Chapter 9: Oppositional Defiant Disorder and Conduct Disorder

When considering the big picture, what kind of disorders are ODD and CD?

Disruptive behavior disorders

What is the most common comorbid disorder with ODD/CD? What is the percentage of comorbidity?

ADHD, 50%

What other disorders have the second highest rates of comorbidity with ODD/CD?

Depression and anxiety

What is the difference between ODD and CD?

Children with CD display more severely aggressive, violent, and antisocial behaviors

Whereas children with ODD only display stubborn, hostile, and defiant behaviors

What is antisocial behavior? When does it become problematic?

The use of aversive behaviors to manipulate others or one’s environment

→ Becomes problematic when it becomes a pattern and/or one’s primary way of interacting with the world

How do different approaches such as legal, psychological, and the DSM define conduct disorders?

1. Legal: juvenile delinquency (even though the majority of children who have broken a law don’t necessarily have an ODD/CD diagnosis)

2. Psychological: abnormally high amount of externalizing behaviors, falling on the high end of a bell curve in comparison to a child’s peers

3. DSM: disruptive behavior disorders (ODD/CD)

When do behaviors of ODD begin to emerge, and at what age must they present by?

Symptoms of ODD may begin to appear as early as 2-3 years old, and symptoms must be present by age 8

What is the DSM diagnostic criteria for ODD?

Must experience at least 4 symptoms for at least 6 months

What are the 3 classifications for types of ODD symptoms?

1. Angry/irritable mood

2. Argumentative/defiant behaviors

3. Hurtful/vindictive behaviors

What is unique about how distress and impairment is determined in ODD and CD?

The child can experience distress and impairment due to their ODD/CD, but so can others!

How is the severity of ODD determined according to the DSM?

Severity of ODD is determined by how many settings that symptoms are present in

1. Mild: symptoms present in 1 setting

2. Moderate: symptoms present in 2 settings

3. Severe: symptoms present in 3 (or more) settings

What is the DSM diagnostic criteria for CD?

Must experience at least 3 symptoms within 12 months, with at least 1 symptom being present within the past 6 months

What is true of all symptoms of CD?

They all violate societal norms and the rights of others

What are the 4 classifications for the types of CD symptoms?

1. Aggression (to people or animals)

2. Property destruction

3. Deceit / theft

4. Serious violation of rules (staying out past curfew before age 13)

What does the age of onset for CD suggest?

The onset for CD suggests trajectories/prognosis

What are the 2 main ages of onset?

1. Childhood-onset: CD develops before age 10

2. Adolescent-onset: CD develops after age 10

Is childhood-onset CD more common among males or females, and by how much? What is inferred about the severity and prognosis of childhood-onset CD?

1. About 2-4x more common among males

2. More severe aggressive and illegal behaviors

3. Prognosis (without early intervention): poor!

When should early intervention occur before in order to help counteract the severity of childhood-onset CD?

Intervention should occur before about 3rd grade

Is adolescent-onset CD more common among males or females, and by how much? What is inferred about the severity and prognosis of adolescent-onset CD?

1. Roughly equal between males and females

2. Less severe

3. Prognosis: less likely to persist

Does ODD lead to the development of CD? What is the percentage?

Most ODD diagnoses do not develop CD, only about 25%

How many children with CD do not have a prior diagnosis of ODD?

About 50%

Can a child have both ODD and CD? Which diagnosis will be the primary diagnosis and why?

Yes, children with CD will almost always have ODD

→ However, the CD diagnosis will be the primary diagnosis since it is more severe

Do the majority of CD diagnoses result in the development of Antisocial Personality Disorder in adulthood? What is the percentage?

No, only about 40% of CD diagnoses result in diagnoses of APD in adulthood

Which onset type of CD makes up the majority of cases where CD leads to Antisocial Personality Disorder in adulthood?

Almost exclusively made up of those with childhood-onset CD

What is one of the best indicators for positive outcomes of CD?

High levels of reading achievement

How is intelligence impacted by CD? How does it present in standardized tests and what is this a result of?

Children with CD have average (if not higher) intelligence

→ But they tend to score about 8 points lower than their peers, or even up to 15 points lower with severe aggression

Scores are a result of other factors, not intelligence

How do children with CD fare with school and academic achievement?

They are at higher risk of all negative outcomes in school, such as:

1. Academic underachievement

2. Low motivation

3. More likely to drop out

4. More likely to be held back

5. Etc.

How does self-esteem tend to be affected in children with CD?

Tend to have an elevated or inflated view of themselves

In what 3 ways are children with CD impacted by their peers?

1. Rejected by prosocial peers

2. Forms friendships with like-minded antisocial peers

3. Hostile attribution bias

Once a child with CD is rejected by their prosocial peers, will they ever be accepted by those peers in the future?

No, once children with CD are rejected, prosocial peers only notice the negative behaviors of the child with CD even when they make positive improvements later

What does the formation of friendships with antisocial peers among children with CD lead to?

