Applied Psychology 651 (3-0) Disorders of Learning and Behaviour. Final Exam. Dianne L. Ballance. University of Calgary

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1 APSY 651 Final Exam 1 Running Head: APSY 651 Final Exam Applied Psychology 651 (3-0) Disorders of Learning and Behaviour Final Exam Dianne L. Ballance University of Calgary Dr. Brent Macdonald December 8, 2009

2 APSY 651 Final Exam 2 Section 1: Issues of Comorbidity in Child Psychopathology Issues of comorbidity in child psychopathology are prevalent across the different childhood disorders. As defined by Mash and Barkley (2003) comborbidity generally refers to the manifestation of two or more disorders that co-occur more often than would be expected by chance alone (p. 37). As evidenced throughout the text and our class presentations, it is common for children to exhibit multiple symptoms and disorders. Although challenges with the definition, study, identification, and treatment surround the issue of comorbidity it clearly exists within child psychopathology. Considering the prevalence and impact of comorbidity within children, it necessitates a comprehensive understanding and value on the part of professionals. Due to the inevitability of encountering comborbidity in future practice as a school psychologist developing a deeper understanding of its complexities is both practical and constructive. This discussion will review the concept of comorbidity, issues and challenges, and implications for practice, including highlights of personal experience, thoughts on the topic, and suggestions for future personal development and research. Comorbidity As mentioned, comorbidity refers to the incidence of co-occurrence of multiple disorders by children at a time. Mash & Barkley identify the most common co-occurring disorders for children and adolescents as attention-deficit/ hyperactivity disorder (ADHD) and conduct disorder (CD), autistic disorder and mental retardation (MR), and childhood depression and anxiety. Prevalence of comorbidity vary between clinical and community samples, demonstrating higher rates in clinical samples. Issues with prevalence will be reviewed later in the discussion; however there is agreement in the field of child psychopathology that comorbidity is a valid construct. Terms such as co-occurrence, dual diagnoses, and

3 APSY 651 Final Exam 3 covariation are often used when discussing comorbidity, and some debate continues into the definition and nature of true comorbidity. Clearly our class presentations illustrated incidences of comorbidity. Generalized anxiety disorder (GAD) reviewed several possible comorbidities including depression, oppositional defiant disorder (ODD), separation anxiety disorder (SAD), and ADHD. Childhood bipolar disorder (BPD) illustrated comorbidity with ADHD, CD, anxiety, obsessive compulsive disorder (OCD), and substance abuse disorders (SAD). The group presenting on communication disorders highlighted co-occurring diagnoses of other language disorders, ADHD, and various learning disabilities (LD). Eating disorders were linked with depression, OCD, and personality disorders. Comorbidities for conduct disorder included ADHD, depression, SAD, and LD. Information on child maltreatment discussed the relationship of possible outcomes regarding comorbidity, and the development of symptoms of many possible disorders and diagnoses. The Mash & Barkley text supports the comorbidities identified during the presentations. The importance of these examples is that comorbidity is widespread across all disorders with high rates, which potentially influence our definitions and treatment of disorders. Relationships between comorbid disorders are not always clear, but will obviously have impact on outcomes for children. Reflecting on personal experience as a learning support teacher (LST) the concepts of comorbidity are validated. Research into comorbidity rates and wide variety of potential concurrent disorders has extended basic concepts built upon this background in special education. It continues to be a practical challenge in assessment, treatment, evaluation, and follow-up for meeting the needs of children. Issues associated within one disorder are often complex to deal with in reality when considering available resources, and levels of understanding and skills of professionals and families. Comorbidity compounds these issues even further in

