CHAPTER 23 DISRUPTIVE BEHAVIOR DISORDERS

Disruptive behavior disorders include

problems with the person’s ability to regulate their own emotions or behaviors. They are characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression toward people and property.

Kleptomania

is characterized by impulsive, repetitive theft of items not needed by the person, either for personal use or monetary gain.

• lower self-concept and lack competence in social situations.

• learning appropriate behavior and learning to refrain from inappropriate behavior are impaired

Pyromania

is characterized by repeated, intentional fire-setting. The person is fascinated about fire and feels pleasure or relief of tension while setting and watching the fires

Oppositional defiant disorder (ODD)

consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations

Acceptable behavior of adolescene

Occasional psychosomatic complaints

Inconsistent and unpredictable behavior

Eagerness for peer approval

Competitive in play

Erratic work–leisure patterns

Critical of self and others

Highly ambivalent toward parents

Anxiety about lost parental nurturing

Verbal aggression to parents

Strong moral and ethical perceptions

Abnormal behaviors of Adolescence

Fears, anxiety, and guilt about sex, health, and education

Defiant, negative, or depressed behavior

Frequent hypochondriacal complaints

Learning irregular or deficient

Poor personal relationships with peers

Inability to postpone gratification

Unwillingness to assume greater autonomy

Acts of delinquency, ritualism, obsessions

Sexual aberrations

Treatment for ODD

is based on parent management training models of behavioral interventions.

These programs are based on the idea that ODD problem behaviors are learned and inadvertently reinforced in the home and school

Intermittent explosive disorder (IED)

involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes

there may be physical injury to others, destruction of property, and injury to the individual as well. The intensity of the emotional outburst is grossly out of proportion to the stressor or situation

Many people with IED have a comorbid psychiatric disorder, most commonly substance use/abuse, ADHD, ODD, conduct disorder, anxiety disorders, and depression

Treatment for INTERMITTENT EXPLOSIVE DISORDER IED includes

fluoxetine (Prozac)

lithium

valproic acid (Depakote)

phenytoin (Dilantin)

topiramate (Topamax)

oxcarbazepine (Trileptal)

Conduct disorder

is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others

Symptoms are clustered in four areas with conduct disorder

aggression to people and animals

destruction of property

deceitfulness and theft

serious violation of rules.

callous and unemotional traits

similar to those seen in adults with antisocial personality disorder.

They have little empathy for others, do not feel “bad” or guilty or show remorse for their behavior, have shallow or superficial emotions, and are unconcerned about poor performance at school or home.

Mild conduct disorders

The child has some conduct problems that cause relatively minor harm to others.

Examples include repeated lying, truancy, minor shoplifting, and staying out late without permission.

Moderate conduct disorders

The number of conduct problems increases, as does the amount of harm to others.

Examples include vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity.

Severe conduct disorder

The person has many conduct problems that cause considerable harm to others.

Examples include forced sex, cruelty to animals, physical fights, cruelty to peers, use of a weapon, burglary, robbery, and violation of previous parole or probation requirements.

Risk factors include

• poor parenting

• marital problems

• lack of interest in treatment by parents

• low academic achievement

• poor peer relationships

• low self-esteem; protective factors include resilience, family support, positive peer relationships, and good health

Externalizing Behaviors

Lying

Cheating at school

Swearing

Truancy

Vandalism

Setting fires

Bragging

Screaming

Inappropriate attention-seeking

Arguing

Threatening

Demanding

Relentless teasing

Anger outbursts

Internalizing Behaviors

Prefers to be alone

Withdraws

Sulks

Won’t talk

Is secretive

Overly shy

Stares in lieu of verbal response

Physically underactive

Somatic aches and pains

Dizziness

Nausea, vomiting, stomach problems

Fatigue, lethargy

Loneliness

Guilt feelings

Nervousness

Crying spells

Feels worthless, unloved

Limit setting involves the following three steps:

Inform clients of the rule or limit.

Explain the consequences if clients exceed the limit.

State expected behavior.

Providing consistent limit enforcement with no exceptions by all members of the health team, including parents, is essential. For example, the nurse might say,

“It is unacceptable to hit another person. If you are angry, tell a staff person about your anger. If you hit someone, you will be restricted from recreation time for 24 hours.”

NURSING ACTIONS

For Conduct Disorder

Decreasing violence and increasing compliance with treatment

• Protect others from client’s aggression and manipulation.

• Set limits for unacceptable behavior.

• Provide consistency with the client’s treatment plan.

• Use behavioral contracts.

• Institute time-out.

• Provide a routine schedule of daily activities.

Improving coping skills and self-esteem

• Show acceptance of the person, not necessarily the behavior.

• Encourage the client to keep a diary.

• Teach and practice problem-solving skills.

Promoting social interaction

• Teach age-appropriate social skills.

• Role model and practice social skills.

• Provide positive feedback for acceptable behavior.

Providing client and family education

The nurse must show acceptance of clients as worthwhile individuals even if their behavior is unacceptable. This means that the nurse must be matter of fact about setting limits and must not make judgmental statements about clients. The nurse must focus only on the behavior. For example, if a client broke a chair during an angry outburst, the nurse would say,

J., breaking chairs is unacceptable behavior. You need to let staff know you’re upset so you can talk about it instead of acting out.”

CLIENT AND FAMILY EDUCATION

For Conduct Disorder

each parents social and problem-solving skills when needed.

Encourage parents to seek treatment for their own problems.

Help parents identify age-appropriate activities and expectations.

Assist parents with direct, clear communication.

Help parents avoid “rescuing” the client.

Teach parents effective limit-setting techniques.

Help parents identify appropriate discipline strategies.

Points to Consider When Working With Clients With Disruptive Behavior Disorders and Their Families

Remember to focus on the client’s strengths and assets, as well as their problems.

Avoid a “blaming” attitude toward clients and/or families; rather, focus on positive actions to improve situations and/or behaviors.

It is important for the nurse to discuss feelings, fears, or frustrations with colleagues to keep negative emotions from interfering with the ability to provide care to clients with problems with aggression.