Chapter 9 - Conduct Problems in Children and Adolescents PDF

Chapter 9: Conduct Problems in Children and Adolescents  If you were asked to generate a mental picture of a child with “conduct problems,” what image would come to mind?  Types of conduct problems DSM-5 has categorized conduct problems into th...

Chapter 9: Conduct Problems in Children and Adolescents  If you were asked to generate a mental picture of a child with “conduct problems,” what image would come to mind?  Types of conduct problems DSM-5 has categorized conduct problems into three types: Conduct disorder. Oppositional Intermittent defiant disorder. explosive disorder Effects of conduct problems Conflict with caregivers and authority figures. Disrupted relations with parents and teachers. Actions that violate society standards, and the rights of others. Ill-effects on children’s behavioral and socio-emotional development. Increases risk of interpersonal and occupational problems. Mental health and conduct problems: An alarming 50% of children referred for mental health treatment also suffer from conduct problems.  Oppositional Defiant Disorder (ODD) DSM5: disorder characterized by a pattern of Causes distress to not Angry or irritable mood just the child, but also to parents, teachers and other caregivers Argumentative or defiant behavior Adversely affects parent– child interactions. Vindictive behavior Ill-effects on children’s education and social toward others activities.  Distinction with normative child behavior: 1. Developmentally normative increase in oppositional and defiant behavior during toddler or preschool age is normal. 5.Children with ODD consistently throw tantrums, argue 2. Example: A 2-year-old insisting on choosing her own clothes with parents or other adults, and act in mean ways. for school. Tantrums by a 3-year-old before going to bed. 3. Two categories of clinically significant behaviors: 1. Number and frequency of disruptive behavior. 6. Approximately 70% of clinic-referred children are proven to 2. A child’s overall development context. deny adults’ requests or throw tantrums. 4. Children with ODD display greater number of 7. Only 4% to 8% of non-referred children show recurrent problematic behaviors and more frequently, than children defiance. without it. 8. Oppositional and defiant behaviors persist beyond the developmentally normative age in ODD children. Diagnostic Criteria for Oppositional Defiant Disorder  Diagnostic Criteria for Oppositional Defiant Disorder A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of 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.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. 2.The disturbance in behavior is associated with distress in the individual or in others in his or her immediate social context (e.g., family, peer group), or it impacts negatively on social, educational, occupational, or other important areas of functioning. 3.The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder  Diagnosis: DSM-5 guidelines help in determining whether disruptive symptoms are recurrent enough in children to merit a diagnosis. 1.Most ODD symptoms must occur daily in preschoolers or weekly in adolescents. 2.Children must display mean or vindictive behavior at least twice over 6 months to qualify as ODD. 3.Elevated norm-referenced behavior ratings beyond 93rd and 95th percentiles signify severe oppositional and defiant symptoms. 4.ODD symptoms can be easily distinguished: 1.Angry or irritable mood refer to problems regulating emotions. 2.Argumentative and defiant behaviors refer to problems regulating overt actions. 3.Vindictiveness refers to problems regulating both emotions and actions. 5.Angry or irritable mood is a predictor of depression in later life. 6.Argumentative and defiant behaviors are usually consistent with comorbid ADHD. 7.Vindictiveness can give rise to serious conduct problems in adolescence. 8.Children showing symptoms in only one setting may also be diagnosed with ODD. 9.In 96% of ODD related cases, symptoms are almost always directed toward parents. 10.Almost 62% children with ODD show symptoms at home, school or with peers. 11.Severity of symptoms determines the diagnosis: 1.Mild symptoms occur in only one setting. 2.Moderate symptoms occur in two settings. 3.Severe symptoms occur in three or more settings. Davidson’s Escape “If you don’t sit down and behave this minute, your dad will hear about it when we get home!” Upon listening to those words, Dr. Driscoll knew that 6-year-old Davidson and his mother, Mrs. Lepper, had arrived for their appointment. Dr. Driscoll invited them into her office and asked how she might help. “Davidson’s a handful, and I don’t know what to do. He won’t listen to anything I say, and he seems to enjoy giving me grief.” As Mrs. Lepper explained Davidson’s defiance at home, Davidson interrupted, saying, “Hey, Mom, this is boring. Can I have some gum?” Mrs. Lepper replied harshly, “Not now.” Dr. Driscoll added, “I have some coloring books on the table. Let’s find one for you.” Davidson remained interested in coloring for only a few minutes; then, he returned to nagging his mother and interrupting her conversation. His mother explained, “It’s like this all the time. I can’t talk on the telephone without him bothering me. I can’t shower in the morning; he’ll scream outside the bathroom door or walk in on me if I don’t lock it. I can’t go shopping with him because he won’t stop grabbing things from the shelves or embarrassing me.” By this time, Davidson grew impatient and walked to Dr. Driscoll’s office door. After checking to make sure that the adults were watching, Davidson slowly turned the door handle and opened the door slightly. His mother replied, “If you leave this room, you’re going to get it when we get home.” With an ever-widening smile, Davidson opened the door a bit more and placed one foot in the hallway. His mother stood up and began to count, “1... 2... Davidson.” Her son responded by bolting down the hallway, slamming the office door behind him. Mrs. Lepper leaped toward the door with an angry expression. Dr. Driscoll interjected, “Mrs. Lepper, please have a seat.” Exasperated, Mrs. Lepper replied, “I need to get him.” Dr. Driscoll said, “Why? This end of the hallway is empty, and he can’t enter the rest of the clinic without a key card. He’s safe and can’t get into any trouble. Davidson decided he doesn’t want to color and that’s fine. Now he can sit in the hallway for a while.” For the first time, a smile flickered across Mrs. Lepper’s face. What Childhood Conduct Problems Appear in DSM-5? Conduct Disorder (CD) A disorder characterized by a repetitive and persistent pattern of Destruction of property: Causing behavior in which the basic rights of damage to other people’s property others or major age-appropriate 2 through vandalism, arson or societal norms or rules are violated. deliberate, reckless actions. as manifested by the presence of at least three of the following 15 criteria DSM5 in the past 12 months from any of the categories below, with at least one Deceitfulness or theft: Include Signs and criterion present in the past 6 breaking and entering, stealing, or symptoms: months: 3 lying, usually with an end reward in mind or just to avoid responsibility. Aggression to people and animals: 1 Characterized by fighting or physical cruelty, assault and robbery. Serious rule violations: Include 4 staying away all night, playing truant, or running away from home. Diagnostic Criteria for Conduct Disorder Diagnostic criteria for conduct disorder:  Diagnostic Criteria for 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, as 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 firesetting with the intention of causing serious damage. 