1、Carolyn R. Fallahi, Ph. D. Additional slides provided by Mash & Wolfe (your text),Conduct Disorder and Oppositional Defiant Disorder,Introduction to CD,Case Presentation What is Conduct Disorder? Chronic pattern of behavior that causes harm to others Chronic pattern of behavior that violates societa
2、l rules Conduct Disorder and antisocial behavior in children. Actions and attitudes that are age-inappropriate. Violate expectations of family and society. Damage others personal or property rights.,Issues in defining Conduct Problems,Historically, we have defined conduct problems: Legally Psycholog
3、icallyDSM-IV-TR includes: Oppositional Defiant Disorder Conduct DisorderChildren with conduct disorders show a wide range of behaviors.,Environmental Component,CD and ODD is associated with the persons environment Poverty / disorganized neighborhood Violence within the home / neighborhood Abuse/negl
4、ect / inadequate supervision poor quality schools,Community Factors,The History of CD,The Boston boy fiend: 1874 Jesse Pomeroy, age 14. Adolescent gangs in large cities during the 1700s and 1800s. How should we handle juvenile delinquents? If a minor is found guilty of an aggressive act, how do we h
5、andle that in the court system?,Conduct Disorder,CONDUCT DISORDER Persistent pattern of behavior where rights of others/societal norms violated, shown by 3 or more of following in last year, at least 1 in past 6 months: Aggression to people and animals _ _ often bullies, threatens, or intimidates ot
6、hers _ _ often initiates fights _ _ used a weapon that can cause serious physical harm _ _ been physically cruel to people _ _ been physically cruel to animals _ _ stolen while confronting the victim _ _ forced sexual activity Destruction of property _ _ deliberately fire set with intent of doing se
7、rious damage _ _ deliberately destroyed others property other than by fire Deceitfulness or theft _ _ break and entry into a car or house _ _ often lies to obtain things or avoid obligations (“cons others“) _ _ stolen items without victim confrontation Serious violations of rules _ _ often stays out
8、 at night despite parental prohibitions _ _ run away from home overnight at least twice (or 1 extended) _ _ often truant beginning before age 13,Two Subtypes of CD,Childhood-Onset type: 1 criterion of CD present before 10 years old Adolescent-Onset type No evidence prior to 10 years old Severity Mil
9、d, moderate, severe,Cluster analysis of CD,Property Violations Cruelty to animals Lies Sets fires Steals Vandalism,Destructive,Aggression Assaults others Blames others for mistakes Bullies others Cruel to others Physical fights Spiteful/vindictive,Covert Status Offenses Breaks rules Runs away from h
10、ome Swears truancy,Oppositional Overt Angry-resentful Annoys others Argues with adults Defies adults requests Stubborn Temper tantrums Touchy-easily annoyed,Nondestructive,Based on Frick et al. (1993),Oppositional Defiant Disorder,OPPOSITIONAL DEFIANT DISORDER A. 6 month pattern of negativistic and
11、defiant behavior during which at least 4 of following present (considered against what is normal for age level): _ _ often loses temper _ _ often argues with adults _ _ often actively defies or refuses adult requests or rules _ _ often deliberately annoys people _ _ often blames others for own mista
12、kes _ _ often touchy/easily annoyed by others _ _ often angry and resentful _ _ often spiteful or vindictive B. _ _ Does not meet criteria for Conduct Disorder, and does not occur exclusively during psychosis or depression,Issues surrounding CD and ODD,Are ODD and CD distinct categories? Would a dim
13、ensional view be more appropriate? How might DSM-V handle this issue? Does our culture help determine who is diagnosed with ODD and CD? Are girls underdiagnosed? Might an environment create ODD or CD?,Associations with CD & ODD,Intelligence and underachievement in school Lack of emotional intelligen
14、ce Personality factors: impulsive, callous, unemotional Multiple problems in relationships: peers, family, teachers, authority figures. Co-occurring Disorders: ADHD, anxiety, depression, substance abuse.,Epidemiology,Prevalence: 5-8% for CD. 10.2% ODD. Gender differences: the ratio of boys to girls
15、10 to 1 in childhood; 1.5 to 1 in adolescence. Gender differences in symptom expression. Developmental pathways Early onset versus later onset Peer aggression Firesetting and cruelty to animals,Precursors and Course of CD,General Developmental Course,Pg. 161,Pattersons Vile Weed,Course of Child-onse
16、t,Developmental Progression of Conduct Problems Behaviors (ASBs)- Probabilistic Progression,Oppostitional Argues Braggging Demands attention Disobeys at home Impulsive Temper Tantrums Stubborn Teases Loud,Offensive Cruelty Disobeys at school Screams Poor Peer relations Fights Sulks Swears Lying,Deli
17、nquent Sets fires Steals outside Alcohol/Drug use Truancy Runs away Vandalism,PreSchool AdolescenceOvert (often in home) Becomes more Covert,Etiology of Conduct Problems,Etiological Theories Family and twin studies Shared environmental factors Non-shared environmental factors Teratogen exposure pren
18、atally Perinatal stressors Abnormal neurophysiological responding Temperament Ineffective parenting Problematic peers / environmental,Treatment,Working with Parents Problem-solving Training Family Therapy Prevention Issues,Thompson House Rules,1. No setting each other up. This means no name calling,
19、 no tripping, and no elbowing. 2. No violence against other people. This means no hitting, no throwing things at others, and no grabbing others. 3. No property destruction. Violating any of these rules results in no Nintendo, TV, or Gameboy for the rest of the day. Violating either rule after dinner
20、 means no Nintendo, TV, or Gameboy for the rest of the day AND the next day. Additional rules: 4. Morning Nintendo, TV, or GameBoy only after ready for school (dressed, teeth brushed, bed made). 5. Afternoon and evening Nintendo, TV, or Gameboy only after the bedroom is picked up and all homework is
21、 done. Mom will inspect to make sure these rules are met and approve before Tim or Tom plays Nintendo, TV, or GameBoy.,Reward contingencies and token economies,Susans Agreement with Staff Each day I earn at least half () of my Community Participation points (40 points total) , I will be given 15 min
