Conduct Disorder

1. Presented by Julia Hood 5/5/09 Conduct Disorder University of Utah, Department of Educational Psychology Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious Emotional Disturbance/Behavior Disorders US Office of Education 84.325K H325K080308

2. Diagnostic Criteria of 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 three (or more) of the following criteria in the past 12 months, with at least one criterion present in the last 6 months:

3. Diagnostic Criteria of Conduct Disorder • Aggression to people and animals • often bullies, threatens, or intimidates others • often initiates physical fights • has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) • has been physically cruel to people • has been physically cruel to animals • has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery • has forced someone into sexual activity

4. Diagnostic Criteria of Conduct Disorder • Destruction of property • has deliberately engaged in fire setting with the intention of causing serious damage • has deliberately destroyed others’ property (other than by fire setting) • Deceitfulness or theft • has broken into someone else’s house, building, or car • often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others) • has stole items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

5. Diagnostic Criteria of Conduct Disorder • Serious violations of rules • often stays out at night despite parental prohibitions, beginning before age 13 years • has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) • is often truant from school, beginning before age 13 years • The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning • If the individual is 18 years or older, criteria are not met for Antisocial Personality Disorder You must specify age of onset and severity

6. Other Diagnostic Considerations • Must rule out Oppositional Defiant Disorder • Determine if behavior is “proactive” or “reactive” • Determine “overt” or “covert” behavior • Overt behaviors are those that confront or disrupt the environment: aggression, temper tantrums, arguing • Covert behaviors are those that may not be directly noticed by a caregiver: stealing, fire starting, lying

7. Comorbid Disorders and Other Considerations • ADHD • Anxiety • Depression • Somatization • Academic Achievement, Substance Abuse, Risky Sexual Behavior

8. History of Conduct Disorders(Mash & Barkley, 2006) • How societies deal with “bad” children goes back in history to Plato 2,500 • Historical accounts from religious, medicine, and legal field • CD has been in the DSM since the second edition, but has changed as to the diagnostic requirements over the years • There has been an increase of juvenile delinquency in the last 50 years • More females • Peak age was mid-adolescence, but is now late adolescence • Increase in proportion of violent crime to non-violent crime

9. Causes/Contributory Factors (Mash & Barkley, 2006; Frick, 2001) • Multidimensional interaction among causal mechanisms • Individual vulnerabilities • Difficult temperament • Neuropsychological • Problems in child rearing (substance abuse, marital distress/divorce, parental antisocial behavior, low social support) • Stressors in the general social ecology

10. Assessment of Conduct Disorder • Structured interviews • Behavior rating scales (BASC, CBCL, ASEBA, ECBI, etc.) • Functional behavior assessments • Personality tests (MMPI-A, MACI) • Behavior observations • Developmental/medical history • Use multiple measures to get more comprehensive data

11. Treatment Options for Conduct Disorder (Mash & Barkley, 2006; Frick, 2001) • Family-based interventions (parent training) • Short-term effects • Helping the Non-compliant Child (HNC) • Parent-Child Interaction Therapy (PCIT) • Incredible Years • Triple P- Positive Parenting Program • OLSC Training Program • Multisystemic Therapy (MST) • Functional Family Therapy (FFT)

12. Treatment Options for Conduct Disorder(Mash & Barkley, 2006; Frick, 2001) • Skill Training • Social Skills • Cognitive Behavioral Skills Training • Problem-Solving Skills Training • Anger Management • Coping-Competence Programs • Multicomponent Skills Training

13. Treatment Options for Conduct Disorder (Mash & Barkley, 2006; Frick, 2001) • Community-Based Programs • The Achievement Place Program (Teaching Family Model) • Treatment Foster Care • Case Management • Day Treatment • School-Based Treatment • Classroom Management • Involvement in Multicomponent Treatments

14. Treatment Options for Conduct Disorder (Lilienfeld, 2005) • “Get tough” approaches • Scared Straight • Boot Camp • Attachment therapies • Rebirthing, holding, reparenting • Psychopharmacological Treatment • Antipsychotics • Mood Stabilizers

15. Treatment Options for Conduct Disorder (Lilienfeld, 2005) • Scientifically Questionable Treatments (SQT’s) • Peer-group interventions • “get tough” approaches • Attachment therapies • Psychopharmacological as a stand-alone treatment

16. Recent Research Study for CD • Parent training for young Norwegian children with ODD and CD problems: Predictors and mediators of treatment outcome. Scandinavian Journal of Psychology, (2009),50, 173-181. • Authors: Fossum, S., Morch, W., Handegard, B., Drugli, M.B., & Larsson, B.