9.Has deliberately destroyed others’ property (other than by firesetting). 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 (e.g., “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 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. CD Diagnosis ODD and CD 1-To merit a diagnosis, youths must demonstrate at least 1.Although qualitatively different, ODD and three signs or symptoms in the CD can co-occur. preceding year. 2.Many children with ODD may not display the more severe symptoms of CD. 3.CD might be present in youths who display no significant symptoms of ODD. 4.CD is a predictor for future antisocial and substance use problems. 5.ODD is a significant predictor for both behavioral (defying, arguing.. and emotional problems (angry, annoyed…) 2-Diagnostic criteria for CD DSM-5 has allowed children to be reflect diverse behaviors allowing two children with CD to diagnosed with both ODD and CD, provided display dramatically different they meet the criteria for each disorder behavioral patterns. separately Making Mom Miserable Brandyn was a 10-year-old boy who was referred to our clinic by his fourth-grade teacher because of defiant and aggressive behavior at school. According to his teacher, Mrs. Miller, Brandyn became angry and resentful when- ever she placed limits on him. For example, he would tantrum, throw objects, and hit her when she asked him to pick up his belongings. Brandyn also bullied and intimidated other children in the class in order to obtain toys and to get his way. Mrs. Miller explained, “Brandyn seeks out younger kids and torments them until he gets what he wants. If they stand up to him, he pushes or pinches them. He even choked a classmate because he wouldn’t give him a scented pencil that he wanted.” Brandyn engaged in other acts of aggression designed to get attention from others. For example, he cut a girl’s pony- tail off during class and repeatedly destroyed other students’ belongings. On two occasions, he was caught stealing items from lockers and desks. Classmates often avoided playing with Brandyn because of his aggressive acts. Mrs. Miller commented, “I don’t know what to do with him. He doesn’t seem bothered when we reprimand him and we can’t keep him in the time-out chair.” Brandyn’s mother reported similar problems with aggression and defiance at home. “He doesn’t listen to me at all,” she explained. “He seems to enjoy making my life miser- able.” She added, “It’s hard enough being a single mother and working a crummy job. Then, I have to come home and deal with him. I love him, but I don’t know what to do. It scares me sometimes because I see him heading down the same road as his father. I guess the apple doesn’t fall too far from the tree.”  Intermittent Explosive Disorder (IED) Diagnostic criteria: A DSM-5 disorder characterized by repeated angry outbursts resulting in verbal and/or physical aggression. A. Recurrent behavioral outburst: 1. Verbal aggression: occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals. 2. Behavioral outbursts: Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period. B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. C. The recurrent aggressive outbursts are not premeditated. D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences. E. Chronological age is at least 6 years. F. The recurrent aggressive outbursts are not better explained by another mental disorder and are not attributable to another medical condition or to the physiological effects of a substance. CASE STUDY INTERMITTENT EXPLOSIVE DISORDER Road Rage “I’m so sorry,” sobbed Lucas, “I don’t know what came over me.” Lucas looked over the shoulder of the paramedic who was kneeling before him and gazed at the missing rear bumper of his car. The Honda Civic that Lucas had worked all summer to purchase was a mess. “We’re just glad you’re okay,” an officer replied. “Can you tell us what happened?” Seventeen-year-old Lucas was late for his summer job as a lifeguard at a community pool. As he backed out of his driveway, he failed to look both ways for other cars. Another driver honked his horn, warning Lucas to stop. “All of a sudden, I felt this strange sensation in my chest,” Lucas reported. “I got really tense and felt hot all over. I thought, ‘I need to teach this guy a lesson.’” Lucas pulled out of his driveway, accelerated to over 55 mph in a residential neighborhood, and passed the other driver. “I wanted to scare him so I slammed on my brakes so he would have to stop. He couldn’t stop in time and he hit me from behind. How could I have been so stupid?” Lucas’s mother reported that Lucas had a long history of losing his temper. “As a child, he had a short fuse,” she remembered. “He was usually a sweet boy, but he would sometimes get mad at the littlest things. Once, after he struck out during a baseball game, he threw the bat at the umpire. Another time, when I interrupted his play and asked him to take the dog out for a walk, he became angry and dragged the dog so violently I thought he would choke her. Afterward, he’d apologize but at the time I was so frightened.” Lucas had also been in trouble at school for his angry outbursts. In seventh grade, he was suspended for hitting a classmate who called him a name. In eighth grade, he was referred to the school psychologist for anger management therapy after he shoved and threw a chair at a student who (he claimed) made fun of him for getting a low grade on a test. Most recently, Lucas’s mother was fined $1,600 after Lucas pulled the school fire alarm because a teacher scolded him for not completing his homework. “Lucas is hot-headed, just like his father,” his mother added. “His dad would get angry and yell at us. Sometimes he’d also spank Lucas really hard. That’s why I left him. Lucas is a really good kid deep inside. He never does anything to deliberately hurt others. Sometimes, his temper simply gets the best of him.”  