4 APSY 651 Final Exam 4 practice. Responsible professionals will accept comorbidity as a reality and make plans to address the unique experience for each child as it will likely change as they move through different developmental stages. Evident in the research and class presentations is the perception of comorbidity as a risk factor for children. The presence of one disorder elevates risk for further disorders, either as a concurrent disorder or for future disorders, which Mash & Barkley (2003) refer to as successive comorbidity (p. 240). Successive comorbidity suggests overlap between latent constructs of disorders and also supports the possibility of a developmental progression of disorders (Mash & Barkley, 2003, p. 318). Knowledge of typical comorbid conditions when addressing a child with a current diagnosis will aid professionals in their assessment and treatment considerations. Although presentation will be unique for each child, the higher rated comorbid disorders may be affecting the child currently or potentially in the future. Personal experience has witnessed poor child outcomes in terms of successive comorbidity from early behaviour difficulties to later diagnosis of anxiety, and then subsequent substance abuse. Professionals who value this risk will be prepared to meet children s ongoing needs. The idea of prevention can be addressed when disorders commonly lead to earlier onset or prediction of later comorbid disorders. As research has shown successive comorbidity such as ODD and later CD, or anxiety and depression, or BPD and SAD, will influence preventative treatment options. As comorbidity may escalate symptoms it could result in more pernicious outcomes for children, and every effort on the part of the professional to provide early effective treatment has the potential to prevent increased severity of symptoms and associated comorbidity. Comorbidity illustrates the complexities in genetic, environmental, and developmental processes. Multiple models must be used to examine expression, etiologies, and developmental

5 APSY 651 Final Exam 5 pathways of comorbidity. In applying Bronfenbrenner s ecological systems theory to comorbidity it becomes apparent the wide variety of mechanisms that need to be considered when we seek to assess, diagnose, and provide effective treatment for children. Including information and resources from each level in the system from the individual to the community will provide professionals a thorough understanding and potentially maximize services. Collaboration with professionals from the different systems can result in better outcomes for children (parents, teachers, psychologists, paediatricians, family school liaison workers, etc.), which has been evidenced in personal experience, and suggested in class as a means of increasing children s resilience. How children interact with these influences will affect their presentation of disorders, which is evident in a transactional theory or approach. In addition, growth and development of children through developmental pathways will change their presentation, current risk factors, and possible outcomes. Noted by Mash & Barkley (2003) young children may present different symptomology than older adolescents within the same disorder which may affect rates of comorbidity (p. 240, 318). Gender has also been identified as playing a role in rates of comorbidities. Mash & Barkley (2003) review comorbidity of depressed children noting that girls have higher rates of anxiety and boys have higher rates of ADHD and disruptive behaviours (p. 241). Developing further knowledge of how gender and developmental progression affect comorbidity will be part of future personal professional growth. An individualized and problem solving approach when working with children with comorbidity will be fundamental to discovering and attending to these complexities Issues and Challenges of Comorbidity Due to the complex nature of comorbidity there are specific challenges that need to be identified and addressed in professional practice. One of the major challenges is the notion of

6 APSY 651 Final Exam 6 artifactual comorbidity versus true comorbidity, and how differentiations are made in practice. Mash & Barkley (2003) repeatedly discuss throughout the text the reasons why comorbidity may be exaggerated or artificially produced, specifically referring to sampling bias of clinical situations, confusion surrounding conceptualizations and definitions of disorders, high overlap of symptoms and criteria between disorders, differing rates for different developmental stages and progression, and shared causal associations in either genetic or environmental effects. These issues were repeated during several of the class presentations, mainly focusing on diagnostic issues, and multifactory etiologies. Research indicates that community samples provide more accurate rates of comorbidity as clinical samples most often include children with multiple and more severe disorders. Referrals and resulting treatment are more common for children with multiple or more severe disorders. In my experience it is often the children with more complex and severe needs that parents and teachers make repeated referrals and requests for additional support in resources, throughout their school experience. It becomes difficult to identify which disorder precipitates the other, the relationship between the disorders, and identifying underlying causal factors that trigger the joint display of such symptomology (Mash & Barkley, 2003, p. 169). However, it is important to be able to make distinctions between disorders (e.g. identifying ADHD vs. mood disorders) for best treatment practice. This process of distinction has been evidenced in personal experience as ongoing assessment contributes to interventions resulting in clearer determination (e.g. intial diagnosis of ADHD and Gifted was later distinguished as Asperger s and Gifted). The value of identifying these issues is in increasing our professional abilities to draw meaningful conclusions about characteristics of disorders, potential influences, risk factors, and underlying constructs which may affect