An escalation in problem behaviors and severity of behaviors

What is hostile attribution bias?

Perceiving the actions of others as malicious even when they are normal social interactions

What influence most highly correlates with the development of CD?

Family problems!

In what 2 ways can family problems influence the development of CD?

Give examples of each

1. General family disturbances: main dynamic → conflict

   → Ex. 1 or more parents have mental health concerns, 1 or more parents have a history of antisocial behavior, excessive family stress

2. Specific disturbances in parenting practices

   → Ex. excessively harsh discipline, lack of goodness of fit, lack of proper supervision, lack of emotional support

How are health related concerns impacted by CD?

1. Higher rates of risk-taking behaviors

   → 3-4x more likely to die a premature death

2. Generally at a higher risk of injury

What is coercive pain control?

When met with a request that the child does not want to do, they will ignore the request and escalate aggressive behaviors until the parent withdraws the request

How does coercive pain control influence behavior over time?

The child will eventually learn that ignoring and delaying requests don’t get the parent to withdraw the unwanted requests …

→ So next time, the child will resort to tantruming and aggression right away, escalating in severity

What are the 3 main ways that biological influences may contribute to the development of CD?

1. Heritability (about 50%)

2. Temperament (difficult)

3. Neonatal development (drug use during pregnancy)

What are the 4 causal influences/risk factors for CD?

Give examples of each

1. Individual

   → Sociability, talents, temperament, self-esteem, intellect

2. Family

   → Parenting style, socioeconomic status, connectedness, parental mental health

3. School

   → Lack of engagement, school climate, quality of instruction

4. Community

   → Caregivers, connectedness, level of violence

What is also true of the 4 causal influences/risk factors for CD?

Each area can potentially become protective factors!

→ If you can change at least one risk factor to a protective factor, it can act as a buffer and reduce/offset the negative outcomes of CD

What are the 4 stages of antisocial behavior development according to “The Vile Weed?”

1. Basic training

2. Social environment reacts

3. Deviant peers and polishing antisocial skills

4. Career antisocial adult

What are the rules of thumb when treating CD?

1. Treatment must be cross-contextual and involve as many areas of the child’s life as possible!

   → Ex. Individual, family, school and community

2. The further along a child is on the path of “The Vile Weed,” the more that intensive treatment is needed and the poorer the prognosis

Why are group/peer-based treatments ineffective (and harmful!) when trying to treat ODD/CD?

Deviancy training: ODD/CD group treatments facilitate the formation of friendships with like-minded antisocial peers

What is Parent Management Training (PMT)? What does it teach (and to whom)? What does it address? What does it utilize?

A behavioral approach that teaches …

behavior management strategies to parents …

to address noncompliant, aggressive, and tantruming behaviors in their children with ODD/CD …

by utilizing reinforcement

What 3 requirements are included in Parent Management Training (PMT)?

1. Instruction

2. Roleplay

3. Homework

Can Parent Management Training (PMT) only be delivered in group settings?

No, Parent Management Training (PMT) can be taught one on one

→ But groups are preferred to facilitate more engagement in roleplay

What are some barriers to Parent Management Training (PMT)?

1. Parental mental health challenges, thinking there is no problem with their child

2. Getting parents to come (and stay!)

What are some incentives that can be provided to facilitate attendance for Parent Management Training (PMT)?

1. Providing free meals

2. Providing child care during the training

3. Raffle prizes

4. Intensive follow up

What is the effectiveness for Parent Management Training (PMT) short-term and long-term?

There is strong support for short-term effectiveness

→ However, long-term effectiveness is unclear because as a child ages, intervention should change with their development to address additional skills

Who is Parent Management Training (PMT) most effective with?

Younger children

What is Cognitive Problem-Solving Skills Training (PSST)?

A cognitive-behavioral therapy that helps children develop adaptive problem-solving skills for social situations

What 5 steps do children learn to problem-solve in Cognitive Problem-Solving Skills Training (PSST)?

1. What am I supposed to do?

2. Look at all my possibilities

3. I better concentrate and focus

4. Make a choice

5. Did I do a good job or make a mistake?

Cognitive Problem-Solving Skills Training (PSST) is an effective treatment method when it is…

Taught to be applied in different settings

What is Multisystemic Therapy (MST)?

A service delivery model with an emphasis on generalization and maintenance of skills learned

What are the 3 goals of intervention in Multisystemic Therapy (MST)?

1. Targets specific problems

2. Focuses on multiple systems

3. Requires daily and weekly effort by family members

What is Multisystemic Therapy (MST)’s theory of change?

To improve family functioning → Interventions must take place with peers, the school, and the community → To reduce antisocial behavior and improve functioning

Which treatment method is most likely to be effective even in severe cases of CD?

Multisystemic Therapy (MST)!

What are the 2 main goals of preventative interventions for ODD/CD, and how can they be implemented?

1. Provide intervention as early as possible!

2. In as many different contexts/settings as possible!

   → Can be implemented through universal programs