Signs and symptoms: Children with IED may Aggression in IED may also be 01 overreact to minor hassles. 02 directed to strangers if the youth in question feels threatened or wronged. 05 Children with IED do not usually display behaviors like bullying or robbing others. Aggression in IED is usually Youths with IED are known to 03 directed toward family or friends. 04 feel out of control while being aggressive and remorseful after the act.  How Can We Best Describe Children’s Conduct Problems? Overt Covert symptoms: symptoms: Antisocial behaviors Observable and that usually do not confrontational involve physical antisocial acts. aggression or confronting others; examples include breaking and entering, Examples include burglarizing, lying, physical assault, skipping school, and robbery, bullying. running away from home. https://www.youtube.com/watch?app=desktop&v=kpDoDI38ta 0&pp=ygUMI2Fkb3RlZGNoaWxk  Signs and symptoms: Children with IED may Aggression in IED may also be 01 overreact to minor hassles. 02 directed to strangers if the youth in question feels threatened or wronged. 05 Children with IED do not usually display behaviors like bullying or robbing others. Aggression in IED is usually Youths with IED are known to 03 directed toward family or friends. 04 feel out of control while being aggressive and remorseful after the act. How Can We Best Describe Children’s Conduct Problems? Overt Covert symptoms: symptoms: Antisocial behaviors Observable and that usually do not confrontational involve physical antisocial acts. aggression or confronting others; examples include breaking and entering, Examples include burglarizing, lying, physical assault, skipping school, and robbery, bullying. running away from home.  Factor analysis: Based on factor Paul Frick and colleagues (1993) It uses two independent analysis, conduct dimensions to used factor analysis to identify categorize conduct problems can be clubbed under four conduct problems that often problems: heads: occur together. The researchers reviewed data from more than Property violations, reflected in covert and 24,000 youths. They discovered Degree of overtness versus destructive behaviors like covertness. that children’s conduct problems property destruction and theft. could be grouped into four factors based on two independent Aggression, reflected in dimensions Degree of destructiveness overt and destructive versus non- behaviors like bullying and destructiveness. fighting. Rule violations that are covert and typically non- destructive like running away from home or signs of comorbid substance use. Oppositional and defiant behaviors that are both overt and non-destructive How Can We Best Describe Children’s Conduct Problems?: 1.Physical violence or property destruction in response to a threat, a frustrating event, or provocation. Reactive 2.Children with ADHD are more prone to reactive aggression because they have problems inhibiting their impulses. 3.Likely to be present in youths who have emotion-regulation problems. aggression: 4.Children with low capacity for social problem-solving may also use reactive aggression to solve interpersonal dilemma. 5.Youths with a history of physical aggression are also known to demonstrate this type of aggression. 1.Physical violence or property destruction deliberately enacted to obtain a desired goal. Proactive 2.Parents may model this type aggression when they yell at or spank their children. aggression: 3.Children come to believe that proactive aggression is the right way to achieve short-term goals, which is strengthened by positive reinforcements. 4.Children who rely on proactive aggression overestimate the value of rewards through aggression, while undervaluing punishment for doing so. Comparison of reactive and proactive aggression: Children with IED usually Reactive aggression, although demonstrate reactive aggression more serious, usually declines while children with CD may during late teens while proactive demonstrate a mix of both aggression tends to persist and reactive and proactive put children at risk for antisocial aggression. and criminal behaviors as adults.  Adults; risk for antisocial behaviors, Age of onset mental health and substance use problems, work and financial difficulties, Adolescent- domestic abuse, and onset incarceration conduct Increase in aggressive problems: and disruptive Childhood-onset behavior throughout Hits after puberty, conduct problems childhood and problem diminishes first show conduct adolescence. early adulthood problems in Age and preschool or early Antisocial personality Conduct elementary school disorder: pervasive Problems age ≤10 pattern of disregard for and violation of the rights of others; No known histories of Strong need of Impulsive, irritable, predicted by the difficult temperament, autonomy and and aggressive emotion-regulation feeling of number of covert symptoms like problems or neurological resentment toward behavior; reckless or deceitfulness, discrepancies in infancy. those in authority. illegal acts, lack of Manifested in covert and remorse, and failure property destruction Dislike for traditional and theft. non-destructive acts of to live up to social values. stealing or playing truant. obligations. More seen in children from low-income  Limited Prosocial Emotions method of differentiating children with conduct problems is based on the presence or absence of prosocial emotions Signs and symptoms: 1.A specifier used in DSM-5 to describe youths with CD who also show two of the following: (1) lack of remorse or guilt, (2) callousness or lack of empathy, (3) lack of concern about performance, and (4) shallow or deficient affect. 2.To merit a diagnosis, limited prosocial emotions must be present for at least 12 months and in multiple settings. 3.Clinicians also concur youth’s self-assessment reports with those of other informants. 