Childhood disorders: disruptive behavior disorders

Question 1

Disruptive behavior disorders are categorized by:

Answer 1

Externalizing v Internalizing

Disorders

Question 2

Development of trust:

Answer 2

Trust–> Need–>expression–> satisfaction

Question 3

Failure of the development of trust can result in:

Answer 3

HELPLESSNESS

HOPELESSNESS—> and RAGE

Question 4

Symptoms of Conduct Disorder

Answer 4

-Lack of cause and effect thinking
❧Lack of conscience
❧Superficially engaging or charming
❧Destructive to others and material things
❧Cruelty to animals
❧May pose a danger to others

-**Poor peer relationships
❧Self destructive (accident prone)
❧May be seductive and have problems with
sexual aggression
❧Not affectionate on parents terms ( not
cuddly)
❧Preoccupation with fire

Question 5

Conduct Disorder

Answer 5

=Repetitive pattern of behavior in which the basic rights of
others or societal norms are violated. Three or more
criteria in last 12 months. At least one criterion present in
the last 6 months
● Aggression to people or animals
• Bullies, fights
• Cruel to people or animals
• Forced sexual activity
● Destruction of property
• Fire setting, destroyed others property
● Deceitfulness or theft
• Cons others, shoplifting, breaking and entering
● Serious violations of rules
• Truant, runaway, out late against parental wishes
(Danger to others )

Question 6

Some predisposing factors for CD

Answer 6

-Studies give range of 1-10%
❧Parental rejection or neglect
❧Inconsistent child rearing with harsh
discipline
❧Physical or sexual abuse
❧Frequent change of caretakers
❧Early institutional living

Question 7

DSM-5 criteria for Oppositional Defiant Disorder

Answer 7

A pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness lasting at least 6 months as evidenced by at least 4 Sx from any of the following categories, and exhibited during interaction with at least 1 individual who is not a sibling.

• Angry/Irritable mood:
• -often loses temper
• -often touchy or easily annoyed
• -often angry/resentful
• Argumentative/Defiant behavior:
• -often argues w authoritative figures, or for children/adolescents with adults
• -Often actively defies or refuses to comply with requests from authority figures or with rules
• -Often deliberately annoys others
• -Often blames others for his or her mistakes or misbehavior

Vindictiveness:
Has been spiteful or vindictive at least twice within the past 6 months.

Question 8

Oppositional Defiant Disorder:

-prevalence?

Answer 8

*2-16% Prevalence
❧ Directed towards an authority figure
❧ Not always apparent in school or the community
❧ More apparent in interactions with familiar adults
and peers
❧ As preschool children they tend to be highly
reactive and not easily soothed
❧ See themselves as responding reasonably to
unreasonable demands

Question 9

Sex Ratio of ODD/CD

Answer 9

❧ Generally sex differences in
disruptive behavior disorders do not
emerge prior to age 6.
❧ At later ages, however, males
referred for disruptive behavior
disorders significantly outnumber
females anywhere from 4:1 to 6:1.
❧ These children account for somewhere
between one-third and two-thirds of
all child mental health referrals.

Question 10

Comorbidity of ODD/CD

Answer 10

❧ Children with ODD and CD frequently
display other types of problems.
● 34.7 to 48 % of children and
adolescents with ODD/CD also show
evidence of ADHD.
● Comorbidity of12 to 17.6 % have been
found for depressive disorders.
● As many as 19% of children/adolescents
with ODD/CD qualify for a diagnosis of
anxiety disorder.

Question 11

Prognosis of Conduct Disorder

Answer 11

❧ In general, the literature
suggests that
● children who develop conduct
disordered behavior later in
childhood have a somewhat better
prognosis.
● the severity and variety of early
antisocial behavior is a powerful
predictor of serious antisocial
behavior in adulthood.
● the prognosis may be worse for those
who also have comorbid disorders.

Question 12

Cost of Conduct Disorder _______

over 7-year period

Answer 12

$70,000

❧ N=396 high risk
❧ N=268 normative
❧ Cost
● General health
● Inpatient and
Outpatient mental
health
● Justice system
● School (eg Special ed)

Question 13

Possible causes

Answer 13

Evidence of genetic basis—family studies show that
approximately 20% of first-degree relatives of people with ASP
also have ASP

Question 14

Twin studies

Answer 14

High concordance in monozygotic twins (vs

dizygotic twins)

Question 15

There appears to be highly heritable
general vulnerability to
________ disorders

Answer 15

externalizing

Question 16

List Ex’s of externalizing disorders

Answer 16

Conduct Disorder
Antisocial Personality Disorder
Alcohol Dependence
Drug dependence

Question 17

Adoption studies

Answer 17

Adoptees with biologic background of ASP
more likely to
develop disorder than those without

Question 18

Unresponsive nervous system:

Answer 18

Chronic under arousal leads patients with ASP to seek
out dangerous or risky situations to raise level of arousal;