17. Recent Research Study for CD • Method • 121 subjects • Subjects’ Inclusion Criteria • Ages 4- 8 • Parent referral for conduct problems • Child does not have a debilitating physical impairment • Child’s behavior was within clinical range on the Eyberg Child Behavior Inventory (ECHI) based on Norwegian norms • Child meets diagnostic criteria (DSM-IV) for ODD and/or CD • If children met one less criterion than that reqired for diagnosis and they displayed severe conduct problems, they were still included

18. Recent Research Study for CD • Treatment conditions • Random Assignment to one of three conditions • Parent training (n=47) • Parent training combined with child training (n=52) • Waiting list condition (n=28) • Subject characteristics in the two active treatment conditions • Mean age was 6.6 years (SD=1.3) • 28 children (28.3%) lived in one-parent families • Step parent involved in 18 families (18.2%) • 6 children (6.1%) living in foster care • Of which, 2 (2%) were in kinship foster care • 2 families (2%) not native-speaking Norwegians

19. Recent Research Study for CD • Assessments • ECBI • Kiddie-SADS diagnostic interview with mother • Teacher questionnaires • Dyadic Parent-Child Interaction Coding System-Revised (DPICS-R) to observe parent-child interactions • Preschool Behavior Questionnaire (PBQ) • Teacher Report Form (TRF) • Parental Stress Index (PSI) • Beck Depression Inventory (BDI) • Parenting Practices Interview (PPI) (adapted version)

20. Recent Research Study for CD • Treatment: IY intervention program (Webster-Stratton, C.) • BASIC parent training condition • Aim is to strengthen families and promote parent competencies by increasing their positive and self-confidence in parenting, reduce negative parenting practices, improve parents’ problem-solving skills and anger management, and improve school involvement • Divided into groups of 10-12 parents (parents of approx. 6 children) • Met weekly for 12-14 weeks for 2 hours with 2 accredited therapists • Watched 250 video vignettes of parent-child interactions • Therapists led discussions about aspects of vignettes • Parents received home tasks and and parents shared experiences at the beginning of next session • On average, parents attended 92% of meetings (M=11.2, SD=1.6)

21. Recent Research Study for CD • Treatment (cont.) IY intervention program & the “Dinosaur School” • Parent training and child training combined • Met simultaneously at clinic, but groups were held separately • Approximately 6 children met for 2 hours weekly, 18-20 weeks • 2 therapists • Video-based program with 100 video vignettes of children in multiple settings • Fantasy play with life-size puppets (a boy, a girl, various animals) • Exercises sent home with children • Attendance in child sessions was an average of 91% (M=15.6, SD=1.9)

22. Recent Research Study for CD • 2 families (2%) dropped out • Both males and from Parent Training condition • 15 therapists for PT, 9 therapists for children • Trained in programs • Followed treatment manual • Completed standardized checklists • Tracked group activities • Sessions videotaped for peer, self, and trainer evaluation

23. Recent Research Study for CD • Outcome Variables • Child functioning at home • Independent observation of negative parenting • Child behaviors in day care or school • Results • 37 (39.8%) rated responders and 56 (60.2%) non-responders, significant difference between mean scores • 30 mothers (34.1%) achieved 30% or greater reduction in observed negative parenting, 58 (65.9%) non-responders • 28 children (32.6%) scored below cut-off (rated by teacher) but difference was not significant

24. Recent Research Study for CD • Results (cont.) • Logistic regression analyses • Independent variables of ADHD, female, and maternal stress predicted worse outcome • Treatment effects lower than original study (not uncommon) • Post-treatment: two-thirds of children scored within norms • No child or family variables predicted unfavorable outcomes • Limitations of the study • Parental factors not controlled for • Parents more neutral interactions when observed than U.S. parents

25. References • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4thedn. Text Revision). Washington, DC: American Psychiatric Publishing. • Fossum, S., Morch, W., Handegard, B., Drugli, M.B., & Larsson, B. (2009). Parent training for young Norwegian children with ODD and CD problems: Predictors and mediators of treatment outcome. Scandinavian Journal of Psychology, 50, 173-181. • Frick, P.J., Kamphaus, R.W., Lahey, B.B., Loeber, R., Christ, M.A., Hart, E.L., & Tannenbaum, L.E. (1991). Academic underachievement and the disruptive behavior disorders. Journal of Consulting and Clinical Psychology; 59, 2, 289-294. • Lilienfeld, S.O. (2005). Scientifically unsupported interventions for childhood psychopathology:A summary. Pediatrics, 115; 761-764. • Mash, E.J. & Barkley, R.A. (2006). Treatment of Childhood Disorders (3rd edn). New York: The Guilford Press.