7 APSY 651 Final Exam 7 diagnosis and treatment. Accuracy of diagnoses will make direct implications for children regarding early intervention and appropriate treatment. A practical challenge of comorbidity addresses children who present with additional symptomology but do not merit a secondary diagnosis. The question of whether this is a reflection of assessment, stages of early onset of secondary disorders, influences from the various systems or developmental pathways, or simply a period of increased symptoms due to other factors would need to be investigated. This would be an area of interest for future research in addition to practical methods of addressing children s needs in this type of situation. Implications for Practice Given the complexities and challenges associated with comorbidity psychologists and other professionals will need to be involved in a collaborative problem solving and treatment approach. Each stakeholder in the community or team will have different expertise and potential contributions to meet the diagnosis and ongoing needs of children. Acting as a community partner will enhance the effectiveness of this approach. The role of the psychologist will need to move from an individualized consultant perspective to a systems perspective, where involvement is part of the larger diverse systems outside the child. One challenge of collaboration would be timely assessment and treatment. It will be the responsibility of individuals to develop competent collaboration skills required in this model. Contributions of psychologists will need to follow the professional code of ethics, utilize the four pillars of assessment and empirically based strategies for assessment and interventions, education of stakeholders regarding the value of psychologists contributions, assisting others when needed with their engagement in the collaborative model, focusing on problem solving models and professional flexibility. Awareness, knowledge, and understanding the ecologies of

8 APSY 651 Final Exam 8 disorders and comorbidity will assist psychologists in becoming proactive in their services. Developing knowledge of the contributions of other stakeholders would also assist psychologist s collaborative efforts, and cross-discipline communication. Challenges of collaboration and the realities of available time and workloads would need to be addressed directly for the benefit of children and their families. Ideally through an effective collaborative model the provision of better services for addressing comorbidity in child psychopathology will be established. Connected to the issue of comorbidity is the practice of differential diagnosis, in which distinctions are made between disorders by comparing signs and symptoms to determine causes and accurate identification of conditions. Psychologists have the ability to make valuable contributions to this process. The use of reliable instruments that are able to separate symptoms in combination with additional proficient assessment methods are valuable tools for differentiation of disorders. Understanding the links between common comorbid disorders, potential successive comorbidity, and prognosis of the different comorbidities will provide insight into differential diagnoses and current services. As evidence shows that some disorder clusters have poorer prognosis than others, as in the case of Cluster B personality disorder comorbidity mentioned by Mash & Barkley (2003), it will likely increase risk factors for children (p In some cases increased reliability in diagnoses and early intervention will reduce rates of comorbidity, which has been noted in MR and autism comorbidity in recent years. Collaborative treatment may contribute to differential diagnosis in some instances where medication and psychotherapy influence symptoms and resulting diagnoses and treatment. Differential diagnosis will provide psychologists with meaningful information that can be used in the collaborative framework.

9 APSY 651 Final Exam 9 Reflecting upon almost ten years in the field of special education there are many practical limitations and challenges to the theoretical implementation of meeting the needs of children with comorbid disorders in the school environment. Issues of funding, available resources, skills of teachers, lack of understanding and knowledge regarding disorders and treatment, time for meetings and planning for intervention, willing participation of stakeholders and professionals, complex student demographics in classrooms, resistance to change, duties outside the classroom that affect levels of involvement, plus many other additional challenges in the educational environment. A particular challenge in special education is adequately addressing children s complex needs through the Individual Program Plan and resulting interventions. Choosing the priority needs that can realistically be met through current presentation, and available resources and personnel can be a difficult process. Often as professionals we have to balance between global and realistic goals. Children with comorbidities with even higher levels of complexity will amplify this challenge. Experience as a LST provided many opportunities to act as an advocate for children in multiple situations and with different professionals. Advocating from the beginning stages of referral, through in-depth assessments, diagnosis, and implementation of treatment, promoted increased knowledge and understanding of children s conditions resulting in improved collaboration and consistency of service. Obvious benefits come from ongoing involvement with individual children as well as in the system level. Continued involvement is especially relevant for comorbidity due to its dynamic complex nature. Integral to supporting children with comorbidities is keeping current with new theories and approaches through research and personal professional development. Perhaps one of the largest barriers among these challenges is the traditional role of the psychologist that limits services to assessment and recommendations. Children that have the complexities associated with comorbidity require