4.Youths with limited prosocial emotions have many characteristics of adults with psychopathy  Not in DSM-5 A term used by some mental health professionals to describe a syndrome characterized by antisocial behavior, impulsivity, shallow affect, narcissism, and disregard for the suffering of others; also associated with callousness, a lack of emotional responsiveness, and superficial charm. The condition of psychopathy is usually preceded by histories of coerciveness, manipulation, and serious violations of rights and dignity of others. Similar to ASPD in that both are characterized by antisocial behaviors that violate others’ rights and dignity. Different from ASPD in its interpersonal and emotional traits. Psychopathy: The term psychopathy is usually not associated with children due to its potential stigmatizing effects. Limited prosocial emotions increase the risk of long-term behavioral problems beyond what might be expected by CD alone. Youths with both CD and limited prosocial emotions are more prone to get involved in serious crimes than those with CD alone. Long-term antisocial and criminal behavior are the worst effects of limited prosocial emotions. Children with both CD and limited prosocial emotions are usually less responsive and more resistant to treatment because of a lack of willingness to open up to the therapist or their insensitivity to punishments/ Callous Cade –case study Cade was a 14-year-old boy who was referred to our clinic by his caseworker from the juvenile court. Cade had a history of disruptive behavior. His mother remembered, “As a toddler, he was a handful. He was always getting into mischief, dis- obeying me, and throwing tantrums. When he was 5, he cut all of the whiskers off our cat and set our living room rug on fire.” By the time Cade was in second grade, he had been sus- pended twice for physical aggression at school. Once, he stuck a nail from the inside of his shoe through the toe and kicked classmates on the playground. On another occasion, he shoved a classmate down the stairs. Cade got in trouble for playing pranks, such as “mooning” other children in gym class, spraying classmates with a bottle of urine, and pulling the fire alarm on several occasions. By the time Cade reached the sixth grade, he had few friends his own age. He preferred to spend time with older boys at the nearby junior high school who introduced him to more serious antisocial behaviors. Cade began using alcohol and marijuana and skipping school. He was arrested for the first time in seventh grade for vandalizing school buses, causing several thousand dollars of damage. At the time of the referral, Cade was attending an eighth- grade classroom for youths with behavior problems. He had gotten into trouble earlier in the year for making sexually suggestive and racially offensive comments to two girls at the school. Most recently, he used a box cutter to injure a classmate during a fight. One teacher said, “Cade deliberately tries to provoke others—calling people names, swearing, making offensive remarks. He seems to take delight in hurting others, and he doesn’t care about being punished.” The psychologist who interviewed Cade was most concerned about Cade’s fascination with fire and explosives. Cade said proudly, “About 2 years ago, I began building bombs in my house. I use cigarette lighters, aerosols, gasoline, fireworks, batteries, Styrofoam containers... whatever I can get my hands on. My friends and me build them and set them off in the field.” Cade’s mother commented, “I know Cade has made a lot of trouble, but he’s really not a bad kid. I think if his father played a larger role in his life, he’d be okay.”  Prevalence ODD in boys CD in boys IED in boys and girls: and girls: and girls: Almost 3.3% youths Approximately 5% Close to 2.5% youth meet the criteria for youth meet the meet the criteria for ODD. criteria for CD. IED. The chances of boys Boys are twice or The lifetime developing ODD thrice more likely to prevalence for both before puberty is develop CD than boys and girls is twice that of girls. girls, across all ages. roughly about 5%. For boys, the Post-puberty, the lifetime prevalence chances are almost of CD is between 5% equal. and 10%. Lifetime prevalence For girls, the lifetime of ODD in boys is prevalence of CD is 11%, while in girls it between 2% and 4%. is 9%.  Disorders Associated With Conduct Problems Depression 1. Girls are twice as likely as boys to develop Academic difficulties Substance use problem comorbid anxiety and depression. ADHD Having both ADHD A common set of genes may 2.ODD symptoms of anger and irritability 41% of youth with and conduct predispose children to both are strong predictors of anxiety and CD have ADHD. problems conduct problems and substance depression in later life. 3.Dual failure model: Posits that conduct Hyperactive, more increases chances use. n with a genetic predisposition problems cause children to experience aggressive of poor academic may inherit a sensitivity to rewards failure in two important areas of Possible genetic performance. in conduct problems, to obtain functioning: peer relationships and association for Children with CD excitement, and in substance use, academics; failure in these areas both disorders will devalue school to obtain pleasure. contributes to depression Causes of Conduct disorders 1- Genetic Risk Approximately 40% to 50% of the variance in children’s conduct problems are attributed to genetic factors. Genetic Factors like gender, unique temperament, and cognitive factors: functioning, along with parent– child interaction, peer group and after-school activities account for most of the remaining 50% variance. Shared environmental factors like healthcare, nutrition, and housing Shared play a lesser important role in the emergence of conduct problems. In all likelihood, genetic factors environmental lead to the development of a difficult temperament, physical factors: underarousal, and high-risk behavior, along with an atypical sensitivity to reward and punishment. Causes: 2-Difficult temperament & emotion- regulation problems Definition of temperament: a child’s typical psychological, emotional, and behavioral responses to stimuli in their environment, primarily determined by genes. Three types of problem: inhibits the development of effective emotion- regulation skills, and prevents parents from responding sensitively to their children. Strained parent–child interactions, owing to the fact that some parents might adopt hostile and angry disciplinary techniques, reflecting aggression. Peer rejection on account of emotion- regulation difficulties, and the consequent association with disruptive youths. Causes: 3- Physiological Underarousal and Punishment Insensitivity Early neurological signs: Many children with conduct disorder show early neurological signs of low emotional arousal and reduced autonomic activity, like resting heart rate or brain activity. Physiological underarousal inhibits children from experiencing adequate levels of pleasure, excitement, and exhilaration. Low autonomic activity entails these youth to engage in high-rate, and often dangerous activities like stealing and reckless driving to experience excitement. These children are less likely to experience guilt or fear of punishment. Corticolimbic pathway: 1. The corticolimbic pathway in the brain that secretes serotonin, allows us to understand negative consequences. 2.In some children with conduct disorders, the corticolimbic pathway shows underactivity resulting in the low sensitivity to punishment. Low sensitivity to punishment: results in: 1. Inability to internalize parental rules and regulations. 2.Inhibits development of a conscience, and capacity for moral reasoning. 3.Display of premeditated, aggressive behaviors with little regard for others’ rights. 