) Deceitfulness or theft 10) has broken into someone else s house, building, or car 11) often lies to obtain goods or favor or to avoid obligations (i.e, cons others) 12) has stolen items of nontrivial value without confronting a victim (e.g, shoplifting, but without breaking and entering; forgery) Serious violation of rules 13) often stays out at night despite parental prohibitions, beginning before age 13 14) has run away from home overnight at least twice while living in parental home (or once with out returning for a lengthy period) 15) is often truant from school, beginning before age 13 years Age of Onset of Childhood-onset CD display at least one characteristic of the disorder before age 10 Adolescent-onset CD does not display symptoms of the disorder until after 10 years Children with childhood-onset CD are more likely to be boys, show more aggressive symptoms, account for a disproportionate amount of illegal activity, and persist in their antisocial behavior over time ODD typically begins around age 6 CD typically begins around 9 years Characteristics Associated with Lower language skills Problems in school: Underachievement, school drop-out, behavior problems in school ADHD commonly co-occurs with conduct disorders, and may be the cause of academic problems Poor relationships with peers due to poor social skills Early antisocial behavior combined with associating with delinquent peers is the most powerful predictor of conduct problems in adolescence 3

4 Characteristics Associated with Family Problems General family disturbances: Family history of antisocial behavior, family instability, poverty, antisocial family values Specific disturbances in parenting practices and family functioning: Excessively harsh discipline, lack of supervision, lack of emotional support Health Problems: Injuries, Overdoses, Sexually transmitted diseases Substance Abuse Potential Factors that May Cause Genetics: Biologically-based traits such as difficult temperament or impulsivity may predispose children to antisocial behavior Neurobiological Factors: Behavioral inhibition system (BIS) in the brain inhibits behavior Those with antisocial behavior may have an underactive BIS system Cognitive Factors: Antisocial children oftentimes have difficulty taking the perspective of others Hostile attributional bias: More likely to attribute negative intent to others Potential Factors that May Cause Family Factors: Poor parenting practices, violence in the home, marital conflict, unstable family structures, antisocial parents Reciprocal influence: Poor parenting practices can increase children s antisocial behavior, which can lead to even worse parenting practices Societal Factors: Poverty and neighborhood crime are related to antisocial behaviors in youth Media: TV violence has a strong correlation with aggression Cultural Factors Kapaukuof Western New Guinea: At about 7 years of age, a Kapaukuboy begins to be separated from his mother and spend time only with other men. In training to be a brave warrior, the father engages his son in mock stick fights. The fights gradually become more serious and possibly lethal when the father and son shoot real war arrows at each other. Groups of boys play at target shooting, they also play at hitting each other over the head with sticks (Ember & Ember, 1994, as cited in Mash & Wolfe, 2002). The homicide rate among the Kapaukuwas estimated at 200 per 100,000 people each year 4

5 Cultural Factors Lepchaof the Indian Himalayas: The Lepchaare very clear about what they expect from their children. Good children help out with the work, tell the truth, listen to the teachings of the elders, help old people, and are peaceable. Bad children quarrel and insult people, tell lies, draw their knives in anger and do not do their share of the work (Ember & Ember, 1994, as cited in Mash & Wolfe, 2002). The last confirmed murder among the Lepchawas 200 years ago Treatment Most effective treatment uses a combination of approaches with the child, family, school, and community Family problems must be addressed together with addressing the conduct disorder Treatments for the child must be tailored to the child s developmental level Treatment Group therapy is often not effective Two types of treatment: Ongoing interventions to help youth and families cope with social, emotional, and school problems Early interventions for young children just beginning to demonstrate antisocial behaviors Parent Management Training Teaches parents to change their child s behavior at home Teach parents specific new parenting practices through direct instruction, modeling, and role playing Skills include setting clear rules, use praise and rewards for desirable behavior, supervising children s behavior 5

6 Cognitive Problem-Solving Skills Training Philosophy: Child s perceptions of the environment trigger antisocial responses. Changes in this thinking will result in changes in behavior Steps (For a role-play in a problem situation that may trigger an aggressive response) Step 1: What is the goal in this situation? Step 2: Brainstorm the possible responses. Step 3: What are the likely outcomes of each response? Step 4: Choose the best response Step 5: Evaluate whether the response was appropriate or inappropriate Multisystemic Treatment Views conduct problems as caused by dysfunctional family relationships Goal: Empower caregivers to improve youth and family functioning Treatment includes all family members, school personnel, peers, and other important people in the child s life. Uses multiple forms of therapy at all levels Effective on extremely antisocial and violent youths Preventative Interventions Conduct problems can be treated more easily and effectively in younger children Counteracting risk factors and strengthening protective factors at a young age can prevent or limit antisocial behavior Preventative interventions will reduce substantial costs of conduct disorders Every time you stop a school, you will have to build a jail. Mark Twain Preventative Interventions Prevention can teach parenting skills to at-risk parents Prevention can also teach children socialcognitive skills necessary for effective interpersonal problem solving and emotional regulation 6

CONDUCT DISORDERS. What to do with your oppositional defiant child. Humberto Nagera MD

CONDUCT DISORDERS. What to do with your oppositional defiant child. Humberto Nagera MD What to do with your oppositional defiant child Humberto Nagera MD This Lecture is based on the findings of research conducted at the Inpatient Units for Children and Adolescents of The University of South