10 APSY 651 Final Exam 10 additional resources and ongoing support. Potentially psychologists may be able to provide many of those services when they are advocated for and supported at the system level. Conclusion Mash & Barkley discuss the importance of studying and understanding comorbidity as essential to understanding the underlying risk factors, the relationships among... symptoms, the developmental continuities and discontinuities, and the validity of... syndromes themselves (p. 315). The result is an increased ability to draw meaningful conclusions for diagnosis and treatment. Considering the high rates of comorbidity, developing a comprehensive understanding is one of the components in providing competent school psychology services. Knowlege of comorbidities can guide assessment and practice, however, the awareness of the multiple etiologies, systems and pathways need to be considered to allow for ongoing transformation. Research can guide the practice of psychology, and professionals can prevent its potential limitations by participating in collaboration and a problem solving approach. Regardless of diagnosis and comorbidity, children can benefit from support and interventions to address their current symptoms and presentation. Psychologists can potentially be involved in all the stages in addressing children s needs, providing ongoing service and collaboration including prior to diagnoses. It will be an ongoing process to combine and consolidate personal experience as an LST and new learning s within the School and Applied Psychology program. Being at the beginning of the program there will be many upcoming opportunities to build the knowledge base, assessment skills, specific psychological interventions and services, that are required to implement the concepts discussed in this paper in the role of school psychologist. Experience in class and personal research has consolidated and enhanced previous thoughts of the issues and

11 APSY 651 Final Exam 11 challenges of comorbidity from a basic level to developing a deeper understanding and appreciation of its complexities. Future practice will optimally bring the skills and knowledge from the background in special education to enhance school psychology services.

12 APSY 651 Final Exam 12 Section II: Conduct and Oppositional Defiant Disorders and Substance Use Disorders Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), and Substance Use Disorders (SUD) are of interest when considering prevalence, comorbidity, associated risks, potential pernicious outcomes for children, and societal concerns, that have significance for research and implications for psychological services. These disorders will likely be encountered in future practice either independently or concurrently, and often are associated with considerable debate and attention, as witnessed through our class presentations, discussion board, and personal experience. A recent reduction in local funding has affected the general acknowledgement and resources for these disorders and deficits in both these areas will result in challenges for individuals, families, and the larger community. Developing an understanding of the critical issues will hopefully lead to skills in advocating for services and meeting the needs of children with these disorders. This discussion will examine diagnostic challenges, critical issues, roles of gender, and associated risk factors. Conduct and Oppositional Defiance Disorders Conduct Disorder and Oppositional Defiance Disorders are disorders of behaviour in children and adolescents. The Diagnostic and Statistical Manual of Mental Disorders [DSM-IV- TR] by the American Psychiatric Association (2000) identifies the essential feature of CD as a repetitive and persistent pattern of behaviour in which the basic rights of others or major ageappropriate societal norms or rules are violated (p.93). Conduct Disorder includes serious overt and covert antisocial behaviours that result in personal and social impairment for children and adolescents (Mash and Barkley, 2003, p. 152). The DSM-IV-TR (2000) reviews descriptive features of CD that include little empathy and concern for the well-being of others, misperceptions of the intentions of others as hostile and threatening, callousness and lack of guilt

