Conduct Disorder and Oppositional Defiant Disorder

What are the identifying features of Oppositional Defiant Disorder (ODD)?

Oppositional Defiant Disorder (ODD) is characterized by a persistent pattern of angry and irritable mood and defiant or vindictive behavior. Symptoms can be shown toward parent, teachers, and/or peers.

- Most symptoms must be shown for at least 6 months, indicating long-standing oppositional behavior.

- Symptoms must be developmentally unexpected and interfere with children's social or academic functioning.

What are the identifying features of Conduct Disorder (CD)

Conduct Disorder (CD) is a more serious condition characterized by repetitive behaviors in which the basic rights of others and age-appropriate social norms are violated. Symptoms fall into four groups:

- Aggression to people and animals

- Destruction of property

- Deceitfulness or theft

- Age-inappropriate rule violations (e.g., truancy, staying out all night)

Conduct problems are related to antisocial behavior!

(Age-inappropriate actions and attitudes that violate family expectations, societal norms, and the personal or property rights of others; Not necessarily considered a mental disorder)

Delinquency

Legal term for antisocial behavior

Conduct disorder: externalizing behavior:

Mix of impulsive, overactive, aggressive, and delinquent acts)

What are the three main symptom clusters for ODD?

Children with ODD show at least four symptoms of noncompliant and defiant behavior toward adults that fall into three groups:

1. *Angry or irritable mood*

- losing temper

- being touchy/easily annoyed, angry and resentful)

- easily annoyed by others, acting angry and resentful)

2. *Argumentative or defiant behavior*

- arguing with adults

- defying adults' requests or refuses to comply deliberately annoying others

- blaming others for his or her own behavior)

3. *Vindictiveness* (at least twice in past 6 months)

- acting spiteful

- seeking revenge against others

ODD: Why are the different specifiers important and what do they indicate?

These symptoms cause distress in the individual or others in his or her immediate social context, or impacts negatively on social, educational, occupational, or other areas of functioning.

The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

What are the four main symptom clusters for CD?

For 12 months or more has repeatedly violated rules, age-appropriate societal norms or the rights of others. Shown by 3 or more of the following, with at least one of the following occurring in the past 6 months:

(a) *aggression to people and animals*

- Aggression to people and animals involves initiating physical fights, physical cruelty to or assault of others, robbery (with confrontation), forced sex, often starts fights, bulling or threatening, use weapons that could cause serious injury

(b) *destruction of property*

- Destruction of property involves intentionally damaging others' belongings through vandalism, arson, or other reckless acts.... Notes: Deliberately set fires to cause serious damageDeliberately destroyed the property of others (except fire-setting)???

(c) *deceitfulness or theft*

- Deceitful behaviors include breaking and entering, stealing (without confrontation like burglary, forgery, shoplifting), or lying to earn a reward or to avoid a responsibility (conning).

(d) *serious violations of rules*

- Beginning by age twelve, frequently stayed out at night against parents' wishes

- Runaway from parents overnight twice or more (once if for an extended period)

- Frequent truancy before age 13

Conduct disorder: Why are the different specifiers important and what do they indicate?

*Childhood-onset type*: Individuals show at least one symptom characteristic of Conduct Disorder prior to age 10 years.

*Adolescent-onset type*: Individuals show no symptom characteristic of Conduct Disorder prior to age 10 years.

*Unspecified onset*: Criteria for a diagnosis of Conduct Disorder are met, but there is not enough available to determine

whether the onset of the first symptom was before or after age 10 years.

Specify current severity:

*Mild*: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relative minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking).

*Moderate*: The number of conduct problems and the effect on others are intermediate between those specified in "mild" and those in "severe" (e.g., stealing without confronting a victim, vandalism).

*Severe*: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause

considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking

and entering).

