MODULE 5 CHAPTERS 8 AND 9.pdf

MODULE 5 CHAPTERS 8 AND 9 ADHD Initially described by the DSM-2 as a hyperkinetic reaction of childhood, DSM-3 as ADD, and now DSM-5 as ADHD A neurodevelopmental disorder, NOT socially constructed, characterized by inattention and hyperactivity Behavioural symptoms →...

MODULE 5 CHAPTERS 8 AND 9 ADHD Initially described by the DSM-2 as a hyperkinetic reaction of childhood, DSM-3 as ADD, and now DSM-5 as ADHD A neurodevelopmental disorder, NOT socially constructed, characterized by inattention and hyperactivity Behavioural symptoms → attentional, hyperactivity, and impulsivity problems. Problems with focus, memory, sitting still, following through, playing quietly, acting without thinking and problems with delaying gratification Diagnostic criteria → children have to show at least 6 out of 9 possible symptoms of either inattention OR hyperactivity/ impulsivity ○ Must last for at least 6 months ○ NOT appropriate for developmental level ○ Have to have symptoms that exceed inattention ad hyperactivity/impulsivity shown for their age and gender ○ Norm referenced rating scales would be used to evaluate ○ Symptoms need to be present in AT LEAST 2 different settings ○ Child has to show some symptoms before age 12 Heterogeneity → not all cases look the same ○ People will show symptoms in multiple settings; might have a similar pattern too ○ Some symptoms are more noticeable and impairing in some activities than others ○ Symptoms can range from mild to severe; minor to marked impairment in functioning ADHD predominantly hyperactive-impulsive presentation ○ Children show hyperactive and impulsive symptoms, but may show only subthreshold problems with inattention ○ “Driven by a motor”, “constantly on the go” ○ More common in boys than girls; more problematic interactions with others ○ Symptoms emerge during preschool years (3-4 years) ○ May transition to combined presentation around age 12 ADHD combined presentation ○ Inattentive and hyperactive-impulsivity symptoms ○ Difficulties with inhibition, sustained attention, and delayed gratification  ○ Symptoms present in school and at home ADHD predominantly inattentive presentation ○ Most common presentation in the population ○ Problems with inattention ○ Often overlooked by parents and teachers due to their subthreshold hyperactive-impulsivity symptoms ○ More commonly diagnosed in girls than boys ○ Emerges around 8-12 years old INATTENTION: During preschool years, we see children will play for shorter amounts of time (3 mins). In school-age years, activities are brief (10 mins). During adolescence, we see less persistence in tasks than peers (less than 20-30 mins) and dont focus on details, tend to forget about assignments. In college years, we see forgetting about appointments and assignments, less patience for long-term projects. HYPERACTIVITY: Preschool age → cant be settled. School years → restlessness. Adolescence → fidgeting, squirming. College → report feeling restless. IMPULSIVITY: Preschool → no sense of danger, dont listen to warnings. School years → blurt out answers in class, interrupting others, a lot of accidents. Adolescents → speak before thinking, no planning ahead. College years → act before thinking, quick decision making, reckless drivers. Sluggish, Cognitive Tempo ○ Few or no symptoms of hyperactivity–impulsivity; predominantly inattentive ○ At school → drowsy, confused, spacey, disoriented, problems making friends, dont get into trouble, take a long time to respond, trouble engaging in classroom activities ○ Diff cognitive processing problems than other kids with ADHD → internalizing disorder rather than externalizing symtpoms ○ Traditional ADHD meds may be less effective ○ “Concentration Deficit Disorder” → term used to describe children with this type of ADHD (less negative terminology) Sleep Problems ○ Dysomnias Refusing to fall asleep, problems falling asleep and waking up in the morning ○ Movement disorders  Sleep talking, grinding teeth, excessive tossing and turning ○ Parasomnia Night wakings or recurrent nightmares/terrors ○ Reduced sleep increases the problems we have with attention, hyperactivity, and impulsivity The earlier sleep symptoms are subsided, the better prognosis ○ ADHD and sleep problems are both caused by issues in the prefrontal cortex and dopamine Prevalence ○ How do they change over time? Hyperactive symptoms at 3-4 Inattention increases at 5-8, leads to a diagnosis combined presentation Inattention at 9-12, disproportionality girls and are typically diagnosed later as predominantly inattentive Attention, concentration problems