4.Indicates early signs of future antisocial behaviors, delinquency, and criminal offenses.  Causes: parenting behavior: 4-Coercive family process 1.A type of parent–child interaction in which parents negatively reinforce children for noncompliance while children negatively reinforce parents for giving in to their demands or tantrums. 2.A pattern of parent–child interactions in which caregivers unknowingly reinforce children’s oppositional and defiant actions. 3.It is like a cycle that is based on learning theory, especially the principles of operant conditioning. Example: 1.A mother asks a girl, busy playing, to set the table for dinner. 2.The girls might ignore the request, demonstrating what is called trying to extinguish her mother’s request by not complying. 3.The mother might repeat her request by nagging or even yelling, displaying what is called an extinction burst or an increase in the frequency of a behavior when it is not reinforced. 4.The girl might respond with a forceful refusal by whining or throwing a tantrum. 5.Finally, realizing that it is futile to argue with her daughter, the mother may decided to set the table herself. 6.In behavioral terms, the mother withdraws an aversive stimulus in the form of nagging, to reinforce her daughter’s whine or tantrum in the future. 7.On the other hand, the girl negatively reinforces her mother’s reluctance or submission making the latter more likely to back down in the future. Sometime, the coercive process may also begin with the child.  Causes: parenting behavior: 5- Hostile Parenting Behavior Hostile parenting: 1.Harsh disciplinary tactics, such as yelling, arguing, spanking, hitting, criticizing, or using guilt and shame. 2.Parents of children with conduct disorders are often seen to switch from overly permissive to extremely hostile parenting behaviors. Harmful punishments: 1.Punishments, although fruitful in the short-term, are harmful in five different ways: 1.Positive punishments lead children to believe that aggressive behaviors like yelling and spanking are appropriate ways of dealing with conflict. 2.Positive punishment teaches children what to avoid like crying or whining, instead of teaching prosocial behaviors like obeying adults. 3.Intermittent use of positive punishment can be harmful. 4.Frequent punishments strengthens negative reinforcements and may lead children to avoid certain situations altogether. 5.Positive punishment administered under the influence of anger, may lead to verbal and even physical abuse..  Causes: Parenting behavior: 6- Low parental monitoring Definition of low parental monitoring: 1.The degree to which caregivers (1) are aware of their child’s whereabouts, activities, and peers; (2) set appropriate limits on their child’s activities; and (3) consistently discipline their child when the child violates these limits. 2.Low parental monitoring has a strong impact on conduct problems in late childhood and adolescence. 3.Low parental monitoring is a predictor for adolescent-onset conduct problems like theft, truancy, and vandalism. Tackling of low parental monitoring: 1.Low parental monitoring can be tackled by: 1.Setting clear expectations of children’s behaviors. 2.Supervising children’s activities. 3.Putting consequences to children’s rule violations. 2.Parental monitoring is difficult with disruptive children who might be good at keeping their parents in the dark about possible delinquent behaviors.  Causes: Parenting behavior: 7- Parents’ Cognitions and Mental Health Children’s behaviors/misbehaviors: 1.Parents’ perceptions about their children’s behaviors affect both parenting styles and children’s developmental outcomes. 2.Parents can attribute children’s misbehaviors to two types of causes: 1.External and unstable causes. 2.Internal and stable causes. 3.Parents of disruptive children mostly attribute their children’s behaviors to internal and stable causes, making the parent more prone to anger and resentment. 4.Parents of disruptive children often feel powerless and may eventually give up trying to discipline them, thus negatively reinforcing the child’s misbehavior.  Causes: Parenting behaviors: 7- Parents’ Cognitions and Mental Health Predictor of children’s conduct problems: 1.A strong predictor of children’s conduct problems is parental psychopathology: 1.Maternal depression, paternal antisocial behavior, and parental substance abuse can all contribute to ODD in their children. 2.Marital conflict can also affect children’s conduct. 3.Mental health problems of caregivers may strain parent child interactions. – 4.The association between parenting behavior and children's misbehavior is transactional in that they influence each other. Example: 1.A child with emotion-regulation problems may cry and throw tantrums more frequently than other children of his age. 2.His mother may adopt hostile or coercive disciplinary tactics to manage this behavior. 3.This is not an optimal parenting strategy and may lead to severe oppositional and defiant behaviors in future. Stressors: 1.Other stressors like medical illness, financial difficulties and relationship problems may also inhibit sensitive and optimal parenting behaviors. 2.Parents need to be supported for their efforts to improve the quality of parenting despite the numerous stressors in their lives. Causes: Peers and neighborhoods: 8- Peer rejection During childhood and adolescence, friends greatly influence children’s self-concepts and emotional well-being. Prosocial peers can provide protection from stressors, independent of children’s families. Disruptive peers, actually contribute to conduct problems. Children with low academic performance and disruptive behaviors, often face peer rejection. Children avoid hyperactive or highly disruptive classmates and also those who engage in lying or stealing. Not all children with overt aggression are rejected by peers, and sometimes they are even popular. Covert aggressive behaviors like emotion regulation or reactive aggression, are usually rejected by peers. Causes: Peers and neighborhoods: 8- Peer rejection A tendency of peer-rejected children to seek Selective out other rejected youths for their social network. affiliation: The deviant peers tend to introduce boys to more severe forms of antisocial behaviors like vandalism, theft, or substance use. A tendency for peers to reinforce antisocial behavior and ignore, or not reinforce, prosocial behaviour. Peers positively reinforce each other for talking about antisocial activities in contrast Deviancy training: to discussions about prosocial behaviors. Deviant conversations in late childhood is a predictor for delinquency, aggression, and substance use problems by adolescence. Deviancy training can begin as early as the age of 6. Causes: Peers and neighborhoods: 9- Neighborhood Risk Impoverished neighborhoods may lack resources, like good quality day care