13 APSY 651 Final Exam 13 or remorse, tendency to blame others, self-esteem issues, low frustration tolerance, irritability, temper outbursts, recklessness, participation in illegal activities, early onset of sexual behaviour, low academic achievement, and the possibility of low intelligence (verbal IQ). A distinguishing feature for CD is that the aggressive and antisocial actions are not normative during childhood. The essential feature for ODD identified by the DSM-IV-TR (2000) is a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviour toward authority figures (p. 100). Common features include problematic temperament, high motor activity, low self-esteem or overly inflated self-esteem, mood lability, low frustration tolerance, conflicts with others, and the use of alcohol or drugs. Behaviours associated with ODD are considered normative during childhood; the distinguishing factor is the severity and frequency compared to age and sex norms. As evidenced, there is high behaviour overlap among CD and ODD that may potentially relate to shared diagnostic models, etiologies, and risk factors. Diagnostic Challenges Common definition and diagnostic challenges that exist for most disorders as evidenced throughout the text and our class presentation are evident in ODD/CD, given the scope of this paper they will not be reviewed, and only relevant unique challenges will be included. ODD/CD criteria are descriptions of behaviours, which do not adequately describe the psychological features that identify risk or psychopathology in children. Research into affective or interpersonal traits (e.g. callous and unemotional ) is at the beginning stages, but holds promise for validation of diagnoses. The criteria including age of onset subtypes creates two subgroups of children with different levels of risk, profiles, and persistence. An understanding of the subtypes is necessary for understanding, predicting, and treating children with ODD/CD. The heterogenic nature (variety of ways aggression is expressed) of ODD/CD contributes to

14 APSY 651 Final Exam 14 difficulties in classifying subcategories and precise definitions. Professionals in the field also question the validity of ODD as a diagnostic category citing difficulties with the constraints of classification, overmedicalization, and inclusionary symptoms that exist within normal development. A problem with the current definition is conceptualizing ODD/CD as solely intraindividual that results in individual treatment decisions, which possibly ignore systemic prevention and treatment strategies. Understanding the larger context in which ODD/CD occurs will provide meaningful information for diagnosis and treatment. Critical Issues Controversy and debate regarding the theoretical conceptualizations of ODD/CD exists within the field. Mash & Barkley (2003) discuss the multiple causal pathways in etiology and developmental diversity, and heterogeneity of behaviours, mechanisms, and risk variables that result in complexity of the issues surrounding ODD/CD. In particular the overlap of behavioural patterns of Attention-Deficit/Hyperactivity Disorder (ADHD) and high rate of comorbidity between ODD/CD and ADHD has implications for etiology, diagnosis, treatment considerations, and validity of these behavioural categories. Children with both ODD/CD and ADHD display a more pernicious form of psychopathology, earlier onset of ODD/CD, and negative outcomes later in life. This comorbidity results in stronger predictors of escalation and persistence of ODD/CD than when occurring alone. The issue of developmental progressions is associated with ODD/CD outcomes. Research shows relative stability in antisocial behaviour over time, though the patterns and expressions of the behaviour change with development. Study of these patterns may contribute to prediction and prevention. Further details of these pathways will not be discussed in consideration of the constraints of the paper, however, Mash & Barkley (2003) noted two key

15 APSY 651 Final Exam 15 concepts; 1) pathways expand into multiple trajectories over time for many children with ODD/CD, and 2) the trajectory of ODD to CD has relatively low predictive power as most children with ODD do not later on develop CD diagnosis (although very high rates of children with CD previously met ODD criteria). In these situations ODD may signify an extreme of normal development variation, linked with important triggering factors...transitory in nature, and not portending escalation to a toxic course (p. 162). Research into the protective factors will provide professionals valuable knowledge for prevention, early intervention, and treatment. Role of Gender The majority of research has pertained largely to males with ODD/CD, and only recently has there been more focused attention on female manifestation of this disorder. The study of gender differences discussed by Mash & Barkley (2003) provides an in-depth discussion of which only the key points will be summarized. Rates of ODD/CD are similar for boys and girls in early childhood, however by preschool years males typically predominate, and by adolescence girls demonstrate a rise in rates and the ratio becomes closer to even for both genders. The type of aggression tends to be different, where boys typically manifest in direct physical and verbal aggression, and girls more often present with indirect aggression or relational aggression. Theories of socialization have been presented to explain these different expressions, noting that from early development girls intraindividual processes (play styles, levels of activity, cognitive and emotion-regulation capacities, etc.) combine with socialization patterns that promote internalizing expressions of aggression. Boys early development typically includes different processes (more physical and active involving greater risks) which may result in boys missing the socialization processes regarding norms and aggression. Due to the nature of how girls express aggression it may have