Identify three ways in which ODD and CD differ from one another. **

Key ODD features:

- Argumentativeness

- Noncompliance with rules and negativism

- Emotion regulation problems (not included in CD definition)

Children with ODD typically do not 1) show physical aggression to people or animals, 2) deliberately destroy property, or 3) frequently engage in theft and deceitfulness

In what way can CD be viewed as an extension of ODD into late childhood and adolescence? **

Children with ODD and CD show the same pattern of oppositional, defiant, and disrespectful attitudes toward adults in authority.

Some young children continue to show an increase in

oppositional and defiant behavior during early childhood and merit the diagnosis of ODD

Most experts view ODD and CD as distinct, but related,

disorders. Suggested that ODD is a precursor to CD in

some children. Although most children with ODD do not develop CD, a certain percentage of children will show more severe conduct problems.

PIC ON DESKTOP

Identify the factors that contribute to cause the development of ODD

50% variance attributable to genetics, 50% to environment (lions share = non shared and smaller percentage = shared)

Identify the factors that contribute to cause the development of CD?

TEMPERAMENTAL

- Difficult temperament

- High emotion reactivity

---> Don't learn effective emotion regulation skills

- Children may rely on impulsive decision-making

- Thrill-seeking and recklessness (with CD)

PSYCHOSOCIAL

- Peer rejection, selective affiliation with deviant peers, deviancy training

- High crime neighborhoods

- Parents may have trouble responding sensitively and appropriately

---> Can compromise parent-child interaction quality

- Parents may alternate between overly permissive and hostile and angry disciplinary tactics

---> Low parental monitoring

---> Maternal depression

---> Paternal substance abuse

Identify the factors that contribute to cause the development of antisocial behavior (even though it is related to CD...)

NEUROBIOLOGY

- Decreased NTs: Serotonin, Dopamine

- Increased hormones: Testosterone

- Low levels of autonomic arousal

- Underarousal of HPA axis

*Remember: For CD with LPE, also see hypoarousal of the amygdala*

COGNITIVE BEHAVIORAL

- Rewards for aggression (what types? podcast)

- Hostile attribution bias

- May perceive and label their own arousal as anger

--> Feeling excited from working out, and feel they must be angry

- Focus on positive aspects of aggression and lack of responsiveness to emotional stimuli

- *Social learning*

--> Modeling new aggressive behaviors, disinhibition of aggression

- *Reinforcement trap*

--> Giving in to a child's tantrum

-->Mother reinforces child's behavior and reinforces her own behavior

(What type of reinforcement?: Throw tantrum, then give them what they want, but they learn if they throw tantrums then they get what they want)

Identify comorbid disorders, and evaluate how they can be distinguished from CD?

*ADHD*: ADHD may be viewed as the "motor" which drives some children's oppositional and disruptive behavior. Question later that asks more

ODD (pod)

*Anxiety disorders*: It is likely that the relationship between conduct problems and anxiety depends on the personality characteristics of the child. Moderate levels of anxiety is good because then they fear punishment. However, certain children and adolescents have

personality traits that make them slow to respond to punishment. These children may have underactive BIS, making them persist in misbehavior despite threats of discipline these children and adolescents, comorbid anxiety might be associated with an increase in conduct problems, especially hostile and aggressive behaviors

*Depression*: According to the dual failure model, internalizing symptoms (including anxiety) occur in youths with conduct problems due to failure in (a) relationships and (b) academics.

*Substance use*: A common set of genes may underlie problems with both behavior and substance use. Furthermore, deviant peers often model and reinforce substance use to youths with CD

*Low academic achievement*: They are more likely to earn low grades, to repeat a grade, and to drop out of school before graduation than youths without conduct problems (Kazdin, 2005b). Disruptive youths

usually show problems in critical areas of academic achievement, especially reading and mathematics. Low income schools don't help.

Identify comorbid disorders, and evaluate how they can be distinguished from ODD?

- Often (but not always) precedes the development of conduct disorder (CD)

Comorbid with:

- *Anxiety disorders & Major depressive disorder* According to the dual failure model, internalizing symptoms occur in youths with conduct problems due to failure in (a) relationships and (b) academics.