or public schools, to meet Lack of educational children’s needs. Lack of optimal educational services for children with learning disabilities may lead them to: resources: Experience academic difficulties. Undervalue learning. Exhibit problematic behaviors. Inadequate Lack of access to prosocial activities in low-income neighborhoods. Absence of good recreation centers, after-school monitoring: programs or organized sports may lead youths to engage in unsupervised, antisocial activities. High crime neighberhood  Causes: Peers and neighborhoods: 9- Neighborhood Risk Family cohesion Prosocial after- Protective factors: and parental school activities: monitoring: Encourage youths to Parents can set high participate in sports and expectations for their other activities after children’s behaviors. school. Reduces likelihood of Parents can rigorously children developing support prosocial conduct problems, behaviors or be aware of irrespective of gender children’s whereabouts. and neighborhood risks. What Are Three Developmental Pathways Toward Conduct Problems?: Robins paradox: Epidemiologist Lee Robins demonstrated the difficulty in predicting the course of children’s conduct pathways. The paradox presents two facts: Most adults with antisocial behavior have a history of antisocial behavior in childhood. But, most children with antisocial behavior do not become antisocial adults. Following development backward, and tracing childhood histories of antisocial adults, present a clear picture. Following development forward and attempting to predict developmental outcomes of children, has less certain outcomes. Several biological, psychological, and socio-cultural factors influence children’s development in a probabilistic rather than deterministic way. The Oppositional Defiant Disorder Only Pathway: 1. Describes children who experience ODD in childhood, but not CD in later years of development. 2. Children with ODD pathway, most likely inherit a genetic risk characterized by disruptive behaviors, and difficult temperament. 3. Almost 50% of these children may be diagnosed with ADHD. 4. ADHD, coupled with difficult temperament may lead to parenting stress. 5. Parenting stress may inhibit their ability to attend to children’s positive aspects of functioning. 6. Coercive parent–child interactions may negatively reinforce disruptive behaviors in children. What Are Three Developmental Pathways Toward Conduct Problems?: The Childhood-Onset Conduct Disorder Pathway Symptoms: 1.Children inherit a genetic risk for developing conduct problems. 2.Disruptive behaviors manifested in difficult temperament, and hyperactive-impulsivity in childhood. 3.These children develop oppositional, defiant, and non-compliant behaviors in adulthood. Meet diagnostic criteria for ODD: 1.75% of these youths meet diagnostic criteria for ODD. 2.Leads to peer rejection and association with deviant peers. 3.Youths on this pathway often resort to aggression to make up for low social problem-solving skills. 4.An alarming 50% of such youth are prone to substance use problems. 5.Almost one-thirds of youth with childhood-onset CD also exhibit limited prosocial emotions. 6.Such children exhibit emotion underarousal, lack of empathy or guilt and little concern over their academic performance. Engage in overt/destructive activities: 1.Likely to engage in overt and destructive activities. 2.Approximately 10% children follow this pathway, of which about three-fourths will go on to experience behavioral or emotional problems as adults. 3.40% are also diagnosed with ASPD and can also develop features of adult psychopathy. What Are Three Developmental Pathways Toward Conduct Problems?: The Adolescent-Onset Conduct Disorder Pathway Symptoms: 1.Hits after puberty. 2.Manifested in acts of property destruction, theft, and rule violations. 3.Children on this pathway protest and often resent limitations brought in by parents and other figures of authority. 4.Experience peer rejection and affiliation to deviant peers. Children with adolescent-onset CD: 1.Many children with adolescent-onset CD continue to display disruptive behaviors well into their 20’s. 2.Also marked by health and substance use problems, limited opportunities to participate in higher education, or employment  Evidence-Based Treatment PMT Parent Management Training (PMT): PMT is a behavioral intervention that is based on the notion that children’s disruptive behaviors often develop in the context of coercive parent–child interactions. Most PMT programs require weekly participation of parents in sessions without their children. The Defiant Child program lays down 10 steps or skills for parents to apply at home every week. https://www.youtube.com/watch?v=9PFq8_fJjs8 2 Why do children misbehave? Parents learn about the causes of child misbehavior and what they can do to reduce behavior problems at home. Pay attention! Many parents of disruptive children focus on their children’s misbehavior. In this session, the therapist teaches parents to attend to positive aspects of the child’s behavior. Increasing children’s compliance Parents learn to use attention and praise to reinforce their children’s appropriate behaviors. Using a token economy Parents are taught to implement a token economy at home to reinforce compliance. Using time-out at home Parents learn to use the token system as a form of punishment using response cost. Tokens are withdrawn for inappropriate actions. Parents also learn how to use time-out at home. Initially, time-out is used for only one or two problem behaviors. Practicing time-out Parents gradually expand their use of time-out to other behavior problems. Managing children in public places Parents learn to use time-out in stores, restaurants, and other places outside the home. Parents learn to plan for children’s misbehavior in public. Using the daily school behavior report card Teachers are asked to complete a daily report card regarding the child’s behavior at school. Parents use the home token economy to reinforce appropriate behavior at school, based on teachers’ reports on the card. Handling future behavior problems The therapist and parents discuss how to deal with future behavior problems and challenging situations. Booster session and follow-up meetings Parents attend a follow-up session 1 month after training ends to check on the family’s progress. Parents can use this session to troubleshoot new problems or to discuss ways to fade the token system. Follow-up visits may be scheduled every 3 months as needed. 