in adolescence and substance use problems with car accidents ⅔ of adults continue to have inattention and restlessness Gender ratio is 10:1 clinically, but 3:1 in community samples. Large gap is likely related to referral bias; boys are more likely to have conduct and externalizing symptoms, and therefore more likely to get a referral Academic Problems ○ Lower achievement scores, more school problems, memory problems, cognitive processing problems Cognitive problems can cause children to miss information presented to them Problems with working memory interfere with ability to perform multi-step academic tasks, and they may have trouble holding info in their memory long enough and organizing info and relay it to others ○ Special education pathways → tutoring, special ed, repeating a grade Parent-child Interactions ○ Parents more hostile, less sensitive, and less responsive ○ Children are more negative and more defiant ○ Tends to be more negative interactions – may lead to ODD and conduct disorder later  These parents report high levels of parenting stress, fewer positive interactions, and less control than they would like Higher rates of marital conflict Parents may use alcohol to cope with children’s misbehaviour Peer Rejection or Neglect ○ Serve as models for adult relationships and promote the development of identity ○ One of the best predictors of social and emotional wellbeing in adolescence ○ Symtpoms of ADHD and comorbid disorders often lead to peer rejection ○ Kids often develop negative reputations, which can make the child’s symptoms worse How is ADHD a Risk for Conduct problems? ○ 54-67% of kids with ADHD will develop ODD Persistence, stubborness, non-compliance with adults, talking back, tantrums, disobedience, spitefulness towards caregivers ○ 20-50% of children with ADHD will develop conduct disorder Behavioural disorder characterized by peer problems, aggression, and antisocial behaviour ○ Increased risk in substance abuse problems in chldren with ADHD 6x more likely than peers to misuse alcohol, nicotine, etc later in life Kids with ADHD are more than 2x as likely to vape than their peers; have difficulty with quitting Kids report vaping helps regulate attention and behaviour The more symptoms, the higher the likelihood of vaping and smoking Stimulants can prevent children with ADHD from turning to other substances down the road ○ High rates of peer rejection because of high rates of difficult behaviour → children may build friendships with more deviant peers Psychostimulants ○ Most commonly prescribed for ADHD; effect dopamine and epinephrine ○ Increase attention and behavioural inhibition ○ Classes: Amphetamine → increases release of dopamine → more dopamine output Adderall, dexedrine, vyvanse  Methylphenidate → slows the dopamine transmitter system → allows dopamine to stay in cleft for longer Concerta, daytrana, focalin, ritalin ○ Targets dopamine in the frontal striatic circuit and prefrontal cortex ○ Side effects → insomnia, cardiovascular problems, suicidal ideation, stomach problems, dizziness Nonstimulant Meds ○ SNRI’s (selective norepinephrine reuptake inhibitor) Atmoxetine and Guanfacine → targets norepinephrine, not dopamine For kids who dont respond to stimulants or have ticks or heart conditions, or substance abuse problems Side effects → sedation, daytime sleepiness, dangerously low blood pressure in the case of abrupt discontinuation Evidence-Based Treatment ○ Efficacy and limitations? All meds are effective for disruptive behaviour, academic/cognitive/social functioning. Stimulants are MOST effective Not all children respond to medication Stopping meds will almost always result in return of symptoms Stimulants need to be used cautiously in children with tics or tourettes Some families are reluctant to give their children medication ADHD meds can be used as illicit drugs Non-Pharmacological Treatment for ADHD ○ Clinical Behaviour Therapy Typically in clinics or hospitals 3 parts: parent consultation → parent/caregiver is taught to effectively manage child’s behaviour. School consultation → helping the teacher eliminate the disruptive behaviour for the child in the classroom and help the child stay on task. Home-school reward system → teacher sends home a school report to the parents about the child’s behaviour, and parents can reward the behaviour at home Limitations? Parental involvement, training, and implementation is necessary for it to be effective  Doesnt always normalize the child’s behaviour Most effective for younger rather than older children ○ Summer Treatment Programs Direct contingency management