(10-10-13)
Characteristics of Conduct Disorders
(4-24-14)
Conduct problems: problems with aggression, compliance with adult commands, rule breaking.
- Have been referred to by a variety of labels: acting out, externalizing, hyperaggressive, antisocial
- Patterson: 5% most extreme aggressive, noncompliant, rule breaking identifies an “at risk” population.
- Prevalence:
- 4% to 10% of children under the age of 18 (Breen & Altepeter, 1990).
- 6-16% of males: more symptoms of violence
- 2- 9% of females: more symptoms of relational violence
- one year prevalence of 2% to more than 10%, with median prevalence of 4% (DSM 5, p. 473)
- 4% to 10% of children under the age of 18 (Breen & Altepeter, 1990).
- DSM 5 (APA, 2013)
- “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” (p. 469). Requires 3 (of 15) symptoms over 6 month period.
Course:
- developmentally stable
- Once identified this pattern of behavior appears to be highly stable with exacerbation of symptoms the rule.resistant to change
- Very limited empirical evidence supporting our ability to systematically and reliably alter the life course of youth with Conduct Disorder diagnoses.
- Best results with behavioral interventions, but transfer to natural settings and maintenance over time have been continuing difficulties.
- Little benefit report with available pharmacological interventions.negative adult outcome
- Poor adult outcome on educational achievement measures (HS graduation, obtaining GED, years of schooling, need for special education), work record (unemployment, underemployment, history of transient or menial jobs), military service record (less than honorable discharge, rank earned), criminal record, relationships (divorce, separation, estrangement, quality of relationship rated by proband or significant other), mental health history; in fact on any measure of adult adjustment outcome that has been evaluated.
High Comorbidity with other problems:
- * ADHD
- * LD
- * Substance Abuse (adolescence)
- * Depression, Anxiety
- * Delinquency (legal problems)
Subtypes
Etiology
Treatment
Conduct Disorders: criteria (paraphrased)
DSM 5 defines Conduct Disorder in terms of:
- A pattern of behavior in which the basic rights of others or major norms and rules are violated, as manifested by 3 or more the the following symptoms within a six month period of time
- bullies, threatens, or intimidates others
- initiates physical fights
- uses a weapon in a fight
- is physically cruel to people
- is physically cruel to animals
- has stolen with confrontation of the victum
- has forced sexual activity upon someone
- has set inappropriate fires
- has destroyed property for no reason
- has broken into a building or property
- frequently lies to obtain goods or to avoid punishment, lies to “con”
- has stolen without confrontation of the victum
- stays out late without parental permission before the age of 13 years.
- runs away from home twice or once without returning for lengthy period.
- is more frequently truant than is typical of neighborhood, beginning before age 13.
- The pattern of conduct problems causes clinically significant impairment in adjustment and functioning.
- If the indivdual is older than 18, then they do not meet criteria for Antisocial Personality Disorder.
Subtypes:
- Childhood-Onset Type: onset of at least one of the above symptoms prior to age 10.
- Adolescent-Onset Type: absence of any criteria prior to the age of 10.
Specifiers:
- With limited prosocial emotions:
- lack of remorse or guilt
- callous-lack of empathy
- unconcerned about performance
- shallow or deficient affect
- specify current severity:
- Mild: few problems beyond minimum to make diagnosis and relatively mild harm to others
- Moderate: intermediate number of problems and harm
- Severe: many problems beyond what is necessary to make diagnosis, or considerable harm to others
Subtypes of Conduct Disorders
(10-10-13)
Early onset pattern
- Unsocialized Aggressive Reaction—- Jenkins, DMS-II
- Psychopathic Delinquent—————- Quay
- Childhood Onset Type——————– DSM-IV, DSM 5
Later onset pattern
- Socialized-Subcultural Reaction—– Jenkins, DMS-II
- Group Delinquent————————- Quay
- Adolescent Onset Type—————– DSM-IV, DSM 5
A possible, less frequent, third pattern
- Runaway Reaction———————– Jenkins, DSM-II
- Disturbed Neurotic Delinquent——- Quay
- Not Otherwise Specified—————- DSM-IV; Unspecified Conduct Disorder DSM 5
with all attempts at subgrouping, there is a considerable population of unclassifiable cases
- Unspecified Conduct Disorder/Other Specified Conduct Disorder——DSM 5
- Not Otherwise Specified—————- DSM-IV
Differentiation of subtypes:
- subtypes do not different in terms of problem behaviors (externalizing/acting out symptoms)
- but may differ in other features of psychological and interpersonal functioning:
| subpattern: | unsocialized-aggresssive | socialized-subcultural | disturbed-neurotic |
| peer relationships | poor | some good | poor |
| social context ofantisocial behavior | low (isolate) | high | low (isolate) |
| goals/motivation forantisocial behavior | functional | functional & social | unclear/”conflicted” |
| anxiety/remorse | low | low (unless group) | sometimes high |