3 Evidence-Based Treatment PMT Youths with parents enrolled in PMT display more prosocial behaviors. Children with their parents in PMT are also known Benefits OF PMT: to have fewer disciplinary troubles at school. PMT enables children to function like their normal peers, post the completion of treatment. The long-term effects of PMT may last anywhere between 10 and 14 years, after training completion. Less effective for single or low-income parents, and even parents facing marital conflicts. Parents with problems of substance use or mental health often drop out of PMT. Limitations OF PMT: Less effective with adolescents, who show more resistance to treatment. Most clinicians are not formally trained in PMT, making it difficult for parents to access an experienced therapist.  Evidence-Based Treatment PCIT Parent–Child Interaction Therapy (PCIT): A variation of PMT in which parents and children are coached by therapists as they interact in real time. designed for families with disruptive preschoolers or young school-age children. 5 Evidence-Based Treatment PCIT PCIT is based on Diana Authoritative parenting is Children’s behavior Baumrind’s (2013) characterized by high problems often arise developmental theory of levels of both when parents show low parenting. Recall that demandingness and demandingness (i.e., Baumrind believed that responsiveness: parents indulgent parenting), low parenting behavior can set high expectations for responsiveness (i.e., be described along two their children’s behavior authoritarian parenting), independent dimensions: and provide support to or low levels of both (i.e., demandingness and help them meet those uninvolved parenting). responsiveness. expectations. 6 The 4 Parenting-styles: Permissive: Authoritative: Child-driven Solves problems together with child Rarely gives or enforces rules Sets clear rules and expectations Responsiveness Overindulges child to avoid conflict Open communication and natural “Whatever you want” consequences “Let us discuss this” Neglectful: Authoritarian: Uninvolved or absent Parent-driven Provides little nurturance or guidance Sets strict rules and punishment Indifferent to child’s social-emotional One-way communication, with little and behavioral needs consideration of child’s social- “I don’t care” emotional and behavioral needs “Because I said so” Demandingness 7 Evidence-Based Treatment PCIT In PCIT, the therapist uses modeling and positive reinforcement to teach parents to engage in authoritative parenting behaviors, improve the quality of parent–child interactions, and reduce children’s behavior problems. Parents in PCIT have reported increased confidence in managing their children’s behaviors. Known to reduce parental stress. 8 Evidence-Based Treatment PCIT Features: 1.Both parents and children together attend sessions. 2.Clinicians observe parent child interaction, and provide suggestions to parents to manage children’s behaviors – during sessions. 3.Parents communicate with therapists through an electronic device, and the latter coaches them in real-time without the child’s knowledge. 4.PCIT is administered in two phases of child-directed and parent-directed interactions. 5.Child-directed interaction: 1.Aimed at increasing parent’s sensitivity to child’s behavior to improve the quality of their relationship. 2.Parents have to follow the lead of the children, who select a play activity for the session. 3.Parents have to practice praising, reflecting, imitating, and describing their children’s appropriate behaviors in an enthusiastic way, summarizing the PRIDE component of the therapy. 4.Parents are encouraged to show acceptance and warmth. 6.Parent-directed interaction: 1.Aimed at helping parents set more realistic expectations of their children. 2.Parents are also supported to decrease the use of hostile and coercive techniques, and to use discipline consistently. 3.Parents are taught to give command clearly and concretely, when children are attentive. 4.Commands must always have a follow-up consequence either in the form of reward or punishment. 5.The therapist coaches the parent to perform the skills adequately with the child during the session. 6.Therapists exemplify positive reinforcement by using praise and encouragement with the parents 9 Evidence-Based Treatment Videotaped modeling is a final variant of PMT. A series of behavioral modules designed for parents, teachers, and children. Videotaped Modeling The program uses videotaped modeling and consists of separate treatment modules for children, parents, and teachers. Specifically designed for low-income and high-stress families. Example: Through videotaped vignettes, problematic parent–child interactions that cause conduct problems, are demonstrated. The Incredible Years Parents, on watching the tapes with other parents, discuss child management principles and parenting BASIC parent training skills. The therapist, who acts as a collaborator, encourages program: parents to device ways of implementing each principle to tailor the program to meet specific family needs. 10 Evidence-Based Treatment A cognitive intervention in which disruptive youths Problem-solving skills learn ways to perceive, interpret, and respond to interpersonal problems in more effective (less training (PSST): biased) ways. Aims to correct biases in information-processing styles of aggressive children by teaching them adaptive ways to problem-solve. Across studies, PSST-trained children showed greater symptom reduction than those participating in attention control groups. Efficacy: Treatment effects have been found to last for 1 year. Families undergoing both PMT and PSST, had better outcomes than those in only one treatment. 11 Evidence-Based Treatment Problem-solving skills training (PSST): Steps to solve a problem: 1.The child starts by identifying the problem and determining how she should act. 2.The child then generates as many courses of action as possible. 3.The child then moves on to evaluating possible courses of action. 4.In the fourth step, the child chooses her best response. 5.In the final step, the child evaluates her actions. 6.The therapist usually presents the child with a familiar situation from her life like a problem on the bus. 7.The child is then taken through the steps to solve the problem, followed by a role play of the situation. 8.The therapist acts as a coach, using praise and encouragement to teach the child. 9.At times, parents are also the problem-solving steps to be able to reward the children at home for using the steps. 12 Evidence-Based Treatment 1.a multimodal treatment designed for adolescents with histories of disruptive, aggressive, and antisocial behavior. Aggression Based on the notion that adolescents who engage in antisocial acts lack the behavioral, affective, and cognitive Replacement Training skills needed for prosocial actions. Delayed onset of social problem-solving, emotion regulation, and moral reasoning tend to interfere with children’s ability (ART) to display compliant and constructive behaviors. RT includes the three components of skillstreaming, anger control training, and moral reasoning training. Effective in improving abilities learn and apply social skills. Across studies, it has been seen that youths who undergo Efficacy: ART, show: Increased anger control. Improved moral reasoning. Decreased probability to resort to crimes. 