Therapist will rely on punishments and rewards to shape the child’s behaviour Children will be with other children of the same age and mentality Counsellors and staff will work with children throughout the camp Art class, behavioural instruction, academic instruction, and recreation to help build social and motor skills Using bief and clear commands with the children to help them comply; doesnt require a lot of sustained attention, doesnt rely on working memory, doesnt provide opportunity for the child to get distracted Reinforcements from the staff for desirable behaviour May use tokens or point systems for children to promote desired behaviours ○ Behavioural Classroom Management Psycho-social, school-based program Administered by psychologists, teachers, or other ed. Specialists Can supplement the summer treatment programs Short, behavioural training each day Parent-training sessions to implement behavioural systems at home Children in the STP are assessed to see if meds are necessary Classroom is geared to be more structured to elicit appropriate behaviour ○ Challenging Horizons Program School-based intervention program, after-school program combined Helps with academic engagement and performance Kids learn organization and focus skills ○ MOSAIC (Making Socially Accepting Inclusive Classrooms) Program Group intervention over short period of time Improves social functioning and behaviour Strives to help peers to be more accepting/forgiving of their friends’ ADHD behaviours  Kids who participate are less rejected by peers and have more reciprocal relationships than kids who participate in more traditional programs Multimodal Treatment Study of Children with ADHD (MTA) ○ Largest study that has looked at the effects of medicine and behavioural therapy on kids with ADHD ○ 4 groups of children: Meds alone (14 months) → methylphenidate administered by the researchers Behaviour therapy alone → 8 months of clinical behaviour therapy and STP during the summer Combined treatment → meds and behaviour therapy, administered by researchers Community care → kids referred by mental health professionals in their community. Could receive treatment, but not from the researchers. Most were prescribed meds ○ Medication alone is more effective than behavioural treatment alone during middle childhood ○ Combined treatment is ideal for some groups ○ Best Practices Based on this Study? Preschoolers → behaviour therapy should be first line of treatment for ADHD. meds can be prescribed if not responding. Only about 50% of preschoolers with ADHD receive behaviour therapy School aged/adolescents → combo therapy is best, with consent of caregivers and assent of youth Adults → meds and behaviour therapy programs are best ○ Treatment that most children get actually DONT meet the treatment standards of these “best practice” recommendations ○ Community treatment received is often not ideal ○ There is a need for evidence-based, high-quality interventions to be administered more Underlying Causes? ○ Behavioural genetics ADHD is heritable; concordance rates for monozygotic twins is 50-80%. Higher for hyperactive-impulsive symptoms  Adults with ADHD have a 58% chance of having a child with ADHD as well Siblings of children with ADHD 3-5x more likely to have it ○ Molecular Genetics Dopamine and serotonin receptors are prevalent in brain areas responsible for regulating attention and inhibiting behaviour; striatum and prefrontal cortex People with lesions in these areas often have signs of ADHD Dopamine transporter gene (DAT1) → codes for dopamine. Some children show mutation on this gene Dopamine D4 and D5 → code for dopamine receptor genes. Some children show mutation on this gene ○ Genes and early environment Non-shared environmental factors Prenatal risks → Exposure to cigarette smoke as a fetus Perinatal risks → hypoxia, premature and low birth weight Postnatal risks → breathing problems during sleep ○ The Brain Mesolimbic Neural Circuit (Heightened Reward Sensitivity) The pathway where we respond to reinforcement and punishment ○ Ventral tegmental area (VTA) and nucleus accumbens (in the midbrain), the amygdala and hippocampus (in the limbic system), and the prefrontal cortex People with ADHD are less sensitive to reinforcement if it is not very salient. That is due to this circuit and the way it functions in their brain The behavioural inhibition system (BIS) is responsible for slowing and stopping behaviour when we are punished or not reinforced. Children with ADHD have underactivity of the BIS, interfering with their ability to behave even if they know how they should The