*Substance use* A common set of genes may underlie problems with both behavior and substance use. Furthermore, deviant peers often model and reinforce substance use to youths with CD

Review the effectiveness of Parent Management Training for young children with conduct problems. What are the limitations of this type of interventions?

*Parent Management Training (PMT)*

- Teach parents the causes of disruptive behavior problems

- Show parents how to attend to and praise appropriate behavior immediately and consistently

- Time out for serious rule violations

- Structure the environment to help their children behave

- Generalize to other settings

Pros:

Functioning similar to peers without conduct problems for at least 3 years

Cons:

Less effective for parents under high stress

Seems to be less effective for adolescents, over whom parents have less control

Few clinicians in the community are skilled in PMT

Review the effectiveness of Parent-Child Interaction Therapy for young children with conduct problems. What are the limitations of this type of interventions?

*Parent-Child Interaction Therapy (PCIT)*

- Parents and children attend therapy together

- Parents develop skills: Praising, Reflecting, Imitating, Describing, Enthusiasm

- Parents create more realistic expectations for children's behavior

- Give effective, clear, concrete commands followed by praise or discipline

- Identify child's cognitive deficiencies and approaches to social situations

- Improvements are maintained for at least 1-2 years

- Hands on approach to PMT

Pros:

- effective at reducing disruptive behavior in very young children, both at home and in the classroom

- seems to improve the sensitivity and care parents show to their children, decrease parental hostility and criticism toward their children, and reduce parenting stress

Cons:??

Identify and explain the practices used in evidence-based therapies and their strengths and weaknesses in

treating CD and ODD: Multisystemic Treatment (MST)

(What is Multisystemtic Therapy? Why is it particularly effective for adolescents with conduct problems?)

*Multisystemic Treatment (MST)*

- Targets family, school, and peers

- Therapists work in teams of 3-5 and are available 24/7

- Usually lasts 3 months

Pros:

- Family

--> Help parents effectively interact with and monitor kids

Remove obstacles that interfere

- School

--> Increase parental involvement in education

Remove obstacles to academic achievement

- Peers

--> Limit opportunities for interactions with deviant peers

--> Increase interactions with prosocial youths/new peer networks

*Lowers probability of future offenses and arrests*

Cons:

- Only available to ~1% of adolescents with serious conduct problems

- Costly, but not as much as incarceration

Identify two potential weaknesses in the DSM-5 diagnostic criteria for CD?

Why might a clinician ask parents at what age their children's conduct problems began to emerge?

FOR COMPLETE DIAGNOSIS: Always include ALL appropriate specifiers for a complete (and accurate) diagnosis

Specify whether:

*Childhood-onset type*: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.

*Adolescent-onset type*: Individuals show no symptoms characteristic of conduct disorder prior to age 10 years.

*Unspecified onset*: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.

Why are adolescent girls less likely to be diagnosed with CD than adolescent boys?

Girls tend to exhibit relational aggression; that is, they harm other people's mood, self-concept, or social status by damaging or manipulating interpersonal relationships

Should the DSM-5 for Conduct Disorder be changed to include symptoms of relational aggression? If so,

what might be some of the symptoms of relational aggression?

Yes, the book says these symptoms are overlooked. Think physical vs relational aggression, still harmful. (may learn to use relational aggression to express anger, frustration, and discontent. relational aggression may be more effective than physical aggression at harming other girls! girls' relatively more advanced language skills make relational aggression possible)

Symptoms: Spread rumors, ostracize another girl from a social network, share another girl's secrets without her consent, steal another girl's on-line identity, or make fun of another girl's weight, clothes, or general appearance. These tactics can be used either reactively (e.g., because the girl is angry at something another girl did) or proactively (e.g., because the girl wants to gain popularity or social status by harming a peer))

What is temperament?

An individual's behavioral style and characteristic emotional response

- Closely linked with personality (enduring personal characteristics)

- Consistent across the lifespan

How can temperament can contribute to children's conduct problems?

