Disruptive Behavior Problems in Youth

Chapter 14: Disruptive Behavior Problems

Nature of Disruptive Behavior Problems in Youth

  • Develops over time and is influenced by a variety of factors including:

    • Genetics

    • Biology

    • Family Factors

    • Cultural Factors

    • Environmental Factors

    • Learning Experiences

  • Youth often lack insight into the underlying motivation for their behaviors.

  • Common manifestations of disruptive behavior problems include:

    • Conflicts with authority figures

    • Destruction of property and theft

    • Aggression toward self, others, or animals

  • If left unaddressed, these problems typically progress over time.

  • It is crucial to be sensitive to the context when diagnosing problem behaviors.

DSM-5 Disorders Associated with Disruptive Behavior Problems

The following disorders are categorized under disruptive behavior problems:

  • Oppositional Defiant Disorder (ODD)

  • Conduct Disorder (CD)

  • Intermittent Explosive Disorder

  • Pyromania

  • Kleptomania

  • ODD can progress to CD if not properly addressed.

  • The prevalence rates for these disorders are approximately 19%.

  • Males are diagnosed more frequently than females.

Oppositional Defiant Disorder (ODD)

  • Definition: ODD is characterized by a pattern of noncompliance along with anger, irritability, and vindictiveness.

  • Symptoms often begin in early childhood and affect up to 3% of youth.

  • Individuals with ODD display:

    • High emotionality

    • Frequent interpersonal conflicts (at least once per week)

    • An intention to annoy others, avoid responsibilities, and blame others for personal problems

  • To be diagnosed, the behaviors must result in significant impairment.

ODD DSM-5 Diagnosis Criteria

  1. Must exhibit at least 4 of the following symptoms over at least 6 months when interacting with someone who is not a sibling:

    • Angry/Irritable Mood

    • Often loses temper

    • Is often touchy or easily annoyed

    • Is often angry and resentful

  2. Argumentative/Defiant Behavior

    • Often argues with authority figures or adults.

    • Violates the rights ofothers, shows lack of empathy, and defies rules and expectations consistently.

    • Actively defies or refuses to comply with requests from authority figures or with rules

    • Deliberately annoys others

    • Blames others for mistakes or misbehavior

  3. Vindictiveness

    • Has been spiteful or vindictive at least twice within the past 6 months.

Additional Criteria for ODD

  • Criteria B: The disturbance must cause distress to the individual or others in their immediate social context or result in negative impacts in social, educational, occupational areas.

  • Criteria C: Behavior does not occur exclusively during a psychotic, substance use, depressive, or bipolar disorder, and criteria for disruptive mood dysregulation disorder are not met.

  • Specific Severity Levels:

    • Mild: Symptoms only in one setting (home, school, work, etc.)

    • Moderate: Symptoms present in at least two settings

    • Severe: Symptoms present in three or more settings

Conduct Disorder (CD)

  • Definition: Conduct disorder includes a more severe symptomatology similar to that of ODD.

  • It is diagnosed in approximately 4% of youth.

  • Symptoms typically emerge in middle childhood or adolescence.

  • Youth with CD violate the rights of others and major social norms aggressively and can act with cruelty toward people, animals, or property.

  • It includes acts that carry serious potential consequences.

Conduct Disorder DSM Diagnosis Criteria

  1. Criteria A: Must exhibit three or more of the following 15 criteria in the past 12 months, with at least one criterion present in the past 6 months:

    • Aggression Towards People and Animals:

    • Often bullies, threatens, or intimidates others

    • Initiates physical fights

    • Uses weapons capable of causing serious harm (e.g., bat, gun)

    • Engages in physical cruelty towards people or animals

  2. Destruction of Property:

    • Engages in fire setting to cause serious damage

    • Destroys others' property deliberately

  3. Deceitfulness or Theft:

    • Breaks into houses, buildings, or cars

    • Lies to obtain goods or favors or to avoid obligations

    • Steals items of nontrivial value without confronting a victim

  4. Serious Violations of Rules:

    • Often stays out at night despite parental prohibitions

    • Runs away from home overnight at least twice

    • Often truant from school before age 13

  • Criteria B: The behavioral disturbance must cause clinically significant impairment in social, academic, or occupational functioning.

  • Criteria C: If age 18 or older, criteria for Antisocial Personality Disorder are not met.

  • Specifiers:

    • Childhood-Onset Type: Symptoms before age 10

    • Adolescent-Onset Type: Symptoms after age 10

    • Unspecified Onset: Inadequate information to determine onset time.

Differential Diagnoses

  • Consider alternative or co-occurring diagnoses which may include:

    • Neurodevelopmental disorders

    • Anxiety or depression

    • Stress and trauma

    • Physical discomfort

  • May abuseof substances can often exacerbate these feelings, leading to a cycle of worsening mental health and physical health symptoms.

Assessment of Disruptive Behavior Problems

  • Utilization of specific assessment tools is recommended.

  • Consideration of co-occurring disorders and differential diagnoses is essential during assessment.

  • Referrals for physical evaluations may help rule out medical causes.

  • Comprehensive assessment should include developmental history, demographics, and risk factors.

  • Diagnostic interviews and standardized assessments can present a fuller picture of the behaviors.

Integrated Treatment Components

  • Establishing a strong therapeutic relationship is key to treatment efficacy for these disorders.

  • Best practices are essential due to the high stakes involved when working with this population.

  • Counseling efficacy improves with family engagement.

  • Interventions may include:

    • Behavioral and emotional regulation strategies

    • Problem-solving skills training

    • Dialectical Behavioral Therapy (DBT)

    • Multisystemic Therapy (MST)

    • Family interventionis crucial in fostering communication and trust among family members, ultimately leading to more effective problem-solving techniques.