behavioural activation system (BAS) is responsible for adjusting behaviour to achieve reinforcement. Children with ADHD show overactivity in the BAS, so their behaviour is governed by  immediate reinforcement and they have a greater sensitivity to immediate reward. The Striatum Near the center of the brain with 3 smaller regions in it Regulates behaviour in response to feedback Rich in dopamine Dopamine activity in here prompts us to look for excitmenet, novelty, and reward Maturational delay, dysregulation of major transmitters, and reduced neural activity between the striatum and right prefrontal cortex can all be seen in youths with ADHD Default Mode Network (Daydreaming and Mind Wandering) Consists of the medial prefrontal cortex, medial parietal cortex, and the medial temporal cortex Activated by default when we’re resting and not thinking about anything in particular Neural connections are strengthened in early childhood, and by early childhood most children can inhibit this network when they need to focus on tasks Children with ADHD often arent able to inhibit this network, which may explain their daydreaming, inattention, and distractability Barkly’s Neurodevelopmental Model Problems in neurodevelopment are caused by genetic and early biological risks that lead to problems with behaviour in life Behavioural inhibition helps kids to consider adaptive ways of responding to a situation. When kids can resist impulses to act or ignore distracting stimuli that is competing for another behaviour Executive Function ○ The focus of executive function is for kids to control their behaviour rather than have their behaviour be controlled by the stimuli around them, and to help kids be influenced by delayed reinforcers and set long-term goals ○ Barkley described 4 basic functions: working memory (holding info in your short-term memory and working  through it), internalized speech (helps to guide our behaviour and give us control over our actions), emotional regulation (inhibit our immediate behaviour), and creative problem solving (learn about environment, think about things in new ways) ○ Children with ADHD have deficits in executive function. They often dont consider consequences of their actions or learning from past mistakes, have difficulty regulating their own moods, struggle to remail motivated, are heavily dependent on immediate reinforcement, and more Conduct Disorder, Intermittent Explosive Disorder, and ODD ODD (Oppositional Defiant Disorder) ○ Angry, irritable mood, argumentative or defiant behaviour, and vindictiveness toward others Vindictiveness has to happen twice over the course of 6 months to qualify as ODD ○ Lasts at least 6 months ○ Causes significant impairment and distress Usually causes distress moreso to the parents, teachers, peers, and others. It will affect the parent-child interaction and affect the child’s social life and activities ○ ODD vs normal child behaviour? Tantrums or arguing over small things (bedtime, clothes) is normal Think about 2 categories: 1) number and 2) frequency of disruptive behaviours and the child’s developmental context Children with ODD will CONSISTENTLY show tantrums, argue with other adults, and act in generally mean ways. 70% of referred children show this recurrent defiance, only 4% who are not referred show this. ○ Angry, irritable mood → predictor of depression later in life ○ Argumentative and defiant behaviour → often comorbid with ADHD ○ 96% of ODD cases, symptoms are directed at parents. 62% of children show symptoms at home/school/with peers ○ Severity  Mild → one setting Moderate → two settings Severe → three or more settings ○ Gender Differences 3.3% of youth meet criteria Boys are 2x more liekly than girls to be diagnosed Post puberty, the chances are almost equal Lifetime prevalence → boys 11%, girls 9% Conduct Disorder ○ Diagnosis Persistent pattern of violating rights of others and societal norms. Aggression toward people or animals, breaking rules, lying and theft, and more Behavioural disturbance causing significant impairment in social, academic, or occupational functioning Diagnosed if someone is too young to be diagnosed with ASPD OR if they are over 18 but do not meet full criteria for ASPD Must show 3 signs or symtpoms within a year Childhood onset → at least 1 symptom before age 10 Adolescent onset → showing no symptoms until after age 10 Unspecified → the criteria for diagnosis is met, but there wasnt enough info to determine if first symptom occurred before or after age 10 “Limited pro-social emotions” → DSM-5 specifier that has to be present for at least 12 months