16 APSY 651 Final Exam 16 lead to underestimates of prevalence. Of particular concern for girls is the rise in adolescence presentation, and higher rates of comorbidity, resulting in significant mental health problems that may not be addressed individually or at a system level. Controversy regarding additional symptom presentation in girls continues that might contribute to future indicators continue (e.g. somatisation, sexual promiscuity, substance use/abuse). Different developmental trajectories have also been suggested for each gender. Studies currently demonstrate that boys outnumber girls for early onset of the disorders and risk factors. As girls enter adolescence their presentation of covert and externalizing symptoms increases with a peak of physical aggression in early adolescence, which indicates a particular period of risk (boys peak age is at the end of adolescence). Some reliability has been shown that early physiological development and maturation interactions with environmental risks may represent a generative mechanism for behaviour problems. Predictive relationships for girls with ODD/CD, and examination of girls with externalizing aggression are areas that require further study. As research is relatively new, developing practical applications of pathways is somewhat limited. Risk Factors Multiple risk factors exist for ODD/CD ranging from intraindividual to systems mechanisms. Intraindividual factors include; comorbid disorders of ADHD, low achievement or Learning Disabilities, other internalizing disorders (depression, anxiety), genetic influences (temperament, neuropsychological, and neurophysiological factors), cognitive processing, and patterns of emotion dysregulation. Familial factors identified as increasing risk consist of parental psychopathology (parental Antisocial Personality Disorder [ASPD], substance use disorders, and depression), family structure and conflict (single-parents, large family size, divorce, young age of mothers), parents with low levels of education, poor supervision, harsh

17 APSY 651 Final Exam 17 and inconsistent parenting styles, insecure parent attachment and high conflict parent-child interactions, family socialization of aggression, and abuse. These family risk factors are often associated with other risk factors, which contributes to the complex nature of influences. Peer rejection and association with antisocial peer groups are related to the development of aggression in different ways for different subgroups of children with ODD/CD. Peer rejection is strongly related to early onset, and peer antisocial association is related to later-onset; however, both processes are noted to have multiple levels and transactional influence. Low levels of socioeconomic status (SES) and its associated risks (impoverishment, high crime rates, family crowding, multiple family transitions, unemployment, school-based violence etc.) are indentified risks for ODD/CD. Research links the developmental pathways and propensity of life course persistence of these disorders to the constellation of socioeconomic in combination with other risk factors. Poverty and low social support in socioeconomic disadvantage propel the continuation, intensification, and chronicity of early aggressive behaviour patterns into later childhood and adolescence (Mash & Barkley, 2003, p. 165). Components of low SES operate in a transactional manner which influences levels of current risk. Particularly interesting is the potential influence of interactive and protective factors (e.g. positive family variables) to reduce risk and effects of low SES environments. No one risk factor may be identified as the sole causal mechanism, as emphasized by Mash & Barkley (2003) combinations of risk factors, interacting and transacting in chain-like fashion, are crucial for the development of persistent aggression and ASB (p. 170). Substance Use Disorders Substance Use Disorders (SUD) refer to Substance Dependence and Substance Abuse disorders, and are related to the maladaptive use of alcohol and other drugs (Mash & Barkley,

