Conduct Problems Flashcards

Conduct Problems

Definition

• Conduct problems involve actions and attitudes inappropriate for a person's age that violate:
  • Family expectations
  • Societal norms
  • Personal or property rights of others
• Behaviors range from:
  • Annoying minor behaviors (e.g., temper tantrums)
  • Serious antisocial behaviors (e.g., vandalism, theft, and assault)
• Consideration of types, pathways, causes, and outcomes is necessary.
• Associated with family and neighborhood circumstances.
  • These circumstances can help in understanding and prevention, but do not excuse the behavior.

Perspectives

Legal

• Juvenile delinquency: Excludes antisocial behaviors of very young children at home or school.
• Minimum age of responsibility varies.
  • 7-12 years in most US states.
  • 10-14 years in South Africa.
• Only a subset of those legally defined as delinquent meet the criteria for a mental disorder.

Psychological

• Exist on a continuous dimension.
  • Externalizing dimension
    • Rule-breaking behavior
    • Aggressive behavior
  • Overt-covert dimension
  • Destructive-nondestructive dimension
• Crossing overt-covert with destructive-nondestructive yields four categories:
  • Overt-Destructive (Aggression)
  • Overt-Nondestructive (Oppositional Behaviors)
  • Covert-Destructive (Property Violations)
  • Covert-Nondestructive (Status Violations)

4 Categories of Conduct Problems

• Overt-Destructive (Aggression)
  • Assault
  • Fights
  • Bullies
  • Cruel
  • Spiteful
  • Blames others
• Overt-Nondestructive (Oppositional Behavior)
  • Annoys
  • Temper
  • Defies
  • Swears
  • Argues
  • Stubborn
  • Angry
  • Breaks rules
  • Touchy
• Covert-Destructive (Property Violations)
  • Cruel to animals
  • Fire setting
  • Vandalism
  • Steals
• Covert-Nondestructive (Status Violations)
  • Runaway
  • Lies
  • Truancy
  • Substance use

Psychiatric

• Viewed as distinct mental disorders based on DSM symptoms.
• Disruptive behaviors are persistent patterns of antisocial behavior.
• Includes disorders like:
  • Intermittent Explosive Disorder
  • Pyromania
  • Kleptomania
  • Oppositional Defiant Disorder
  • Conduct Disorder

Public Health

• Blends legal, psychological, and psychiatric perspectives with public health concepts.
• Goal: To reduce injuries, deaths, personal suffering, and economic costs associated with youth violence.
• Cut across disciplines to:
  • Understand conduct problems in youths.
  • Determine how these problems can be treated and prevented.

DSM-5 Defining Features

• Two DSM-5 disruptive behavior disorders:
  • Oppositional defiant disorder (ODD)
  • Conduct disorder (CD)
• Both disorders predict future psychopathology and enduring impairment in life functioning.
• CD is the strongest predictor of adverse outcomes in adult functioning.

DSM-5 Diagnostic Criteria: OPPOSITIONAL DEFIANT DISORDER

A.

• A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months.
• Evidenced by at least four symptoms from the following categories, and exhibited during interaction with at least one individual who is not a sibling.
  • Angry/Irritable Mood
    1. Often loses temper.
    2. Is often touchy or easily annoyed.
    3. Is often angry and resentful.
  • Argumentative/Defiant Behavior
    4. Often argues with authority figures or, for children and adolescents, with adults.
    5. Often actively defies or refuses to comply with requests from authority figures or with rules.
    6. Often deliberately annoys others.
    7. Often blames others for his or her mistakes or misbehavior.
  • Vindictiveness
    8. Has been spiteful or vindictive at least twice within the past 6 months.
• Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic.
  • For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8).
  • For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8).

B.

• The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C.

• 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.

Specify current severity

• Mild: Symptoms are confined to only one setting.
• Moderate: Some symptoms are present in at least two settings.
• Severe: Some symptoms are present in three or more settings.