in multiple settings, with a report of behaviour from others in their life Sort of a sociopathic specifier. The child feels no guilt or remorse, shows little emotion, does not display empathy Severity Mild → few if any conduct problems in excess; just meeting the criteria. Occurrences cause relatively minor harm to others Moderate → number of conduct problems and effect on others are intermediate. Stealing without confronting a victim or vandalism Severe → many conduct problems in excess of diagnostic criteria, causing significant harm to others  40% of boys diagnosed develop ASPD in adulthood ○ Gender Differences 5% of youth meet criteria Boys are 2-3x more likely than girls Lifetime prevalence → boys 5-10%, girls 2-4% How can ODD and Conduct Disorder Cooccur? ○ Conduct disorder is a predictor for future antisocial and substance abuse problems ○ ODD is a predictor for future behavioural and emotional problems ○ Conduct disorder can be present in youth who display no significant symptoms of ODD ○ DSM-5 allows for children to be diagnosed with ODD AND conduct disorder, provided they meet the criteria for each one separately Intermittent Explosive Disorder (IDD) ○ Diagnostic criteria Recurrent behavioural outbursts – verbal and/or behvaioural Verbal aggression → needs to occur 2x weekly on average for a period of 3 months Physical aggression → doesnt need to result in damage or destruction of property, and doesnt result in significant harm to people or animals 3 behavioural outbursts → damage or destruction of property or physical assault involving damage to a person or animal within a 12 month period Magnitude of the outbursts is really out of proportion to the situation Children might overreact Usually directed towards family or friends, could be directed towards strangers if the child feels threatened or wrong Children are out of control during the outburst and usually remorseful after the act. Bullying or robbing is not common Outbursts are not premeditated and cause significant distress to the person or impairment in functioning. May result in financial or legal consequences Cant be diagnosed until a child is at least 6  Outbursts cant be explained by any other mental disorder and arent attributable to another medical condition or physiological effects of substances ○ Gender Differences 2.5% of youth meet criteria Lifetime prevalence for boys and girls is 5% Relational aggression → harming others mood, self-concept, or social status, or manipulating relationships by harming others relationally Seen disproportionately in girls. They rely more on relational aggression than boys ○ Girls are less likely to engage in physical aggression ○ Girls depend more on their relationships to develop social identities ○ Girls have more advanced language skills, contributing to relational aggression Overt vs Covert Symptoms in Conduct Problems ○ Overt Confrontational and observable antisocial behaviour ○ Covert Antisocial behaviors that dont involve aggression or confrontation with others; breaking and entering, lying, skipping school, running away from home ○ 2 dimensions that categorize conduct problems The degree of covertness vs overtness Destructiveness vs non destructiveness 4 categories of conduct problem behaviours Property violations → covert and destructive behaviours that involve destroying or stealing property Aggressions → overt and destructive behaviours like fighting and bullying ○ Reactive → violence or destruction done in response to feeling threatened, frustrated or provoked  Children with ADHD more prone to this, youth with emotional regulation issues, issues with problem solving, and with a history of physical violence Children with IED demonstrate this This tends to lessen at the teenage years ○ Proactive → self-initiated, conducted to achieve a goal Parents may model this when they yell or spank Children overestimate the value and rewards for aggression and undervalue the punishments for doing so This tends to persist into the teenage years, and may predict risk of antisocial and criminal behaviour as adults ○ Children with conduct disorder display a mix of reactive and proactive aggression Rule violations → covert and non-destructive like skipping school or lying Oppositional defiant behaviours → overt and non-destructive Dunedin Multidisciplinary Health and Development Study ○ Childhood vs adolescent onset of conduct problems? Child onset A developmental pathway where the kid shows conduct problems before age 10 Risk of ASPD in adulthood Difficult temperament as babies, difficulty with emotional regulation, delayed motor development, low