COURSES ARTICLE - THERAPYTOOLS.US

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1 COURSES ARTICLE - THERAPYTOOLS.US Conduct Disorder Conduct Disorder A Clinical Information Guide Course meets the qualifications for2 hours of continuing education credit for MFTs and/or LCSWs as required by the California Board of Behavioral Sciences" Course Objectives: Upon completion of this course, the LCSW or MFT or Healthcare professional will be able to Identify: INCIDENCE AND PREVALENCE of Conduct Disorders, Etiology, Symptoms and Diagnosis of Conduct Disorder, and Assessment and Treatment of Conduct Disorders. INTRODUCTION Conduct Disorder is a psychiatric disorder of childhood and adolescence that is characterized by a persistent disregard for societal norms and rules, as manifested by aggression toward people or animals, destruction of property, theft or persistent lying, and other serious rule violations such as truancy and running away from home.1 Oppositional Defiant Disorder is a psychiatric disorder of childhood and adolescence that is characterized by a persistent pattern of negativist, hostile, or defiant behaviors. Hallmark behaviors of this disorder include frequent arguments with adults, disregard of rules, refusal to comply with the requests of adults, loss of temper, vindictive or spiteful acts, and displays of anger or resentment.1 Conduct Disorder encompasses a more serious disregard for societal norms than Oppositional Defiant Disorder. In both diagnoses, the behaviors must occur more frequently than expected given the child or adolescent's age or developmental level, and must cause significant impairment in social, academic, or occupational functioning. INCIDENCE AND PREVALENCE Conduct disorder is one of the most frequently diagnosed disorders of childhood and adolescence.1 Currently, two to six percent, or from one to four million children and adolescents in the United States have Conduct Disorder.41 Conduct Disorder is as prevalent in preadolescent youths as in adolescent youths. Research has found prevalence rates of Conduct Disorder from six to 16 percent for boys and two to nine percent for girls.1, 6,7 The prevalence of Oppositional Defiant Disorder is two to 16 percent. After puberty, Oppositional Defiant Disorder is as prevalent in girls as in boys. Youth diagnosed with Conduct Disorder and Oppositional Defiant Disorder show a high rate of co-morbidity with other psychiatric diagnoses, including depression, mania, and substance abuse disorders. Approximately 30 to 50% of adolescents diagnosed with Conduct Disorder have a substance abuse disorder. 40% of youth diagnosed with Conduct Disorder meet criteria for mania.15, 16, 17 According to researchers, this pattern of co-morbidity exists at the same rates in preadolescent and adolescents, regardless of gender.5,18 ETIOLOGY

2 There has been much speculation about the cause of Conduct Disorders. Conduct Disorder has been linked to brain damage, genetic vulnerability, school failure, traumatic life experiences, and physical and sex abuse during childhood A recent seven year longitudinal study of 177 boys ages 7- to 12-years-old examined physical fighting in childhood as a risk factor for the development of mental health problems in later life. In this study, conduct disorder was best predicted by Oppositional Defiant Disorder in year one and persistent fighting over the seven years. At year seven of the study, persistent fighting was significantly associated with psychiatric impairment.48 Young children with Attention Deficit Hyperactivity Disorder (ADHD; a psychiatric disorder characterized by poor impulse control, attentional problems, and hyperactivity) are at greater risk for developing Conduct Disorder during adolescence and adulthood.17,18,19 While many studies have shown that children with ADHD suffer some deficits in auditory information processing, a recent study found that children having both ADHD and Conduct Disorder possess a greater deficit in auditory information processing than ADHD alone.50 Another study found that children having both Conduct Disorder and ADHD symptoms are at greater risk for developing persistent antisocial behaviors. Finally, family factors appear to contribute to the development of Conduct Disorder and Oppositional Defiant Disorder. Research shows a high correlation between these disorders and low socioeconomic status, poor parenting, parental alcoholism, and parental antisocial personality disorder SYMPTOMS AND DIAGNOSIS The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) describes Conduct Disorder as an ongoing pattern of behaviors that clearly violate the rights of others or disregard the accepted rules of home, school, or community. Oppositional Defiant Disorder is characterized by an ongoing pattern of behaviors that are defiant and hostile towards others, particularly toward authority figures. 53 In both Conduct Disorder and Oppositional Defiant Disorder, the behaviors must occur more frequently than is typically observed in individuals of comparable age and developmental level and must cause significant impairment in social, academic, or occupational functioning. Age of onset is important when considering a diagnosis of Conduct Disorder or Oppositional Defiant Disorder. The age of onset for Oppositional Defiant Disorder is much younger than that for Conduct Disorder. Many youths diagnosed with Conduct Disorder have a history of Oppositional Defiant Disorder, but not all Oppositional Defiant Disorder cases will progress to Conduct Disorder.53 When Oppositional Defiant Disorder develops into Conduct Disorder, the behaviors initially seen may include fighting, bullying, lying, and vandalism. Later Conduct Disorder behaviors may include school vandalism, running away, truancy, shoplifting, breaking and entering, rape, aggravated assault, and homicide. The DSM-IV diagnostic criteria for Conduct Disorder are: 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 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 six months: 1. Aggression to people and animals

