Externalizing Disorders Study Guide Part 1 PDF

NSG 5720 Psychiatric Management II Conduct Problems Conduct problems consist of age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal or property rights of others. Disruptive and rule-violating behaviors range from annoying minor behaviors to seri...

NSG 5720 Psychiatric Management II Conduct Problems Conduct problems consist of age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal or property rights of others. Disruptive and rule-violating behaviors range from annoying minor behaviors to serious antisocial behaviors such as vandalism, theft, and assault. Multiple types, pathways, causes, and outcomes of conduct problems should be considered. Conduct problems are often associated with unfortunate family and neighborhood circumstances, which do not excuse the behavior but help in understanding and preventing it. Antisocial behaviors appear and decline during normal development, varying in severity from minor disobedience to fighting. Early, persistent, and extreme antisocial behavior occurs in about 5% of children, accounting for 50% of all crime in the U.S. and approximately 30-50% of clinic referrals, with an annual public cost of $10,000 per child. Juvenile delinquency and legal definitions exclude antisocial behaviors of very young children occurring in home or school, with the minimum age of responsibility being 12 in most states. Psychological perspectives view conduct problems falling on a continuous dimension, with various dimensions and categories. Psychiatric perspectives distinguish conduct problems as distinct mental disorders based on DSM symptoms, focusing on disruptive behaviors as persistent patterns of antisocial behavior and the relevance of the diagnosis of antisocial personality disorder (APD). Public health perspectives aim to understand conduct problems in youths, determine treatment and prevention methods, and reduce related injuries, deaths, personal suffering, and economic costs associated with youth violence. DSM-5 defines two disruptive behavior disorders, oppositional defiant disorder (ODD) and conduct disorder (CD), both predicting future psychopathology and enduring impairment in life functioning. CD is highlighted as the strongest predictor of adverse outcomes. Childhood Behavior Disorders Oppositional Defiant Disorder (ODD) is an age-inappropriate recurrent pattern of stubborn, hostile, disobedient, and defiant behaviors that usually appears by age 8. Severe ODD behaviors can have negative effects on parent-child interactions. Conduct Disorder involves a repetitive, persistent pattern of severe aggressive and antisocial acts, often co-occurring with problems such as ADHD, academic deficiencies, and poor peer relations. Childhood-onset CD begins before age 10, occurs more frequently in boys, and is characterized by more aggressive symptoms and criminal activity. Adolescent-onset CD may affect girls as often as boys and is less severe, with lower rates of violent offenses and antisocial behaviors over time. For most children, ODD is an extreme developmental variation and a strong risk factor for later ODD, without signaling an escalation to more serious conduct problems. Most children with ODD do not develop more severe CD, and nearly half of all children with CD have no prior ODD diagnosis. Antisocial Personality Disorder (ADP) and Psychopathic Features are pervasive patterns of disregard for others' rights and involvement in illegal behaviors, often developed by children with CD. A subgroup of children with CD are at risk for extreme antisocial and aggressive acts and poor long-term outcomes, displaying callous and unemotional interpersonal style and lack of guilt, empathy, or behavioral inhibition. Associated Characteristics of conduct problems in youths include cognitive and verbal deficits, school and learning problems, self-esteem deficits, peer problems, family problems, and health- related issues. Most children with conduct problems have normal intelligence but may display verbal deficits and executive functioning deficits, with co-occurring ADHD as a factor. Behavioral and Health-Related Problems in Children The relationship between conduct problems and underachievement is firmly established by adolescence, which may lead to anxiety or depression in young adulthood. Family problems can manifest as general disturbances, specific disturbances in parenting practices, high levels of conflict, lack of family cohesion and emotional support, and deficient parenting practices. Children with peer problems may be rejected by peers, become bullies, display poor social skills, and form friendships with other antisocial peers. Conduct problems in children are not directly related to low self-esteem, but inflated, unstable, and/or tentative view of self may play a role. Children with conduct problems are at high risk for personal injury, illness, drug overdose, sexually transmitted diseases, substance abuse, and physical problems as adults. Childhood conduct problems are found to be associated with attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety, with increasing severity of antisocial behavior associated with increasing severity of depression and anxiety. The prevalence of conduct disorder (CD) and oppositional defiant disorder (ODD) across cultures of Western countries is similar, with a lifetime prevalence rate of 12%. Conduct Problems in Children and Adolescents Conduct problems are more prevalent in boys than in girls during childhood, with boys exhibiting higher rates of oppositional and aggressive behaviors. Gender differences in conduct problems are evident from an early age, with boys showing earlier onset and greater persistence of symptoms. Early symptoms of conduct problems in boys typically include aggression and theft, while early symptoms in girls involve sexual misbehaviors. Potential explanations for gender differences in conduct problems include genetic, neurobiological, and environmental risk factors, as well as different definitions of conduct problems that emphasize physical violence. Girls are more likely to use indirect, relational forms of aggression, while early maturing boys and girls are at risk for being recruited into delinquent behavior by peers. The general progression of conduct problems in children and adolescents follows a pattern of difficult temperament in infancy, hyperactivity and impulsivity in preschool and early school years, and peak of oppositional and aggressive behaviors during preschool years. New forms of antisocial behavior develop over time. Covert conduct problems begin during elementary school and become more frequent during adolescence. Some children deviate from this traditional progression, with some improving, some not displaying problems until adolescence, and some displaying persistent low-level antisocial behavior from childhood/adolescence through adulthood. Conduct problems can follow two common pathways: life-course-persistent (LCP) and adolescent-limited (AL). LCP begins early and persists into adulthood, associated with family history of externalizing disorders, while AL begins at puberty and ends in young adulthood, showing less-extreme and more transient antisocial behavior. Causes of conduct problems include genetic influences, prenatal factors, and birth complications, neurobiological factors such as variations in stress-regulating systems, and the interplay among predisposing child, family, community, and cultural factors over time. Mechanisms and Factors of Antisocial Behavior Structural and functional brain abnormalities in amygdala, prefrontal cortex, anterior cingulate, and insula are related to neural systems and social-cognitive factors. Subcortical neural systems are linked to dysfunctional brain circuits involving the amygdala, contributing to aggressive behavior. Prefrontal cortex is associated with decision-making circuits and socioemotional information processing circuits. Frontoparietal regions are involved in emotions and impulsive motivational urges. Social-cognitive factors include immature forms of thinking, cognitive deficiencies, cognitive distortions, and deficits in facial expression recognition and eye contact, as outlined by the Dodge and Pettit comprehensive social-cognitive framework model. Family factors encompass child risk factors, extreme deficits in family management skills, the complexity of family environment influence, and reciprocal influences between child behavior and parenting behavior. Parent-child interactions provide a training ground for the development of antisocial behavior. High family stress may be both a cause for and an outcome of a child’s antisocial behavior, and there is a relationship between insecure attachments and the development of antisocial behavior under attachment theories. Individual and family factors interact with the larger societal and cultural context in determining conduct problems. Treatment and prevention strategies include various approaches ranging from individual counseling to restrictive measures, with emphasis on a comprehensive two-pronged approach that includes early intervention/prevention programs and ongoing interventions. Effective treatments for children with conduct problems include Parent Management Training (PMT) that teaches parents to change their child's behavior in the home and in other settings using contingency management techniques. Behavior Modification Techniques Problem-Solving Skills Training (PSST) identifies cognitive deficiencies and distortions in social situations and teaches new ways of handling social situations. PSST helps the child to appraise the situation, change attributions about other children's motivations, be more sensitive to how others feel, and generate alternative solutions.  