IQ, poor reading ability, neuro deficits, increased display of aggression into adolescence, increase risk of antsocial behaviour, financial/social problems, domestic abuse and substance issues Adolescent onset Kids start to show symptoms after age 10 Risk of behaviour and employment problems in adulthood  No known history of difficult temp, emotional reg. Problems, no neuro discrepancies, a strong need for autonomy, resentment towards authority, dislike for traditional values Manifested in covert, non-destructive acts Problem gradually diminishes by early adulthood Social Information Processing Model ○ An approach to perceiving, interpreting, and solving social dilemmas or disputes consisting of six steps Encode cues → take in the info to understand what the situation is. Facial expressions, personal feelings, peer actions Interpret cues → was the thing done by accident? Was it on purpose? What happened? Children with conduct disorder will often interpret actions as purposeful and intentional Clarify goals → what should i do? How should i do it? Response access → the child considers the diff strategies they can use to act on or solve the conflict Response decision → selecting a strategy to resolve the situation or conflict Behavioural enactment → physical enactment of the solution ○ Each experience contributes to the child’s database and how they should react going forward ○ Aggressive youths show biases or deficiencies in these steps Reactive aggression → problems in encoding and interpreting cues, may not understand their own emotional reactions to a situation Proactive aggression → problems in clarifying goals, response access, and making a decision Kids act out of self-interest, with a greater interest on their self feelings that the feelings of others Kids emphasize the positive aspects of aggression and minimize the negative effects of aggression when making their decisions ○ Children’s actions in social situations are influenced by their thoughts and feelings Causes of Conduct Problems ○ Peer rejection Peers tend to avoid those with low IQ and behavioural problems, especially those with covert issues Peer rejection in girls is associated with earlier puberty onset. Early maturing girls are more likely to associate with older peers, especially boys who may be deviant At risk moreso if they attend a mixed gender school ○ Selective affiliation → friendships with other rejected youth. Deviant peers tend to introduce younger boys to more severe types of deviant behaviour Deviancy training → tendency of peers to reinforce antisocial behaviour and have convos about deviant behaviour Deviant convos in childhood is a predictor for later deviant behaviours Training can start as young as age 6 ○ Impoverished neighbourhoods with a lack of educational resources. Kids may undervalue education and prosocial behaviour Inadequate monitoring → absence of good rec centers, after school programs, organized sports, parental monitoring High-crime neighbourhoods lack social control networks, organizations or communities encouraging pro-social activities and have a high tolerance for antisocial behaviour in youth ○ Protective Factors? Family cohesion and parental monitoring Prosocial after-school activities encourage youth to engage in those and take up free time for deviant activities, regardless of gender ○ Genetic Risks 40-50% of the variance in conduct disorders is attributed to genetic factors Gender, unique temperament, cognitive function, interactions with others → other 50% of variance Difficult temperament and emotional-regulation problems Inhibited development of emotional regulation due to temperament problems  Strained parent-child interactions → some parents may be hostile and angry that reflects aggression in their disciplinary acts in resposne to the child’s problems, or may model that behaviour first Peer rejection due to temperament and emotion problems ○ Physical Underarousal and Punishment Insensitivity Early neurological signs → low autonomic activity (emotional arousal), less guilt or fear of punishment Underarousal inhibits children from experiencing excitement or anxiety; may partake in risky activities to get that excitement Corticolimbic pathway shows underactivity and leads to low sensitivity to punishment or disappointment. Inhibits the development of a conscious and the ability for moral reasoning ○ The Coercive Family Process The parents negatively reinforce noncompliance when the child throws a tantrum, while children reinforce parents backing down ○ Hostile Parenting Behaviour Harsh disciplinary techniques → yelling, arguing, spanking, hitting, guilting, shaming Parents may switch from overly permissive to extremely hostile Harmful punishments Children believe aggressive behaviour is the best way to resolve conflict Children are taught to avoid crying or whining rather than obey adults Verbal and physical abuse when conducted from anger Low parental monitoring → not knowing where they are, not setting limits on activities, no consistent discipline Strong predictor for adolescent-onset conduct problems. Stronger even than hostile parenting Parental monitoring might be difficult if children are good at lying ○ Parents’ Cognitions and Mental Health Perception of children’s misbehaviours affect their parenting style and their children’s development 2 causes:  External, unstable causes Internal, stable problems ○ Parents of disruptive children often attribute behaviour to this, making them more prone to anger and resentment ○ Parents feel powerless and may eventually give up on discipline, negatively reinforcing bad behaviour Parental psychopathology → strong predictor of conduct problems in children Maternal depression, maternal antisocial behaviour, parental substance abuse, and marital problems can all be a risk factor for children developing conduct problems Medical, financial, and relationship stressors in parents affect the children and inhibit optimal parenting 2-way influence from parent to child and vice versa ○ Robin’s Paradox Most adults with antisocial behaviour have a history of it in childhood Most children with antisocial behaviour in childhood DONT become antisocial adults ODD only pathway Children with ODD in childhood but not conduct disorder in later years Most likely inherit a genetic risk for disruptive behaviour and difficult temperament. 50% will be diagnosed with ADHD Will lead to parenting stress, which will inhibit positive parenting Child onset CD pathway Children inherit genetic risk for CD Difficult temperament and hyper impulsivity in childhood Oppositional defiant and non-compliant behaviours in adulthood 75% of youth will meet criteria for ODD Leads to peer rejection and association with deviant peers Kids resort to aggression to supplement their poor problem solving skills 50% are prone to substance use problems ⅓ of youth also exhibit limited prosocial emotions  Kids engage in overt and destructive activities 10% of children follow this path, ¾ will experience problems as adults, and 40% will be diagnosed with ASPD in adulthood Adolescent onset conduct disorder pathway Hits after puberty Property destruction, theft, rule violations Protest and resent rule limitations from authority Peer rejection, affiliate with deviant peers Continue to display disruptive behaviours into their 20s Problems with health, employment, substance use, and limited opportunities to participate in higher education Treatment for Conduct Problems in Children and Adolescents ○ Parent-Management Training (PMT) Behavioural intervention Based on the idea that disruptive behaviour occurs in the context of those coercive parent-child interactions Most programs require weekly participation with parents without their children 10 steps in 4 general phases: 1) therapist supports the parent to reduce guilt or shame, and parents are encouraged to set clear expectations for behaviour and reinforce appropriate behaviour and avoid coercive interactions 2) parents are taught to use positive reinforcement to increase compliance, taught kids will be motivated to perform an undesirable activity if they know they can participate in a desirable activity after ○ Token system may be used 3) use of discipline and environmental structuring to reduce bad behaviour 4) parents will generalize children’s appropriate behaviours to the school setting. Teachers will submit a daily report card and parents can use rewards for appropriate behaviour Benefits?  Children display more pro-social behaviours Children have fewer disciplinary troubles at school More able to function like their typical peers long after training is done Limitations? Less effective for single, low income, or marital conflict parents, parents with health/mental health problems, or substance issues Less effective when kids show high rates of resistance Not many therapists are trained in this ○ Parent-Child Interaction Therapy (PCIT) Variation of PMT where parents and children are coached by therapists as they interact in real-time Authoritative parenting is encouraged → high in demand and responsiveness Parent-child interactions are observed and treated in the moment, suggestions are made to parents Therapist will coach