-Patients with ASP have more slow-wave EEG activity,
low resting pulse, low resting skin conduction

Question 19

Response to Emotion Stimuli in

Boys with Conduct Disorder

Answer 19

❧ 50% of Boys with CD develop Antisocial
personality disorder
❧ Shown pictures that were pleasant scenes, neutral
scenes, and unpleasant images (e.g. crying and
wounded children, people in despair)
❧ Boys with CD or CD+ADHD evaluated negative
pictures as being less aversive than ADHD or
controls
❧ They also had decrease EDR to all slides

Question 20

Medications

Answer 20

❧Risperidone effective in decreasing
Aggression in CD International Clinical Psychopharm Sep05
❧Lithium in short-term treatment of
aggression A

Question 21

Some things that can help

Answer 21

❧ Assessment of the possibility that the child may have an
attachment problem.
❧ Identify possible precipitating events
❧ Find out how the parents perceive the problem
❧ Help the parents understand some of the dynamics of the
unattached child (e.g… possible etiology, lack of good
cause and effect thinking, and childs need to control)
❧ Explore the kind of support system that are available to the
parents (everything from family support to inpatient
treatment)

Question 22

Cause and Effect problems

Answer 22

❧Extremely important for parents to be
highly consistent with rules
❧Rules need to be logical and enforceable
●
You have to be in bed by 9:00pm instead of
You have to be asleep by 9:00pm Never
try to control a childs biology

Question 23

There should be consequences

for breaking rules.

Answer 23

❧Whenever possible, these should be natural
consequences.
❧Children should be rewarded for appropriate
behavior
❧Dont just assume positive behavior and ,
thereby, let it go unrewarded.

Question 24

Referral of child for treatment

and ________ of parents

Answer 24

encouragement

Question 25

ADHD DSM IV criteria: Impulsivity/Hyperactivity

Answer 25

6 or more of the following--manifested often:
Impulsivity:
-Blurts out answer before ? is answered
-difficulty awaiting turn 
-Interrupts or intrudes on others 

Hyperactivity:

• fidgets
• unable to stay seated
• inappropriate running/climbing (restlessness)
• difficulty in engaging in activities quietly
• “on the go”
• talks excessively

Question 26

ADHD DSM IV criteria: Inattention

Answer 26

Inattention: six (or more) of the following symptoms
of inattention have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with
developmental level:
1. often fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other
activities
2. often has difficulty sustaining attention in tasks or
play activities
3. often does not seem to listen when spoken to
directly
4. often does not follow through on instructions and
fails to finish school work, chores, or duties in the
workplace (not due to oppositional behaviour or
failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes, or is reluctant to engage in
tasks that require sustained mental effort (such as
school work or homework)
7. often loses things necessary for tasks and activities
(toys, school assignments, pencils, books, or tools)
8. is often easily distracted by extraneous stimuli
9. is often forgetful in daily activities

Question 27

Epidemiology of ADHD:

Prevalence & Course

Answer 27

❧ ADHD – Most common behavioral d/o of
childhood
● 6-9% of children
• Boys >> Girls
• Most common in 1st born boys
(Kalplan/Sadock, 1998)
• 75% persist to adolescence
• 65% persist to adulthood
● 3-5% of adults
Earlier onset predicts worse prognosis

Question 28

Comorbidity Almost Always

Complicates the Picture (for ADHD)

Answer 28

Depressive Disorder 20%
Cyclothymia 30%
Bipolar Disorder 5%
Anxiety Disorder 26%
Obsessive-Compulsive Disorder 18%
Learning Disorders 20%

Question 29

Comorbidity Almost Always

Complicates the Picture

Answer 29

complicates the picture

-Oppositional Defiant Disorder 35%
Conduct Disorder 30%
Antisocial Disorder 20%
Psychoactive Substance Use
Alcohol 30%
Drug (THC, Speed) 20%
Tourettes Synd., Chronic Tics ?
• Few ADHD kids have Tourettes
• Up to 60% of kids w/ Tourettes have ADHD

Question 30

Substance Abuse in ADHD Youth Growing Up:

Effect of Pharmacotherapy

Answer 30

MTA STUDY: Multimodal Treatment
Study of Children with ADHD

-14 month, multicenter, randomized, controlled
trial (not blinded, no placebo)
579 Children, 7-9 y/o w/ ADHD Combined Type
(Largest Group of ADHD Children to date)
Medication management utilized dosing
strategies for all day coverage

Question 31

MTA STUDY: Multimodal Treatment
Study of Children with ADHD
-list the 3 main findings

Answer 31

1. Med Mgmt = Med Mgmt + Beh Mgmt > Behavioral Tx and Community Based Treatment
2. TID Ritalin is a preferred dosing regimen
3. Subjects with any form of comorbidity, incl disruptive behavior disorder or anxiety, did better with combined treatment.