Multisystemic Therapy (MST) is an intensive approach that draws on other techniques such as PMT and marital therapy, as well as specialized interventions like special education and substance abuse treatment. Parent Management Training (PMT) focuses on improving parent-child interactions, promoting positive behavior, and decreasing antisocial behavior using contingency management techniques. PSST helps children learn to appraise situations, identify self-statements and reactions, and be more sensitive to others, using cognitive problem-solving steps. MST is an intensive family- and community-based approach for teens with severe conduct problems, aiming to empower caregivers to improve youth and family functioning. Preventive interventions focus on treating younger children with conduct problems to limit or prevent escalation of problem behaviors, reducing costs and long-term rates of criminal behavior. Incredible Years and Fast Track are examples of effective early-intervention programs and components to prevent the development of antisocial behavior in high-risk children. Attention-deficit/hyperactivity disorder (ADHD) is exhibited as persistent age-inappropriate symptoms of inattention, hyperactivity, and impulsivity that cause impairment in major life activities. Core characteristics of ADHD include inattention and hyperactivity-impulsivity, though these dimensions oversimplify the disorder, as attention and impulse control are closely connected developmentally. ADHD and Associated Characteristics Deficits may be seen in one or more types of attention, including attentional capacity, selective attention, distractibility, and sustained attention/vigilance, which is a core feature. Hyperactivity-Impulsivity, which is a characteristic of ADHD, includes an inability to voluntarily inhibit dominant or ongoing behavior, hyperactive behaviors such as fidgeting and excessive talking, and impulsivity such as cognitive, behavioral, and emotional impulsivity. ADHD Presentation Types include predominantly inattentive presentation (ADHD-PI), predominantly hyperactive-impulsive presentation (ADHD-HI), and combined presentation (ADHD-C). For the Predominantly Inattentive Type (ADHD-PI), symptoms may include inattentiveness, drowsiness, learning disabilities, anxiety, and low academic achievement. The Predominantly Hyperactive-Impulsive Type (ADHD-HI) primarily includes symptoms related to hyperactivity-impulsivity and may be most relevant to preschoolers.  Combined Type (ADHD-C) involves children who have symptoms of both inattention and hyperactivity-impulsivity and is often the most referred for treatment. Additional DSM Criteria for diagnosing ADHD requires that the symptoms appear prior to age 12, persist more than 6 months, occur more often and with greater severity than in other children of the same age and sex, occurs across two or more settings, and interferes with social or academic performance, while not being explained by another disorder. What DSM Criteria Don’t Tell Us: Limitations of DSM criteria for ADHD, including being developmentally insensitive and having a categorical view of ADHD, which shapes our understanding of ADHD. Associated Characteristics, children with ADHD, may display other problems, include cognitive deficits, speech and language impairments, developmental coordination and tic disorders, and medical and physical concerns. Cognitive Deficits may affect executive functions, language processes, motor processes, and emotional processes. Examples of Impaired Executive Functions may result in difficulties organizing work, being easily distracted, difficulty completing tasks on time, and being overly sensitive to criticism, among others. The Impact of ADHD on Children's Intellectual and Academic Abilities Children with ADHD typically have normal intelligence but struggle to apply it to everyday life situations. These children often have lower productivity, grades, and scores on achievement tests compared to their peers without ADHD. Learning disorders, particularly in reading, spelling, and math, are prevalent among children with ADHD. Children with ADHD are prone to exaggerating their competence and may have distorted self- perceptions. Speech and language impairments are common in children with ADHD, including difficulty understanding others' speech and inappropriate conversations. Motor coordination difficulties, developmental coordination disorder, and tic disorders are also common in children with ADHD. Children with ADHD are at higher risk for health-related problems such as asthma and bedwetting, sleep disturbances, and accidents due to impulsivity and risk-taking behavior. Social problems such as family conflicts, peer rejection, and difficulty in applying social understanding in social situations are common among children with ADHD.  