Behavioral Interventions

  • Classical and operant conditioning can aid in understanding and changing behaviors.

  • Intervention steps include:

    • Understanding the motivation behind behaviors

    • Removing reinforcing consequences for undesirable behaviors

    • Reinforcing desirable behaviors

    • Practical application in sessions to aid integration into settings like schools

    • Tracking behavior to assess effectiveness

  • Integration of affective (emotional) and cognitive (thought) domains may also be beneficial.

Mindfulness-Based Skills

Bodyscans: These exercises involve focusing attention on various parts of the body to promote relaxation and awareness of physical sensations.

  • Breath Awareness: This practice encourages individuals to focus on their breathing patterns, helping to cultivate a sense of calm and present-moment awareness.

  • Guided Imagery: This technique uses mental visualization to create calming and positive images, which can help individuals manage stress and evoke feelings of peace.

  • Journaling: This practice involves writing about thoughts and feelings to gain insight and foster emotional regulation, enhancing overall mindfulness and self-awareness.

  • Affective awareness, or the ability to recognize and manage emotions, is crucial for effective counseling of this population.

  • Many disruptive behaviors stem from ineffective emotional expression.

  • Emphasizing the connection between feelings and behaviors is essential.

  • Mindfulness techniques can promote present-moment awareness.

  • Breathing exercises can be taught to youth to aid relaxation and focus.

  • Sessions may begin or end with mindfulness practices.

Cognitive Re-Structuring Abilities

  • The interplay between thoughts, feelings, and behaviors is significant.

  • Identifying maladaptive thoughts is crucial for youth with disruptive behavior problems.

  • Cognitive restructuring techniques, especially through Cognitive Behavioral Therapy (CBT), may assist youth in recognizing and modifying negative cognitions.

  • Socratic questioning encourages insight and reflection.

  • Psychoeducation on the Cognitive Triad helps youth connect their thoughts, feelings, and behaviors.

  • Counselors aid clients in recognizing and altering triggers, thoughts, feelings, actions, and consequences.

Problem-Solving Skills Training

  • This CBT-based approach restructures cognitive processes at the root of problem behaviors.

  • The intervention is structured and includes:

    • Steps to problem solving:

    1. What am I supposed to do?

    2. What else can I do?

    3. What will happen if I do this?

    4. What choice should I make?

    5. How did I do?

  • Initially, counselors explain and process each step with the youth.

  • Youth practice through talk therapy and role play.

  • Use of games and relevant scenarios in session, especially in residential treatment settings.

  • Additionally, operant conditioning can support problem-solving behaviors.

Dialectical Behavior Therapy (DBT)

  • Can be used preventively with subthreshold behavioral issues or as an intervention for diagnosable concerns.

  • DBT helps youth recognize triggers, enhance emotional regulation skills, and overcome barriers to employing these skills.

  • Affective education enables youth to comprehend their behaviors and explore healthier emotional relief strategies.

  • Key stakeholders, such as family members, may be integrated into the process.

Integrating Family

  • Counselors should educate families on potential sources of the child's behavioral issues.

  • Providing information about necessary levels of care and the type of support needed from family and social resources is important.

  • Parents can provide insights, support behaviors, and serve as resources for monitoring.

  • Family inclusion in the treatment process is encouraged wherever possible.

Parent Management Training (PMT)

  • PMT provides parents with a clear, effective, and targeted strategy for changing family behavior.

  • The approach is highly structured and manualized, incorporating assessments and worksheets.

  • Goals of PMT include:

    • Enhancing parents' communication of rules and expectations

    • Improving youth awareness of consequences

    • Increasing emphasis on positive reinforcement

    • Building upon youth's successes

Additional Aspects of PMT

  • Educating parents on motivations behind misbehavior is critical.

  • Parents are guided to observe youth behavior carefully.

  • New reinforcement patterns should be encouraged to support positive behaviors.

  • A token economy system may be implemented if reinforcement lacks sufficiency.

  • Anticipation of problematic scenarios, along with establishing clear rules and consequences, is essential to mitigate misbehavior.

Multisystemic Therapy (MST)

  • MST is a comprehensive intervention approach for serious behavioral issues.

  • It incorporates principles from CBT, family therapy, and community psychology.

  • Primary caregivers are viewed as the most influential entity in the change process.

  • Focus is directed at leveraging resources across multiple environments.

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MST Key Principles

MST incorporates the following nine principles:

  1. Identify the underlying functions of behavioral problems.

  2. Emphasize strengths and protective factors.

  3. Encourage the development of responsible behaviors.

  4. Establish concrete, measurable goals and objectives.

  5. Alter interactions in home, school, and community that contribute to behavioral issues.

  6. Apply developmentally-appropriate interventions promoting growth across academic, career, and personal-social domains.

  7. Require regular family participation in interventions (daily or weekly).

  8. Regularly assess readiness to change and progress.

  9. Equip primary caregivers with tools to generalize interventions for maintaining long-term behavior change across various settings.

MST Assessment

  • Assessment takes place in the home following initial referral.

  • Counselors may visit home, school, and other significant youth environments.

  • Desired counseling outcomes are identified by the family and other stakeholders.

  • Goals are developed while exploring behaviors' functions within the family context.

  • Evidence-based interventions are utilized to mitigate risk factors and utilize strengths to facilitate change.

Psychopharmacotherapy

  • Medication is not typically a primary support mechanism although it may be prescribed for comorbid disorders.

  • Some medications are used to target specific symptoms, such as mood stabilizers, antidepressants, stimulants, SNRIs, and antipsychotics.

  • Medications may offer quick relief from distressing symptoms, enabling youth to fully engage in therapeutic interventions.