13 Evidence-Based Treatment 1.An intensive form of family- and community-based treatment effective for adolescents with more serious conduct problems. 2.It consists of (1) family therapy, (2) academic/school support, Multisystemic therapy and (3) increased parental monitoring. 3.Based on Bronfenbrenner’s ecological systems model in which (MST): children’s development is best understood in the context of multiple systems, interacting with each other. 4.The systems may include children’s proximity to parents, teachers and friends, or distal socio-cultural factors like family income or ethnicity. 1.A child may suffer from learning or attention deficits. Her parents may be unable to address this owing to their long hours of work to meet financial needs. Example: The child’s school may also fail to provide top class education owing to fund crunch. This pushes the child to experience greater academic difficulties, dislike for school, and affiliations with deviant peers, which finally lead to antisocial behaviors. 14 Evidence-Based Treatment Systems essential to adolescents’ welfare: Parents are supported to develop better techniques to improve interactions with adolescents at home. Family Parents might be taught to monitor adolescents’ activities after school, or ways to avoid conflicts with them at home. Therapists also strive to remove parental obstacles like marital discord or alcoholism, that deter parents from providing supportive and consistent care. Therapists act as allies for the parents. Parental involvement in adolescent’s education is increased through MST. School Therapists often serve as facilitators between parents and teachers in the interest of the child’s educational needs. Parents learn to monitor adolescents’ attendance and behavior at school. Therapists aim to reduce adolescents’ association with deviant peers and increase affiliation with prosocial youths. Peers Both parents and teachers are encouraged to monitor the adolescents’ whereabouts after school. Adolescents are also encouraged to develop new peer networks like by joining a club at school. 15 Evidence-Based Treatment Efficacy of Multisystemic therapy (MST): MST therapists usually work in teams of three to five, who are available round the clock. Treatment is carried out either at home or community to increase family participation and attendance. Adolescents participating in MST are 25% to 70% less likely to be rearrested. 47% to 64% of MST participants are also less likely to be removed from their foster homes. Improves family functioning and parenting skills, reducing the probability of adolescents to associate with deviant peers, and engage in disruptive behaviors. 16 Is Medication Helpful for Youths With Conduct Problems Methylphenidate: No medication is approved for treating conduct problems. Risperidone: Stimulant medications such as methylphenidate or Concerta, Ritalin, however, are known to reduce aggressive Also known as Risperdal, it is typically used as an and oppositional-defiant behavior in children with ADHD. antipsychotic medication for schizophrenia or bipolar disorder. Primarily used to treat ADHD, it can significantly decrease disruptive behaviors in boys with low cognitive functioning. Improves parent–child interactions, peer relationships, and Can also reduce disruptive behaviors in children with ADHD, involvement at school. who may not respond to stimulant medication alone. The effects only last as long as the youths continue with the medication. 17 Example Treatment of Severe Child Aggression (TOSCA) study: 1.A randomized controlled study that showed that adding risperidone to traditional ADHD treatment could reduce aggression in children who did not respond to traditional treatment alone. 2.Initially, all children were administered with a stimulant medication while their parents attended PMT. 3.Children who continued to display aggression despite the two treatments, randomly received either a risperidone or placebo. 4.The results revealed that adding the risperidone to stimulant medication and PMT provided a faster and a slightly greater reduction in disruptive behaviors. 5.Risperidone is known to benefit children with ADHD and limited prosocial behaviors. 6.Side effects of risperidone include: 1.Weight gain. 2.Digestive problems. 3.Other side effects. 18 What Works, What Doesn’t, and Why Incarceration: Ineffective in reducing the risks of long-term antisocial behaviors. Wilderness challenge programs: Transferring adolescents to adult courts or rehabilitation centers often increases the chances of them reoffending. Aims to reduce antisocial Reduction in antisocial behaviors, Designed to be physically Participating youths are not behaviors in youths by teaching if any, disappears fast once these challenging and encourage found to show any improvements survival skills in a wilderness youths come back to their teamwork. in their disruptive behaviors. setting. families and communities. Incarcerated youths may also continue to engage in criminal activities like adults. 19 What Works, What Doesn’t, and Why Group interventions: Sharing stories of aggression, May increase antisocial Members of support groups truancy, and substance use behaviors among at-risk may engage in deviancy may actually encourage and youths. training. even normalize antisocial behaviors. 20 What Works, What Doesn’t, and Why? Common features of evidence-based treatments 1.Family is the primary change agent: 1.Effective programs support parents to set clear rules, improve parent child interactions, and reduce hostile parenting tactics. – 2.Social-cultural factors: 1.Effective treatments help youths to avoid deviant peers by pushing them toward increased school involvement and more prosocial activities in the community. 2.Environmental stressors like neighborhood disadvantages, poverty, and crime, can also be managed by families in effective programs. 3.Treatment delivery: 1.Most effective therapies are delivered at home or in the community. 2.The goal is to eradicate parental hurdles like lack of a good childcare or transportation, to increase accessibility to families. 4.Behavioral, comprehensive, and individualistic interventions: 1.Therapists bank on positive reinforcements. 2.Treatment recommendations are tailored to suit the immediate family needs. 3.Solutions focus on improving functioning at home, school, and in the community. 5.Treatment effectiveness: 1.For evidence-based treatments to work, they have to be administered faithfully to address family needs. 2.Periodic assessments of children’s functioning during after treatment is important to ensure that treatment works.