- Difficult temperament

- High emotion reactivity

- Don't learn effective emotion regulation skills

- Children may rely on impulsive decision-making

- Thrill-seeking and recklessness (with CD)

What is the HPA axis?

HPA axis

- Hypothalamus -->

- Pituitary Gland -->

- Adrenal Glands

Causes of Antisocial Behavior:

Low levels of autonomic arousal

- Underarousal of HPA axis!

What is "selective ignoring?"

Parents learn to extinguish many of their children's inappropriate behaviors through selective ignoring. That is, parents systematically ignore unwanted behaviors that are aversive but not dangerous (e.g., tantrums, interruptions while parents are on

the phone).

What is the difference between reactive and proactive aggression? Give an example of how an eleven-year-

old boy might show each form of aggression.

*Reactive aggression*: engaging in physical violence in response to a threat, frustrating event, or provocation.

- Impulsivity/automaticity

- No consideration of alternative responses

- Mostly seen in younger kids and those with ADHD

- Also seen in kids with a history of physical abuse and/or bullying

*Proactive aggression*: deliberately engaging in an aggressive act to obtain a desired goal

- Learned through modeling and reinforcement

ADHD and CD frequently co-occur. What might explain their high co-occurrence? How are ADHD and

CD different?

ADHD may be viewed as the "motor" which drives some children's oppositional and disruptive behavior. Children's high-rate and impulsive

behaviors in early childhood elicit negative reactions from caregivers and lead to problems in caregiver-child inter actions. These problems, in turn, often contribute to the development of oppositional and defiant behaviors.

Children with ADHD show deficits in BIS activity and children with conduct problems (but not

ADHD) do not consistently show problems with behavioral inhibition (van Goozen et al., 2004). Instead, they show a more general dysregulation of both BAS and BIS (page 298 for more)

Give two examples of shared environmental factors that might account for children's conduct problems?

Give two examples of nonshared environmental factors that might account for children's conduct

problems?**

Non shared environmental factors: aggressive and non aggressive (stealing, lying, truancy)

Shared environmental factors: non aggressive (stealing, lying, truancy)

Give two examples of CD symptoms that are overt (expressed outwardly). Give two examples of CD

symptoms that are covert (expressed inwardly).

Overt Symptoms

- Bullies, threatens, or intimidates others

- Initiates physical fights

- Physically cruel to people

- Physically cruel to animals

- Uses a weapon

Covert Symptoms

- Steals without confrontation

- Runs away from home

- Breaks into a house, building, or car

- Often truant from school

List the four characteristics of children with "limited prosocial emotions? Why are children who show these

traits at risk for developing conduct problems?

- Must have displayed at least 2 of the following characteristics persistently over at least 12 months and in multiple relationships and settings

- Reflects individual's typical pattern of interpersonal and emotional functioning

- Requires both self-report and report from others

1) Lack of remorse or guilt

2) Callous-lack of empathy

3) Unconcerned about performance

4) Shallow or deficient affect

Why are children who show 4 characteristics of LPE at risk for developing conduct problems?

Those with LPE:

- are more likely to have childhood-onset, severe CD

- show a much more severe, violent, and chronic pattern of antisocial behavior

Traits are relatively stable from late childhood to early adolescence

Those with LPE traits show deficits in processing fear and distress signals in others (amygdala hyporeactivity)

LPE traits tend to be more heritable

Ryan is a nine-year-old boy who has a history of ADHD and conduct problems. Why might Ryan be at risk for substance use problems in adolescence?

Mr. and Mrs. Yoken' s three-year-old daughter, Yvonne, is defiant toward her parents. Yvonne refuses to clean up her toys, tantrums when she is told to get dressed, and sasses back to her parents when they ask her to eat her dinner or go to bed. Does Yvonne have a conduct problem that merits treatment, or is she simply going through a normal phase of development?

• Monica participated in 20 sessions of Parent-Child Interaction Therapy with her five-year-old son, Augustine. After treatment, Augustine showed a marked decrease in behavior problems at home, but not at school. Why?