3 Often bullies, threatens, or intimidates others Often initiates physical fights Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) Has been physically cruel to people Has been physically cruel to animals Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) Has forced someone into sexual activity 2. Destruction of property Has deliberately engaged in fire setting with the intention of causing serious damage Has deliberately destroyed others' property (other than by fire setting) 3. Deceitfulness or theft Has broken into someone else's house, building, or car Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others) Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering) 4. Serious violations of rules Often stays out at night despite parental prohibitions, beginning before age 13 years Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy time period) Is often truant from school, beginning before age 13 years B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. The DSM-IV diagnostic criteria for Oppositional Defiant Disorder are: A. A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four (or more) of the following are present: Often loses temper Often argues with adults Often actively defies or refuses to comply with adults' requests or rules Often deliberately annoys people Often blames others for his or her mistakes or misbehavior Is often touchy or easily annoyed by others Is often angry and resentful Is often spiteful or vindictive DSM-IV notes that a criterion is met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. B. The disturbance in behavior causes clinically significant impairment in social, academic, occupational functioning. C. Criteria are not met for a Conduct Disorder. Note that a person cannot be diagnosed with both Conduct Disorder and Oppositional Defiant Disorder. As a result, the youth who meets the criteria for both diagnoses is

4 diagnosed with Conduct Disorder.1 Conduct Disorder Throughout the Lifespan When diagnosing Conduct Disorder, the DSM-IV emphasizes the age of onset of problematic behavior. For cases of Childhood-Onset Conduct Disorder, at least one criterion of the disorder is met prior to age ten years. For cases of Adolescent-Onset, no criteria of the disorder appears prior to age ten years. Some experts have argued that children with Childhood-Onset Conduct Disorder learn maladaptive behaviors first through social interactions in the home; the scope of these maladaptive behaviors are broadened through contact with a deviant peer group, such as friends who engage in illegal activities and have little contact with pro-social activities. The distinction between Child- and Adolescent-Onset is important because some researchers hold that children with onset of Conduct Disorder after age ten are more likely to discontinue their antisocial behavior prior to adulthood than the Child-Onset onset group. 39-a,40-a Thus, a child who exhibits antisocial behaviors during preschool and elementary school is at greater risk for continuing antisocial behaviors as an adult.52 ASSESSMENT A comprehensive assessment of Conduct Disorder and Oppositional Defiant Disorder should include multiple methods of measurement, including: 54,55 1. Reports and ratings of significant others, including parents, teachers, and therapists. Different reporters have unique perspectives. For example, some adults may view certain behaviors as aversive or problematic, while other adults may view the same behaviors as neutral. In one study, mothers of children with behavior problems tended to rate their children as "deviant" more often than both independent observers and the mothers of children having no problem behaviors Ratings scales such as the Child Behavior Checklist (please see below) is a measure that allows caregivers and people close to the child to report conduct problems. 2. Direct observation of the child's behavior in multiple settings (e.g., home, school, community) collected at multiple points in time. This method works well for observing overt behaviors, such as arguing and fighting. On the other hand, covert behaviors such as drug use or sexual promiscuity are not easy to observe. 3. Institutional Records, including police records that document arrests and station adjustments, and school records that document grades, suspensions, and expulsions. 4. Self report measures can be effective ways to document covert behaviors, such as vandalism, theft, and drug use. The Child Behavior Checklist, and scales of the Minnesota Multiphasic Personality Inventory Adolescent Version (MMPI-A) are often used to assess conduct problems. Child Behavior Checklist - Designed for youth between the ages of years, this measure is used in both clinical and research settings. The test is composed of an extensive list of problem behaviors and numerous questions relating to the child's academic and social-pro-social functioning Scales pertaining to conduct-disordered behaviors include: "Delinquent Behavior," "Aggressive Behavior," and "Attention Problems." Normative data for the Child Behavior Checklist allow the clinician to compare the child's score to the scores of other children in the general population. Different forms of the test are available to collect data from parents, teachers, and children. TREATMENT