An estimated 80% of children with ADHD have a co-occurring psychological disorder, including oppositional defiant disorder, conduct disorder, and anxiety disorders. ADHD (Attention-Deficit/Hyperactivity Disorder)** ADHD can lead to social and academic difficulties as well as greater long-term impairment and mental health problems. ADHD can put individuals at risk of developing mood disorders, with ADHD in early childhood being a risk factor for future depression and suicidal behavior. It may be more likely for children with ADHD to experience other psychological disorders, such as pediatric bipolar disorder. Prevalence rates of ADHD are estimated to be 6-7% of school-age children and adolescents in North America and 5% worldwide, with it being one of the most common referral problems seen at clinics. ADHD is diagnosed more often in boys than girls, and girls with ADHD may be more likely to display inattentive/disorganized symptoms. ADHD affects children from all social classes, with slightly more prevalence among lower socioeconomic status (SES) groups, and its expression and outcomes are similar across cultures. Signs of ADHD may be present at birth, and hyperactivity-impulsivity symptoms become more visible and significant at ages 3-4. Symptoms of ADHD become especially evident when the child starts school, and oppositional defiant behaviors may increase or develop. Many children with ADHD do not outgrow problems and at least 50% of clinic-referred elementary school children continue to suffer from ADHD into adolescence. Some individuals may outgrow or learn to cope with ADHD by adulthood, while others continue to face challenges related to the disorder. Causes and Influences of ADHD Explanations for ADHD include traits from an evolutionary past as hunters, a myth fabricated because society needs it, and various cognitive functioning deficits, reward/motivation deficits, arousal level deficits, and self-regulation deficits. Genetic influences, supported by family, adoption, and twin studies, suggest a 75% heritability estimate for hyperactive-impulsive and inattentive behaviors, with specific genes possibly influencing ADHD expression, particularly those focusing on dopamine regulation and the serotonin system.  Certain factors that compromise the development of the nervous system before and after birth may be related to ADHD, such as a mother's use of cigarettes, alcohol, or other drugs during pregnancy, although it is difficult to disentangle substances' influence from other environmental factors. Neurobiological factors that contribute to ADHD include differences in neural network engagement, psychophysiological measures, under-responsiveness to stimuli, response inhibition deficits, decreased blood flow to specific regions of the brain, and abnormalities in the frontostriatal circuitry implicated in ADHD children, who may have smaller cerebral volumes, smaller cerebellum, and delayed brain maturation. Although no consistent differences have been found in neurophysiological and neurochemical associations between children with and without ADHD, some neurotransmitters may be involved, notably dopamine, norepinephrine, epinephrine, and serotonin, suggesting a selective deficiency in the availability of dopamine and norepinephrine. Sugar is not the cause of hyperactivity, and while genetic factors may explain why food additives affect some children's behavior, low levels of lead may also be associated with ADHD symptoms, though the role of diet, allergy, and lead is still undergoing research. Family influences are seen as potentially contributing to ADHD symptoms or a greater severity of symptoms, due to interacting problems arising from having to manage a difficult child, also likely related to the presence, persistence, or later emergence of oppositional and conduct disorder. Finally, less than half of children with ADHD receive treatment, consisting of a primary approach combining stimulant medication, parent management training, and educational intervention to address symptoms. Treatment Options for Children with ADHD Primary treatments focus on stimulant medication, parent management training, and educational intervention. Stimulant medication includes managing ADHD symptoms at school and home. Parent management training involves managing disruptive child behavior at home, reducing conflict, and promoting positive behaviors. Educational intervention encompasses managing disruptive behavior, improving academic performance, and teaching positive behaviors. Intensive treatment includes summer treatment programs to enhance adjustment at home and future success at school with multiple primary and additional treatments.  Additional treatments involve family counseling, support groups, and individual counseling to cope with ADHD-related stress and emotional support. Stimulant medication, such as dextroamphetamine and methylphenidate, has been effective, although concerns exist about long-term use. Parent management training aims to provide parents with various skills and teach them the biological basis of ADHD and behavior management principles. Educational intervention requires realistic goal-setting and utilizes strategies to reduce disruptive behaviors. Intensive interventions like summer programs maximize peer relations and continuity with academic work. Additional interventions, including counseling and support groups, aim to help family members and children with ADHD develop new skills and relate more effectively. Individual counseling helps children with ADHD deal with their problems and build self- competence. Children with ADHD have inherent strengths that should be recognized and supported.