18 APSY 651 Final Exam , p. 200). Both disorders include a pattern of substance use that leads to significant impairment or distress. The DSM-IV-TR (2000) provides the following features of Substance Dependence; repeated self-administration, tolerance, withdrawal, and compulsive use that may include physiological dependence. Those with Substance Dependence may take the substances in larger amounts or over longer periods of time, and the individual s failure to abstain from using the substance despite evidence of the difficulties it is causing. Features of Substance Abuse include recurrent and significant adverse consequences related to the repeated use of substances, with failure to fulfill major role obligations, use in physically hazardous situations, multiple legal problems, and recurrent social and interpersonal problems. Individuals with Substance Abuse will repeatedly demonstrate intoxication or other substance related symptoms, absences, and continued use despite the persistent negative consequences. An important feature of SUD is it s heterogeneity that results in different possible trajectories. For the purpose of this discussion the broader term of SUD will be used in accordance with how information is referenced for both disorders by Mash & Barkley (2003). Diagnostic Challenges Unique diagnostic challenges for SUD are summarized. Research suggests the separate diagnosis of Substance Dependence and Substance Abuse does not adequately reflect the nature of substance use problems in adolescence, noting that the concept and definition vary across the different systems when applied to adolescents. The type and pattern of adolescent symptomology is not reflected by the current adult criteria. Additionally seen in adolescents with SUD are affective symptoms, blackouts, reduced activity levels, cravings, risky sexual behaviour, poor academic achievement, engagement in delinquent behaviours or deviant peer group, and frequent negative interactions with peers. There is variability in how teens

19 APSY 651 Final Exam 19 experience physiological dependence and the symptoms are demonstrated in different situations. As research in the field progresses in identifying unique features of adolescents modifications to the diagnostic criteria and classification system may result. Critical Issues Some substance use is normative within the adolescent years; however, it involves many possible adverse outcomes and consequences for both individuals and communities. SUD increases the risk and level of severity of these consequences with long-term impact. Mash & Barkley (2003) discuss SUD consequences; impaired driving, mortality, morbidity, impaired developmental competence and psychosocial functioning, and polydrug use. The ramifications of these consequences and outcomes are a critical issue for individual and public health concern. Societal conceptualizations and attitudes of SUD will shape resulting legislation, prevention programs, and treatment options. Professionals may examine additional issues resulting from research to contribute to understanding SUD, as they are not included in the scope of this paper. Comorbidity of SUD and other disorders is a critical issue in understanding the complex connections and consistency of patterns. Most commonly SUD is comorbid with ADHD, ODD/CD, and to a lesser degree mood and anxiety disorders. Connections of SUD and ADHD are controversial when considering the concurrent presence of OD/CDD. Given the high rate of comorbidity, SUD may be considered a manifestation resulting from behavioural problems. Self-medicating is often referred to in this situation, and will present different treatment considerations that affect a wide range of health providers and collaboration of services. Developmental progression is discussed by Mash & Barkley (2003) substance use and substance use disorders show systematic age-related patterns from adolescence into adulthood (p. 207). As substance use typically begins in adolescence, some use is identified as statistically

20 APSY 651 Final Exam 20 normative, with the majority of adolescents demonstrating benign outcomes. Early onset is linked with increased chance of developing SUD, with patterns of steep escalation and more pernicious outcomes. Late onset has been linked to decreased parental supervision experienced in late adolescence. Research identifies peak use and diagnosis of SUD at the stage of emerging adulthood (Mash & Barkley, 2003, p. 208), yet prevention programs are targeted for earlier stages of development. This gap may indicate an area for future research and development. The protective factor of transitioning into adult roles is noted, citing reduced rates of use and SUD during that stage of development. SUD is not necessarily a persistent life disorder, although efforts in treatment to address use and relapse are necessary. Role of Gender Examination of gender provides further insights into SUD. Noted by Mash & Barkley (2003) generally girls tend to use fewer drugs on a less frequent basis at the higher grades, while at younger grades there are similar rates (p. 205). Prevalence may be affected by developmental processes during adolescence. Males are reported to have higher use of heroin, LSD, steroids, tobacco, and daily use of alcohol and marijuana; while girls show higher rates of inhalants, tranquilizers, and amphetamines. Investigation to the motives behind drug choice (use) demonstrates that males and females use drugs for different reasons; social and mood enhancement for males and coping and conformity for females. A noted difference occurs at older ages when females report higher use of tobacco for regulation of weight and anxiety. Different motives will need to be addressed in prevention and treatment programs at all levels. Risk Factors Risk factors for SUD are identified within a range of levels. Due to the heterogenic nature of SUD, multiple mechanisms likely contribute to the condition. Much of the research

