Externalising disorders

1. Externalising disorders ODD; CD; ADHD most common referral high level of impairment poor prognosis high risk of co-morbidity eg. externalising disorder ? risk of internalising disorder, converse is not true

3. Conduct disorder a repetitive and persistent pattern of behaviour in which the basic rights of others and major age-appropriate societal norms are violated often fights, uses weapons cruel to people and animals bullies or threatens steals, sets fires lies truants, runs away

4. ODD/CD Empirical evidence supports distinction between ODD & CD (Fergusson et al. 1994) and between ADHD & both ODD & CD (Hinshaw, 1994) although there is considerable co-morbidity and overlap of symptoms ODD often precedes CD (OR 4.0 in NY Longitudinal study) CD often precedes Anti-Social Personality Disorder

5. Conduct disorder �I would there were no age between sixteen and three-and-twenty, or that youth would sleep out the rest: for there is nothing in the between but getting wenches with child, wronging the ancientry, stealing fighting� William Shakespeare, The Winters Tale

6. ODD/CD - epidemiology estimates vary according to diagnostic criteria, age, sample, and informant incidence and severity increases across development ODD present in 2-16% population, relatively stableover time, but two thirds do not progress to CD 3-7% early onset, life course persistent CD (Fergusson et al., 1996; Moffit, 1993) 20-25 % adolescent limited CD (Moffit, 1993) boys at ? risk for CD (3-4:1), less marked for ODD, but girls may be under-diagnosed, tend to use indirect verbal and relational aggression, including alienation, ostracism and character defamation, not captured by current definitions social disadvantage ? risk girls more likely to be adolescent limited, but if early onset, prognosis is poor some evidence for generational increase, particularly in females

7. etiology - biological factors genes Twin/adoption studies implicate genetic factors temperament increased incidence of �difficult� temperament neuropathology ? incidence of minor physical anomalies - markers of deviant neural development altered neurochemistry eg, reduced serotonin (implicates meso-limbic system), underarousal ? thrill seeking EEGs show reduced frontal activation ? impaired insight/judgement ? Exposure to environmental toxins, infections, maternal substance abuse neuropsychological deficits (may be more important in girls, and in boys without other risk factors ) lower IQ, PIQ > VIQ language, including verbal memory; executive deficits, poor social cognition

8. etiology - family and social influences genetic/environmental interplay Antisocial adults more likely to have children with predisposing difficult temperaments and low IQ and to provide poor social models and maladaptive family environments ie. shared genetic/environment influences attachment/parenting style vulnerable vulnerable adult, difficult child - more likely to experience attachment difficulties and to elicit maladaptive parenting and conflictual interactions socio-demographic factors inverse relationship between CD risk and family income, positive relationship with family size, lax supervision, harsh/inconsistent discipline and parental tolerance of antisocial behaviour

9. peer influences �early onset, life course persistent� aggressive, irritable, oppositional children alienate well behaved children and gravitate to similar, high-risk peers but environmental experience reinforces, does not cause, early onset CD �adolescent limiteds� less severe subgroup, mimic peer behaviour to achieve status in societies with extended adolescence ie. association with deviant peers - a causal relationship

10. Conduct disorder subtypes early (ie < 10 years) versus late onset early onset CD often preceded by ODD CD onset tends to be earlier in boys with aggression or co-morbid ADHD �adolescent limited� versus �life -long persistent� overt (confrontational) versus covert socialised versus non-socialised

11. Conduct disorder - explanatory models Robins (1991) alienation, lack of attachment to conventional society ie. attitudinal problem precedes anti-social behaviour Gottfredson & Hirschi (1990) stable individual differences in antisocial propensity; core features � impulsivity, daring, high activity, low IQ Moffit (1993) two sub-types with different causal explanations (i) �life course persistents� reflect interaction of neurobiology + criminogenic environments (ii) �adolescent limited� explained by peer modelling

12. Conduct disorder - explanatory models Lahey et al. (1999) - an integrated model Children at risk of CD exhibit key temperament dimensions of oppositionality aggression (high heritability) low harm avoidance callousness eg. lack of empathy, diminished guilt, ? need for approval novelty seeking ie. arousal > inhibition but relative strength of causal influences varies across development early starters - temperament + neurobiological factors important, environmental factors increasingly implicated with age i.e. magnitude of genetic influence inversely related, and environmental influence positively related, to age of onset.