| response to frustration | direct & immediate | contingent upon socialmeaning | indirect |
| prognosis | poor | better | unknown, probable poor |
| treatment | environmental | environmental | environmentaland psychotherapy |
| age of onset(DSM-IV subtype) | childhood(Childhood Onset Type) | adolescent(Adolescent Onset Type) | unknown, probably young(Childhood Onset Type) |
DSM 5 has continued the recent pattern in DSM of differentiating Conduct Disorders in terms of age of onset (Childhood-onset type, at least one symptom before 10 years of age; Adolescent-onset type; Unspecified onset type); a new qualified has been added: With limited prosocial emotions (showing at least two of these characeristics: lackof remorse or guilt, callous–lack of empathy, unconcerned about performanace, shallow or deficient affect)
Adolescent Sexual Offenders
(4-5-06)
Adolescents commit 16% of sexual offenses against females over the age of 12, and 17% of other sexual offenses (FBI, 1996)
A population survey found approximately 2% of youth reported having engaged in behavior what would have been considered rape or attempted rape in most legal jurisdictions (Ageton, 1983)
Up to 10-15% of adolescent sexual offenders continue to offend into adulthood (Rasmussen, 1999)
Approximately half of adult sexual offenders report that their first sexual offense occurred during adolescence (Abel et al., 1985; Groth et al., 1982)
25% of adolescent sexual offenders have engaged in sexually abusive behavior before the age of 12 (Ryan et al., 1996)
Developmental Model of Antisocial Behavior in Children
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(Patterson, Oregon Social Learning Center)
This model is based largely on the work of Gerald Patterson and colleagues at the Oregon Social Learning Center in Eugene, Oregon. I believe it reflects the most common pathway to the “unsocialized-aggressive” pattern of conduct disorder in youth: the “early onset” pattern (DSM 5), which is one of the major (most frequent) subtypes.
Risk factors (environment)
- poverty
- social anome
Risk factors (child):
- difficult temperament (Chess, Thomas, Birch et al.)
- * lower intelligence/learning problems
Risk factors (parents)
- * psychiatric disorder
- mothers: depression, substance abuse, criminal behavior
- fathers: antisocial personality disorder, substance abuse, criminal behavior
- * stress: resource deprivation
Training at Home [basic mechanism: coercion hypothesis]
- * parents’ modeling of coercive control [norm of reciprocity]
- * parents’ direct reinforcement of child’s negative behavior
- * parents’ noncontingent reactions to positive and negative child behavior
- poor parental monitoring (considered alone) predicts delinquency (Vitaro, Brendgen, & Tremblay, 2000)
- * negative reinforcement sequences [negative reinforcement trap]
Child Goes to School
- *academic failure
- * poor self esteem
- * internalizing symptoms (depression, anxiety)
goes to:
Making Friends with Deviant Peers
Deviant friends are a risk factor for delinquency, although data from Vitaro, Brendgen, & Tremblay (2000) indicate this fluency can be moderated or even blocked by an unfavorable attitude toward delinquency, improved/nondisruptive behavior profile during childhood, or family experiences (attachment to parents).
Substance Abuse
goes to:
Adult Antisocial Life-Style
diagnosis of Antisocial Personality Disorder (psychopath) occurs in significant percentage of these youth, subthreshold antisocial behavior is usually problematic in those who do not meet criteria for Antisocial Personality Disorder
Protective factors
Maughan & Rutter (1998) consider factors which protect against the continuance of antisocial behavior from childhood to adult life:
intelligence, behavioral inhibition, & prosocial skills
planfulness: “A planful, considered approach to life choices may be especially important for behaviorally deviant youth and for those in situations where family or wider social supports for life-planning are restricted.” (Maughan & Rutter, 1998, p. 33).
high autonomic arousal during teen years (Raine, Venables, & Williams (1995)
Prognostic factors for positive change:
- * intelligence higher intelligence is protective factor (weak), higher intelligence is positive prognostic factor for better course outcome (weak), lower intelligence is risk factor for development (weak), lower intelligence is negative prognostic factor for positive intervention response (moderate)
- Interventions to improve school motivation are associated with reduced delinquency (Yoshikawa, 1994)
- * positive attachment to positive role model positive prognostic factor for better course outcome (moderate)
- * early intervention (mixed results, but appears to be positive prognostic factor for better treatment outcome)
- * motivation/energy of parents commitment of parents appears to be necessary factor for change, investment appears to be moderately associated with better course outcome
- * environmental change usually necessary for change
- * experience of therapist (provisional, some finds suggest more experienced therapists have better outcome)
- *absence of drug use child/adolescent drug use is a strong, negative prognostic factor for these youth