21 APSY 651 Final Exam 21 into risk factors is completed for substance use, but it is suggested that similar effects exist for SUD. Mash & Barkley (2003) review three submodels to explain vulnerability that include specific risk factors. In depth details of the models will not be discussed given the scope of the paper, but a brief review of the associated risks is summarized; temperament and personality (poor self-regulation, low self-esteem, impulsivity, aggression, neurochemical and neuroendicrine responses, heritability ), cognitive functioning (low executive functioning), parenting and socialization (history of use/abuse, style, support, monitoring, conflicts, socialization of drugs), school failure and academic aspirations (increase stress and negative attachment, weaken school attachment), peer influences (deviant peer groups, peer selection and influence), childhood conduct problems, environmental stress, emotional distress or negative affect, alcohol (drug) expectancies and pharmacological effects, and macro-level influences of school and neighbourhoods (social norms, drug access, sanctions/punishments). Of note is the concept of intergenerational transmission of risk which involves multiple interrelated biophysical pathways interacting with the consequences of SUD and environments. More research into the effects of SES as a risk factor is needed due to differing results; however, SUD is present among all levels of SES. Any of the factors identified may play a role in increased risk or potential protective factors, and the interplay between factors are not exclusive. A complex transactional process occurs within the multiple levels of mechanisms. Prevention and treatment programs can be applied to these multi-layers to increase positive outcomes of SUD. Critical Comparison of Disorders Many commonalities exist between ODD/CD and SUD, as might be expected as they are all disorders of behaviour with a high rate of comorbidity between the disorders. The

22 APSY 651 Final Exam 22 heterogenic nature of the group of disorders contributes both to the similarities as well as salient differences. Examination of diagnostic features illustrates a few similarities among all three disorders that exist which include; low self-esteem, low frustration tolerance, reckless behaviour, and illegal activity. Both ODD and SUD involve symptoms of normative behaviour that are demonstrated with either higher severity or frequency in comparison to age norms. Distinctive features between the disorders provide clarification and greater detail for diagnosis. Of note in this regard are pharmalogical effects and physiological symptoms for Substance Dependence Disorder, alcohol or drug use as an inclusionary criteria for ODD, various forms of aggression for ODD/CD, hostile and negativistic symptoms for ODD/CD, the concept of role obligations in SUD, and ODD recognized in children are key differences. Critical issues provide insight into some of the shared concerns surrounding the disorders. ODD/CD and SUD have high comorbid rates with ADHD, and to a lesser extent mood and anxiety disorders. Age of onset (early) and comorbidity are related to more pernicious outcomes, gender results in different expressions, and multiple risk factors are common within these disorders. Rather than a review of the majority of risk factors, perhaps clearer insight is provided by what differentiates the disorders in these issues. Genetic vulnerability is more widely accepted in SUD, ODD/CD show more relative stability, family structure and low SES are not identified as risk factors for SUD, and SUD has higher involvement with system level prevention and treatment programs. Regardless of similarities and differences, ODD/CD and SUD are heterogeneous in nature and involve transactional processes of multiple level factors, pathways, variables, and mechanisms. Simple explanations or conceptualizations will not lead to a deeper appreciation or understanding of the disorders or implications for practice.

23 APSY 651 Final Exam 23 Conclusion In general terms ODD/CD and SUD result in personal impairment on many levels (social, academic, etc.), with violation of social norms that impact communities and result in high levels of social concern. Public interpretations of children and adolescents with these disorders (accurate or not) result in significant ramifications for the individuals associated with the labels and system level prevention and treatment programs. Professionals may use research and knowledge of the disorders, and practical experience to advocate for these children and services..

24 APSY 651 Final Exam 24 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision. Washington, DC. American Psychiatric Association. Mash, E. J., Barkley, R. A. (2003). Child Psychopathology (2 nd ed.). New York, NY: The Guilford Press.