13. Conduct disorder - prognosis 50% persistent disorder (Lahey, 1995; Offord et al., 1992) poor outcome predicted by early onset severity of symptoms, particularly aggression or psychopathy gender or age atypical behaviours co-morbidity (CD + ADHD; CD + LD, CD + mood & anxiety disorders) narrowing opportunities eg. school failure, dysfunctional peers, entry into criminal system, substance abuse) Loeber et al., 2002

14. Conduct disorder - protective factors better prognosis associated with higher IQ better communication skills adaptive parenting close supervision female gender ? more verbal, more empathic, less aggressive

15. Conduct disorder assessment low correlation across informants, but each contribute important information teacher reports of ODD have highest predictive validity self-report critical for CD As pathways to CD are likely to be multifactorial, a careful history is critical Structured, semi structured interview schedules help organise clinical information

16. Conduct disorder - treatment treatment difficult, prevention may be best option need to minimise risk factors and enhance protective factors Structured multi-modal approaches that address multiple risk factors are the most efficacious eg. Fast Track, LIFT empirical support for parent effectiveness training (Patterson, 1982; Dadds et al., 1987) vv early identification/remediation of learning difficulties (Berrueta-Clement et al., 1984) v v environmental change eg. exposure to conforming peers (Feldman et al. 1983) anti-bullying (Roland, 2000) v child problem solving, conflict resolution, stress reduction/empathy building, social skills, anger management (Burke et al., 2002), v pharmacology eg mood stabilisers (lithium), atypical antipsychotics, stimulants (Burke et al., 2002) v �Innoculation� strategies such as boot camps unhelpful and may be harmful psychotherapy unhelpful

19. Tom referred for firelighting also long history disruptive behaviour aggression school truancy/suspensions academic �underachievement�

20. Tom early development born small for gestational age delayed language unsettled, irritable kindergarten restless, unco-operative, aggressive �didn�t listen� school commenced school lacking in requisite social and cognitive skills developed into an oppositional non-reader with conflictual relationships with peers and teachers, paranoid interpretations of social experiences gravitated towards anti-social peers

21. Tom Family intact family, father often unemployed middle child of three parenting fluctuated between being indulgent and punitive father thought aggression was acceptably �male� school failure explained as �laziness�

22. Tom Verbal scale information 8 similarities 5 arithmetic 7 vocabulary 6 comprehension 5 Verbal IQ 78 Performance scale picture comp 12 picture arrange 5 block design 11 object assembly 12 coding 9 Performance IQ 102

23. Tom Q. In what ways is a house built of brick better than one built of wood? A. A brick house might have a fire-place Q. Why do we have to put a stamp on a letter? A. So that it gets to the person on time Q. Why should you keep a promise? A. If you don�t keep a promise, you forget it

24. Tom A lamp is straight and a candle is long A cat chases a mouse A knee and an elbow both stick out You talk on a telephone and you listen on a radio

25. Tom Anna Thompson/of East Sydney/ employed/ as a cleaning woman/ in an office building/ reported/ at the Eastern District/ Police Station/ that she had been held up/ on Smith Street/ the night before/ and robbed/ of fifteen dollars./ She had four little children/ the rent was due/ and they had not eaten/ for two days. The sergeant/ touched by the woman�s story/ took up a collection/ of money for her. Adrian Lesson was caught stealing $15 at the Police Station. She had two kids shivering and the policemen put her into gaol and the kids were safe.

26. Tom A complex interaction of vulnerabilities genetic/family inconsistent parenting parental modelling of antisocial behaviour including tolerance of aggression within-child factors possible neurodevelopmental abnormalities difficult temperament weak language, verbal memory, sequencing and executive skills Social/environmental chronic school failure, social rejection have all contributed to Tom�s diagnosis of CD

27. language deficits may Reduce capacity for �self talk�, reflection, reasoning impair self-regulation of behaviour impair communication + socialisation elicit negative interactions increase frustration

28. children with sequencing deficits may fail to derive meaning from environmental information fail to link cause and effect fail to connect actions with consequences think illogically become angry and paranoid when misinterpretations occur perceive punishment as �unfair�

29. Children with executive deficits may fail to focus on the salient fail to engage in planful, goal directed behaviour �present-oriented� lack strategies for problem solving act impulsively fail to monitor their behaviour and learn from mistakes respond rigidly, fail to adapt to changing circumstances

30. Children with verbal memory deficits may retain only part of an instruction or explanation lose meaning misinterpret the message respond inappropriately appear oppositional and unco-operative be punished for �non-compliance� feel victimised become anxious, paranoid or angry, leading to further reduction in memory capacity give up, act out