5 Early intervention for children exhibiting conduct problems is critical. Research has found that children with a history of childhood conduct problems are more likely than children without these problems to develop problems as adults that include alcohol abuse, psychiatric problems, marital problems, poor work performance, and poor physical health. 11,15,17,27,28,30,31 In addition, one study found that adolescent girls with conduct problems were more likely than children without these problems to become young mothers, to be single parents, and to have children who display early signs of psychosocial maladjustment. 32 Treating Conduct Disorder and Oppositional Defiant Disorder is complex and challenging. Children are frequently uncooperative and often harbor chronic feelings of fear and mistrust towards authority. Treatment usually involves a multi-modal intervention plan that includes a combination of psychosocial interventions and medication. Commonly used psychosocial treatments include parent training, family therapy, social skills training, and group therapy. Psychosocial Interventions Parent and Child Training Many researchers believe that treatment of Conduct Disorder and Oppositional Defiant Disorder should include interventions directed at improving parenting. In a study of children with early onset conduct problems, treatments consisting of both child training and parent training were more effective than either treatment alone.36 Cognitive problem-solving skills training for youth combined with parent management training for parents produced beneficial changes in the youth and improved parent and family functioning. 37 In this same study, a child's ability to sustain long-term benefits of treatment depended on his or her parent's willingness to participate in treatment. Youth whose parents were less cooperative in treatment were more likely to need additional psychiatric or social service intervention during the five years after their initial treatment.37 Dyadic Skills Training This treatment approach is based on the idea that children exhibit antisocial or conduct-disordered behaviors because they experience non-responsive or faulty care-giving during infancy and early childhood. Faulty care-giving leads to the development of insecure attachments, which in turn cause the child to be exhibit conduct problems.67 Dyadic skills training consists of 12 to 18 one hour per week sessions designed for pre-school age children and their parents. Dyadic skills training is recommended when (a) attachment issues are clearly a problem for the parent and child, and (b) parents have difficulty demonstrating positive, accepting feelings toward the child. During treatment, the clinician teaches the parents about children's social, cognitive, and emotional development. Clinicians frequently give homework assignments and use role-playing and videotaping to help parents learn to set limits, problem-solve, and reframe a child's "negative behaviors." Dyadic skills training for youth combined with management training for parents can produce beneficial changes in youth and improve long-term parent and family functioning. 37 Family Therapy Family-based interventions which focus on improving communication within the family have had some success in treating conduct problems In family therapy, the primary goal is to change dysfunctional family systems, clarify family roles, and promote honest and open communication among family members. Family therapy is believed to be a most effective with children who are in early to mid-adolescence and who have not exhibited the most serious conduct problems (e.g., running away, truancy, theft). In one research study, children whose families received family

6 therapy had lower rates of recidivism for low-level offenses for up to six to 18 months following treatment.65 Follow-up studies revealed that siblings who participated in treatment also had a lower rate of police involvement following treatment.66 Multisystemic therapy (MST) A variation of traditional family therapy, MST appears to be an effective method for treating the externalizing and antisocial behaviors of youth in mid to late adolescence. 34 MST focuses on modifying systems that maintain the child's conduct-disordered behaviors, including family, school, peer and community. The primary goal of MST is to provide parents or caregivers with the skills and resources necessary to independently address challenges presented by their children. In MST, the role of the clinician is to assess family strengths, to help the family clarify problems, and to set reasonable short- and long-term goals. In addition, the therapist may work with the child's school, or may assist the caregiver in finding transportation, childcare, food, and medical care. At the conclusion of the first meeting, the clinician provides the family with an action or treatment plan that details problems, goals, and assignments for family members and the clinician. Treatment and assessment are believed to be an ongoing process. Once treatment is terminated, follow-up sessions are made available to the family if needed. While research has been limited, MST has been successful with children who are at imminent risk of being institutionalized due to their chronic delinquent behavior. MST is less expensive than psychiatric hospitalization and appears to improve school attendance and family functioning and to reduce externalizing behavior.35 In a study comparing the effectiveness of MST to "eclectic" (psychodynamic, client-centered, or behavior) individual therapy, participants who completed MST had a 22 percent rate of recidivism compared to 71 percent for those who completed individual therapy. Group Therapy Group therapies, including community-center groups and day-camp groups, attempt to promote change within group settings. In Community Center group therapy, researchers have suggested that minimizing contact with deviant peers and maximizing contact with prosocial peers in supervised settings may decrease conduct-disordered behavior. Recall that many researchers believe peer groups play a prominent role in a child developing antisocial or conduct-disordered behaviors.68 Community Center group therapy, designed for all school-age children, utilizes two basic group approaches: social learning and traditional. In social learning groups, clinicians apply principles of behavior modification (e.g., reinforcement, modeling, role-playing) to increase the frequency of desired behaviors. In traditional groups, the clinician emphasizes rules, norms and consequences rather than behavior modification principles. Social learning and traditional groups consist of 10 to 15 children who meet weekly for approximately three hours throughout the school year. Regardless of the method of group therapy, children who exhibit conduct-disordered behaviors tend to improve more when they are placed in groups with children who do not exhibit these behaviors than when they are placed in groups comprised of other conduct-disordered children.71 Day Treatment Day treatment programs have shown promise for treating youth who cannot be treated successfully on an outpatient basis.38,39 One study found that youth diagnosed with Conduct Disorder or Oppositional Defiant Disorder who were involved in a multi-modal day treatment program utilizing a combination of pharmacological intervention, various forms of individual and group therapy, and family therapy maintained the benefits of treatment over a