parent without the child knowing Phase 1: child-directed interactions → aimed at increasing parent’s sensitivity to the child’s behaviour, practices praising, imitating, accepting prosocial behaviour Phase 2: parent-directed interaction → helps parents set more realistic expectations, decrease hostile techniques and discipline consistently, make demands clearly and concretely that have follow up consequences Therapist will use praise and encouragement with the parents Benefits? Increases parenting confidence Reduces parental stress Is adaptable ○ Videotaped Modeling and the Incredible Years Problem Low income, high stress families Video taped modeling and treatment modules A form of PMT Helps with problematic parent-child interactions  Effective for mothers with depression and fathers with history of substance abuse ○ Problem-solving skills training Cognitive intervention Disruptive youth learn to percieve, interpret, and respond to conflict in a more constructive way Aims to change those negative biases that children with conduct problems hold Goes through the steps of the social info processing model Therapist acts as a coach, using praise and encouragement to teach the child Parents can reward the kids at home Treatment is effective, has been shown to last for 1 year Better outcomes if families are using PMT AND PSST ○ Aggression Replacement Training Multimodal treatment for adolescents with history of disruptive, aggressive, antisocial behaviour Based on the idea that youths lack the behavioural and affective skills they need to partake in prosocial behaviour Skillstreaming Behavioural component Aims at increasing prosocial skills to decrease aggression and arguing Teaches beginner skills related to emotions Anger control training Emotion regulation component Aimed at helping the teen understand external triggers and internal cues that prompt that aggression and anger Participants identify physiological markers Therapist will introduce anger reducing techniques Group members are encouraged to use skillstreaming techniques Moral reasoning Presented with a situation that poses a moral dilemma  Therapist emphasizes the importance of considering others’ rights and feelings The group is encouraged to adopt more mature and less egocentric decision making techniques Shown to be effective in improving social skills ○ Multisystemic Therapy Intensive form of family and community based treatment for more serious conduct problems Involves family therapy, academic school support, and increased parental monitoring Based on the model that behaviour is best understood through these multiple systems that interact with each other Parents are supported and taught to monitor behaviour and activities and to avoid conflict in the home Therpists will support the parents with their own issues Parental involvement in school is increased, the therapist will be a facilitator between teachers and parents Therapists aim to reduce the teens association with deviant peers and increase their association with prosocial peers MST therapists usually work in teams of 3-5 Teens participating are 20-75% less likely to reoffend. We see improved family functioning and a reduction in teens engaging with deviant peers ○ Psychopharmalogical Treatment No meds are approved for specifically treating conduct disorders Some ADHD meds have been shown to reduce aggressive and defiant behaviours, but can increase defiant behaviours in boys with low cognitive function It improves parent-child interactions, with effects only lasting as long as the children take it Risperidone Anti-psychotic med for schizophrenia or bipolar disorder Been shown to reduce disroptive behaviours in children with ADHD who don’t respond to stimulant meds  Coupled with PMT → may lead to faster and greater reduction in defiant behaviour What works, what doesnt, and why? Incarceration → ineffective; youths and young adults may engage in MORE offences Deterrence programs → ineffective; shows an increased chance the youth will reoffend Wilderness challenge programs → no change in behaviour. Any improvement in behaviour disappears when children are back home Group interventions → may increase deviancy and members may engage in deviancy training with each other Common features of evidence-based treatment The family and parents are the primary change agent Addressing socio-cultural factors Delivered at home or in the community to erradicate parental hurdles and increase accessibility Positive reinforcements Addresses behavioural, comprehensive, and individualistic needs Consistent treatment with follow-ups are essential