DSM-5 Diagnostic Criteria: CONDUCT DISORDER

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.
• Manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
  • Aggression to People and Animals
    1. Often bullies, threatens, or intimidates others.
    2. Often initiates physical fights.
    3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
    4. Has been physically cruel to people.
    5. Has been physically cruel to animals.
    6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
    7. Has forced someone into sexual activity.
  • Destruction of Property
    8. Has deliberately engaged in fire setting with the intention of causing serious damage.
    9. Has deliberately destroyed others’ property (other than by fire setting).
  • Deceitfulness or Theft
    10. Has broken into someone else’s house, building, or car.
    11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
    12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).
  • Serious Violations of Rules
    13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
    14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
    15. 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.

C.

• If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

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 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 information available to determine whether the onset of the first symptom was before or after age 10 years.

Specify if

• With limited prosocial emotions: An individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings.
  • Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong.
  • Callous-lack of empathy: Disregards and is unconcerned about the feelings of others.
  • Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities.
  • Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial

Specify severity

• Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others.
• Moderate: The number of conduct problems and the effect on others are intermediate between those specified in "mild“ and those in "severe".
• Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others.

Associated Characteristics

• Many factors are associated with conduct problems in youths:
  • Cognitive and verbal deficits
  • School and learning problems
  • Self-esteem deficits
  • Peer problems
  • Family problems
  • Health-related problems

Cognitive and Verbal Deficits

• Most children with conduct problems have normal intelligence.
• Verbal deficits are present in early development.
• Deficits in executive functioning:
  • Co-occurring ADHD may be a factor.
  • Types of executive function exhibited may differ - cool versus hot executive functions.

School and Learning Problems

• Underachievement, grade retention, special education placement, dropout, suspension, and expulsion.
• The relationship between conduct problems and underachievement is firmly established by adolescence.
  • May lead to anxiety or depression in young adulthood.

Family Problems

• General family disturbances.
• Specific disturbances in parenting practices and family functioning.
• High levels of conflict are common in the family, especially between siblings.
• Lack of family cohesion and emotional support.
• Deficient parenting practices.

Peer Problems

• Young children with conduct problems display poor social skills and verbal and physical aggression toward peers.
• Often rejected by peers, although some are popular.
  • Children rejected in primary grades are five times more likely to display conduct problems as teens.
  • Some become bullies.
• Often form friendships with other antisocial peers.
  • Predictive of conduct problems during adolescence.
• Underestimate own aggression and its negative impact, and overestimate others’ aggression toward them.
• Reactive-aggressive children display hostile attributional bias.
• Proactive-aggressive view their aggressive actions as positive.

Self-Esteem Deficits

• Low self-esteem is not the primary cause of conduct problems.
  • Instead, problems are related to inflated, unstable, and/or tentative view of self.
  • Distorted view of the self to protect against inadequacies and incompetence.
• Challenges to this overestimation of competence results in aggressive responses because this exposes the insecurity and impoverished self-concept.

Health-Related Problems

• High risk for personal injury, illness, drug overdose, sexually transmitted diseases, substance abuse, and physical problems as adults.
• Rates of premature death (before age 30):
  • Are 3 to 4 times higher in boys with conduct problems.
• Early onset and persistence of sexual activity and sexual risk-taking by age 21.
• Substance use disorders and adolescent antisocial behavior are strongly associated.
• Childhood conduct problems are a risk factor for adolescent and adult substance abuse.

Accompanying Disorders and Symptoms

• Attention-deficit/hyperactivity disorder
  • More than 50% of children with CD also have ADHD
  • Possible reasons for overlap
    • A shared predisposing vulnerability may lead to both ADHD and CD
    • ADHD may be a catalyst for CD
    • ADHD may lead to childhood onset of CD
  • Research suggests that CD and ADHD are distinct disorders
• Depression and anxiety
  • About 50% of children with conduct problems also have depression or anxiety
    • ODD best accounts for the connection between conduct problems and depression
    • Increasing severity of antisocial behavior is associated with increasing severity of depression and anxiety

General Progression of Conduct Problems

• Earliest sign is difficult temperament in infancy.
• Hyperactivity and impulsivity during preschool and early school years.
• Oppositional and aggressive behaviors peak during preschool years.
• Diversification: new forms of antisocial behavior develop over time.
• Covert conduct problems begin during elementary school.
• Problems become more frequent during adolescence.
• Some children break from the traditional progression:
  • About 50% of children with early conduct problems improve.
  • Some don’t display problems until adolescence.
  • Some display persistent low-level antisocial behavior from childhood/adolescence through adulthood.