7 five-year period. 39 A second study found that a partial hospitalization program, which included Methylpenidate in combination with behavior therapy, resulted in a decrease in oppositional behavior and an increase in positive social behavior.38 Psychodynamic or Insight-Oriented Therapy Psychodynamic or insight-oriented individual and group psychotherapy have not been found effective for treating Conduct Disorder or Oppositional Defiant Disorder.33,23 70 Medication The majority of research states that psychopharmacological treatment alone appears to be an ineffective method of treating Conduct Disorder and Oppositional Defiant Disorder. Still, medication can be an effective means of treating some of the symptoms associated with conduct disorder or of treating comorbid disorders. For example, it is hypothesized that reducing the symptoms of Attention Deficit Hyperactivity Disorder could facilitate treatment of other disorders. In a pilot study, Bupropion was found to be an effective intervention for reducing the symptoms associated with ADHD among adolescents diagnosed with Conduct Disorder.24 Similarly, preliminary findings suggest that youth suffering from ADHD and comorbidity Conduct Disorder or Oppositional Defiant Disorder showed a decrease in symptoms associated with each disorder over a three-month period when treated with Clonidine, Methylphenidate, or a combination of each medication. 25 References 1. American Psychiatric Association.. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; Biederman J, Faraone S, Milberger S, Jetton J, Chen L, Mick E, Green R, Russell R, (1996). Is childhood Oppositional Defiant Disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD. Journal of the American Academy of Child Adolescent Psychiatry, 35: Langbehn D, Cadoret R, Yates W, Troughton E, Stewart M, (1998). Distinct contributions of conduct and oppositional defiant symptoms to adult antisocial behavior: Evidence from an adoption study. Archives of General Psychiatry, 55: Zoccolillo M, Pickles A, Quinton D, Rutter M, (1992). The outcome of childhood conduct disorder: Implications for defining antisocial personality disorder and conduct disorder. Psychological Medicine, 22: Reebye R, Moretti, M, Lessard, J, (1995). Conduct disorder and substance use disorder: comorbidity in a clinical sample of preadolescents and adolescents. Canadian Journal of Psychiatry, 40: Siminoff E, Pickles A, Meyer J, Silberg J, Maes H, Loeber R, Rutter M, Hewitt J, Eavers L, (1997). The Virginia twin study of adolescent behavioral development: Influences of age, sex, and impairment on rates of disorder. Archives of General Psychiatry 54: Carlson C, Tamm L, Gaub M, (1997). Gender differences in children with ADHD, Oppositional Defiant Disorder, and co-occurring ADHD/Oppositional Defiant Disorder identified win a school population.,journal of the American Academy of Child and Adolescent Psychiatry, 36: Hinshaw S, Anderson C, (1996). Conduct and Oppositional Defiant Disorders. In Mash E, Barkley R, (Eds.), Child Psychopathology (pp ). New York: Guilford Press. 9. Toupin J, Dery M, Pauze R, M, Fortin L, (2000). Cognitive and familial contributions to conduct disorder in children. Journal of child Psychology and Psychiatry 41: Rey J, Walter G, Plapp J, Denshire E, (2000). Family environment in attention deficit hyperactivity, oppositional defiant, and conduct disorders. Australian & New Zealand Journal of Psychiatry 34: Lahey B, Loeber R, Hart E, Frick P, Applegate B, Zhang Q, Green S, Russo M, (1995). Four-year longitudinal study of conduct disorder in boys: Patterns of predictors of