22、utes of extra phone time, or 15 minutes of extra Walkman time, whichever I choose. My extra 15 minutes can be used on day shift only, at a time determined by staff.Things I can do to earn more points: 1. get up on time, after 2 prompts or less. 2. attend unit meetings on time, after 2 prompts or les
23、s. 3. attend school on time, after two prompts or less. 4. follow directions from staff. 5. actively participate in unit activities.Things I should not do or I will not earn points: 1. refuse to get out of bed. 2. stay in my room during unit activities. 3. refuse to participate in unit activities. I
24、f I earn 40 Community Participation points for 4 days out of 7, my mother will be allowed to bring my dog in during visiting hours on Saturday or Sunday. If I earn 50 points for 5 days out of 7, my mother will also be allowed to bring pizza in for my dinner on Saturday or Sunday.,Parent behavioral t
25、raining,Three parenting mistakes to avoid Over-reacting/personalizing Verbosity (Act, dont yak!) Inconsistency Inconsistency Inconsistency Inconsistency,Social Skills Training,Multisystemic Therapy,Targets multiple systems with a treatment “team“ Family, including siblings School Personnel Peers Juv
26、enile Justice System Effective but very expensiveor is it?,Additional Treatments,Prevention Institutionalization Medication,Empirically Supported Treatments,According to Chambless & Hollon, ESTs are:“.clearly specified psychological treatments shown to be efficacious in controlled research with a de
27、lineated population.”,Criteria for ESTs,These treatments are identified by asking the following questions: Has the treatment been shown to be beneficial in controlled research? Is the treatment useful in applied clinical settings, if so, with what patients under what circumstances? Is the treatment
28、cost effective relative to alternative interventions?,Treating Conduct Problems,In general, the further along a child is in the progression of antisocial behavior, the greater the need for intensive interventions and the poorer the prognosis,ESTs for ODD and CD,Parent Management Treatment Multi-Syst
29、emic Treatment Cognitive Problem Solving Skills Treatment Preventative Interventions,Multi-Systemic Therapy,An intensive family and community approach for adolescents with severe CPs Draws on a number of techniques and is carried out with all family members, school personnel, peers, juvenile justice
30、 staff, and other individuals in the childs life,Cognitive Problem-Solving Skills Training,Focuses on the cognitive deficiencies and distortions in interpersonal situations Provides instruction, practice, and feedback to teach new ways of interacting,Preventative Interventions,Recent efforts have fo
31、cused on trying to prevent CPs through intensive programs of early intervention Example: Fast Track (The Conduct Problems Prevention Research Group),Two Specific ESTs for CP,“The Incredible Years” Webster-Stratton Fast Track The Conduct Problems Prevention Research Group,The Incredible Years,Group P
32、arenting Skills Training Group Teacher Classroom Management Training Child Training,The Incredible Years,Parent Skill Training Focuses on: Increasing positive parent-child interactions Behavior tracking,Behavior Tracking,The Incredible Years,Parent Skill Training Focuses on: Increasing positive pare
33、nt-child interactions Behavior tracking Using “time-out” to discourage problem behaviors Making household contingencies explicit Reward contingencies,Rewards: Sticker Chart,The Incredible Years,The Child Curriculum focuses on: emotional literacy empathy or perspective taking friendship skills anger
34、management interpersonal problem solving school rules how to be successful at school,Outcome Studies,Improves parent child interactions Reduces parent reliance on violent or critical discipline methods Reduces child conduct problems At 3 year follow up, 2/3 of children continued to show clinically s
35、ignificant behavioral improvements (Webster-Stratton, 1990b).,Fast Track,Fast Track is a multi-site, comprehensive, 10-year intervention project designed to prevent serious antisocial behavior. Begins when children are in 1st grade School-wide program with pull out groups for children high in CD.,Fa
36、st Track,Focuses on improving child competencies parenting effectiveness school context school-home communications,Fast Track: Components,Teacher-led classroom curricula (called PATHS) directed toward the development of: emotional concepts social understanding self-control (including weekly teacher
37、consultation about classroom management),Fast Track: Components,Parent training groups designed to promote the development of positive family-school relationships and to teach parents behavior management skills, particularly in the use of praise, time-out, and self-restraint Home visits for the purp
38、ose of fostering parents problem-solving skills, self-efficacy, and life management,Fast Track: Components,Child social skill training groups (called Friendship Groups) Child tutoring in reading Child friendship enhancement in the classroom (called Peer Pairing).,Fast Track: Outcomes,Compared with c
39、hildren in the control group, children in the intervention group displayed significantly less aggressive behavior at home, in the classroom, and on the playground. By the end of third grade, 37 percent of the intervention group had become free of conduct problems, in contrast with 27 percent of the
40、control group.,Fast Track: Outcomes,Placement in special education by the end of elementary school was about one-fourth lower in the intervention group than in the control group. Court records indicate that by eighth grade, 38 percent of the intervention group boys had been arrested, in contrast wit
41、h 42 percent of the control group.,Fast Track: Outcomes,Psychiatric interviews after ninth grade indicate that The Fast Track program intervention has reduced serious conduct disorder by over a third, from 27 percent to 17 percent.,Summary,There ARE ESTs for Conduct Problems Better to prevent or intervene early than to treat full blown Conduct Disorder Parent participation is integral to treatment success,