Two Common Pathways

Life-Course-Persistent (LCP)

• Begins early and persists into adulthood.
  • Antisocial behavior begins early
    • Subtle neuropsychological deficits heighten vulnerability to antisocial elements in the social environment.
  • Complete, spontaneous recovery is rare after adolescence.
  • Associated with family history of externalizing disorders.

Adolescent-Limited (AL)

• Begins at puberty and ends in young adulthood.
  • Less-extreme antisocial behavior, less likely to drop out of school and have stronger family ties.
  • Delinquent activity is often related to temporary situational factors, especially peer influences.

Social-Cognitive Factors

• Immature forms of thinking
• Cognitive deficiencies
• Cognitive distortions
• Deficits in facial expression recognition and eye contact
• Dodge and Pettit comprehensive social-cognitive framework model

Dodge & Pettit’s social-cognitive model

• Step 1 Encoding (How much social information can I take in?)
• Step 2 Interpretation (How do I understand what the social cue means?)
• Step 3 Response Search (What behavioural responses do I have available that can respond to the social cue?)
• Step 4 Response Decision (Which is the best response?)
• Step 5 Enactment (Perform behavioural response)

Steps in the Thinking and Behavior of Aggressive Children in Social Situations

• Step 1: Encoding
  • Socially aggressive children use fewer cues before making a decision. When defining and resolving an interpersonal situation, they seek less information about the event before acting.
• Step 2: Interpretation
  • Socially aggressive children attribute hostile intentions to ambiguous events.
• Step 3: Response Search
  • Socially aggressive children generate fewer and more aggressive responses and have less knowledge about social problem solving.
• Step 4: Response Decision
  • Socially aggressive children are more likely to choose aggressive solutions.
• Step 5: Enactment
  • Socially aggressive children use poor verbal communication and strike out physically.

Family Factors

• Severe forms of antisocial behavior
  • Are associated with a combination of child risk factors and extreme deficits in family management skills
• Influence of family environment is complex
• Reciprocal influence
  • Child’s behavior is influenced by and influences the behavior of others
    • Child behaviors exert greater influence on parenting behavior than the reverse
• Coercion theory
  • Parent-child interactions provide a training ground for the development of antisocial behavior
    • Four-step escape-conditioning sequence
      • The child learns to use increasingly intense forms of noxious behavior to avoid unwanted parental demands (coercive parent-child interaction)
• Attachment theories
  • Children with conduct problems have little internalization of parent and societal standards
    • There is a relationship between insecure attachments and the development of antisocial behavior

Effective Treatments

Parent Management Training (PMT)

• Teaches parents to change their child's behavior in the home and in other settings using contingency management techniques.
• The focus is on improving parent-child interactions and enhancing other parenting skills (e.g., parent-child communication, monitoring, and supervision).

Problem-Solving Skills Training (PSST)

• Identifies the child's cognitive deficiencies and distortions in social situations and provides instruction, practice, and feedback to teach new ways of handling social situations.
• The child learns to appraise the situation, change his or her attributions about other children's motivations, be more sensitive to how other children feel, and generate alternative and more appropriate solutions.

Multisystemic Therapy (MST)

• An intensive approach that draws on other techniques such as PMT, PSST, and marital therapy, as well as specialized interventions such as special education, and referral to substance abuse treatment programs or legal services.

Problem-Solving Skills Training (PSST)

• Focuses on cognitive deficiencies and distortions in interpersonal situations
• Five problem-solving steps are used to:
  • Identify thoughts, feelings, and behaviors in problem social situations
• Children learn to:
  • Appraise the situation
  • Identify self-statements and reactions
  • Alter their attributions about others’ motivations
  • Learn to be more sensitive to others

Multisystemic Therapy (MST)

• Intensive family- and community-based approach
  • For teens with severe conduct problems who are at risk for out-of-home placement
• Attempts to empower caregivers to improve youth and family functioning
• Effective in reducing long-term rates of criminal behavior
  • Reduces association with deviant peers

Topics Not Covered

• Prevalence
• Gender (including explaining gender differences)
• Adult outcomes
• Genetic influences
• Prenatal and birth complications
• Neurobiological factors
• Societal factors
• Cultural factors
• Preventive interventions