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10 as a risk factor for later mental health problems. Journal of American Academy of Child Adolescent Psychiatry, 4, Schulenberg, S.E. & Soundy, T. (2000). Epidemiology of physical and sexual abuse in young persons diagnosed with conduct disorder: A retrospective chart review. SDJ Medicine, 53, Rothenberger, A., Banaschewski, T., Heinrich, H., Moll, G.H., Schmidt, M.H., Van't Klooster, B. (2000). Comorbidity in ADHD-children: Effects of coexisting conduct disorder or tic disorder on event-related brain potentials in an auditory selective-attention task. European Archives of Psychiatric Clinical Neurosciences, 250, (2), Toupin, J., Drey, M., Pauze, R., Mercier, H., and Fortin, L. (2000). Cognitive and familial contributions to conduct disorder in children. Journal of Child Psychology and Psychiatry, 3, Kazdin, A.E. (1987). Conduct disorder in childhood and adolescence. Newbury Park, CA: Sage. 53. Loeber, R., Lahey, B., & Thomas, C. (1991). Diagnostic conundrum of Oppositional Defiant Disorder and conduct disorder. Journal of Abnormal Psychology, 100, (3), Practice parameters for the assessment and treatment of children and adolescents with conduct disorder. (1997). Journal of American Academy of Child and Adolescent Psychiatry, 36, October (36) 122S-139S. 55. Patterson, G..R., Reid, J.B., & Dishion, T.J. (1992). Antisocial Boys. Eigene, OR: Castalia. 56. Achenbach, T.M. (1991). Manual for the Child Behavior Checklist-4/18 and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry. 57. Achenbach, T.M. (1991). Manual for the Teacher's Report Form and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry. 58. Achenbach, T.M. (1991). Manual for the Youth Self-Report and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry. 59. Pelham, W.E., Gnagy, E.M., Greenslade, K.E., & Milich, R. (1992). Teacher ratings of the DSM III-R symptoms for the disruptive behavior disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 31, Pelham, W.E., Evans, S.W., Gnagy, E.M., & Greenslade, K.E. (1992). Teacher ratings of the DSM III-R symptoms for the disruptive behavior disorders: Prevalence, factor analyses, and conditional probabilities in a special education sample. Journal of the American Academy of Child and Adolescent Psychiatry, 31, Craighead, W.E., Curry, J.F., & Hardi, S.S. (1995). Relationship of children's depression inventory factors to major depression among adolescents. Psychological Assessment, 7 (2), Kazdin, A.E. (1985) Treatment of antisocial behavior in children and adolescents. Homewood, IL: Dorsey Press. 63. Jacob, T. (1975). Family interaction in disturbed and normal families: A methodological and substantive review. Psychological Bulletin, 82, Jacob, T. (Ed.) (1987). Family interaction and psychopathology: Theories, methods, and findings. New York: Plenum Press. 65. Alexander, J.F., & Parsons, B.V. (1982). Short-term behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81, Klein, N.C., Alexander, J.F. & & Parsons, B.V. (1977). Impact of family systems intervention on recidivism and sibling delinquency: A model of primary prevention and program evaluation. Journal of Consulting and Clinical Psychology, 45, Speltz, M.L. (1990). The treatment of preschool conduct problems: An integration of behavioral and attachment concepts. In M.T. Greenberg, D. Cicchetti, & M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp ). Chicago: University of Chicago Press.

11 68. Feldman, R.A. (1992). The St. Louis experiment: Effective treatment of antisocial youths in prosocial peer groups. In J. McCod & R.E. Tremblay (Eds.). Preventing antisocial behavior. (pp ). New York: Guilford Press 69. Feldman, R.A., Caplinger, T.E., & Wodarski, J.S. (1982). The St. Louis conundrum: The effective treatment of antisocial youths. Englewood Cliffs, N.J: Prentice Hall. 70. Kazdin, A.E. (1985). Treatment of antisocial behavior in children and adolescents. Homewood, IL: Dorsey Press. 71. Dishion, T.J., & Andrews, D.W. (1995). Prevention escalation in problem behaviors with high-risk young adolescents: Immediate and one-year outcome. Journal of Consulting and Clinical Psychology, 63, Copyright 2011 THERAPYTOOLS.US All rights reserved