Externalizing Behaviors: IED, Conduct Disorder

Question 1

Intermittent explosive disorder (5)

Answer 1

1. Outbursts last for less than 30 minutes
2. Occur in response to minor provocation by a close intimate associate
3. Cannot be given to someone who ha sa medical condition in which substance is causing outburst
4. Mood disorders and substance abuse are associated with intermittent explosive disorders
5. 2.7% of population

Question 2

IED Risk Factors (4)

Answer 2

1. Environmental: history of physical or emotional trauma during first two decades
2. Genetics and physiological:
3. First degree relatives with a history of the disorder (twin studies show strong correlation)
4. Lower prevalence in some parts of the world—(Romania and Nigeria or in regions, Asia and middle East)

Question 3

IED Diagnostic Criteria (7)

Answer 3

1. Recurrent behavioral outbursts representing a failure to control aggressive impulses
   a. Verbal aggression occurring twice a week for a period of three months—no property destruction or physical injuries
   b. Three behavioral outbursts resulting in damage or destruction of property or physical assault against animals or other individuals occurring in a 12 months period
2. Out of proportion to provocation or psychosocial stress
3. Not premeditated
4. Cause marked distress in individual or impairment in occupational or interpersonal functioning and may result in legal or financial consequences
5. Must be six years of age
6. Not better explained by another disorder
7. Can occur in addition to ADHD, CD, ODD, and autism spectrum disorder when outburst are excessive

Question 4

IED Comorbid Disorders (5)

Answer 4

1. Disruptive mood dysregulations
2. Antisocial personality disorders or borderline personality disorder
3. Delirium, major neurocognitive disorder, or personality change due to medication
4. Substance intoxication or withdrawal
5. ADHD, CD, ODD, or Autism spectrum disorder

Question 5

Who is at risk for conduct disorder? (10)

Answer 5

1. Infants who are especially “fussy”
2. Early maternal rejection
3. Separation from parents, without an adequate alternative caregiver
4. Early institutionalization
5. Family neglect, abuse or violence
6. Harsh discipline
7. Parental mental illness
8. Parental marital discord
9. Large family size, crowding
10. Poverty

Question 6

Conduct disorder screening questions (6)

Answer 6

Ask the following questions to assess for conduct disorder:

1. Have you had any run-ins with the police? If yes, what were the circumstances?
2. Have you been in physical fights? If yes, what were the circumstances? How many?
3. Have you been suspended or expelled from school? If yes, what were the circumstances?
4. Have you ever run away from home? Overnight? How many times?
5. Do you smoke, drink alcohol or use other drugs? If yes, what is the frequency and duration of your use? Which drugs?*
6. Are you sexually active?*
   * Consider age in these patients

Question 7

Conduct disorder dif dx/comorbidities (7)

Answer 7

1. Attention deficit hyperactivity disorder
2. Oppositional defiant disorder
3. Bipolar mood disorder
4. Major depressive disorder
5. Alcohol/drug dependence
6. Adjustment disorder
7. Intermittent explosive disorder

Question 8

Conduct disorder diagnostic criteria (6 with info for each)

Answer 8

1. A repetitive and persistent pattern of behavior in which basic rights of other or major age appropriate societal norms or rules are violated
2. Three of the 15 criteria in the past 12 months with one criterion in the past 6 months
3. Aggression to people and animals
   a. Often bullies, threatens or intimidates others
   b. Often initiates physical fights
   c. Has used a weapon that can cause serious harm
   d. Has physically been cruel to people or animals
   e. Has stolen while confronting a victim
   f. Has forced someone into sexual activity
4. Destruction of Property
   a. Has deliberately engaged in fire setting with the intention of causing serious damage
   b. Has deliberately destroyed others property (other than by fire setting)
5. Deceitfulness of Truth
   a. Has broken into someone else’s house, building or car
   b. Often lies to obtain goods or favors or avoid obligations
   c. Has stolen items of nontrivial values without confronting a victim (shoplifting but without breaking and entering
6. Serious Violation of Rules
   a. Often stays out at night despite parental prohibition before age of 13 years
   b. Has run away from home overnight at least twice or once without returning for a long period
   c. Is often truant from school before age 13

Question 9

Other criteria for ODD (3 with 3 onset types)

Answer 9

1. Must cause significant impairment in social functions
2. If 18 years or older, criteria are not met for antisocial personality disorder
3. Specify when onset
   a. Childhood onset (before age 10 year)
   b. Adolescent onset type (no symptoms prior to 10 years)
   c. Unspecified onset – History is not available

Question 10

Other associated specifiers (3 with info)

Answer 10

1. Shows 2 or more of the following characteristics persistently over at least 12 months and in more than one relationship or setting.
   a. Lack of Remorse or Guilt:
   i. Does not feel bad or guilty when he/she does something wrong (except if expressing remorse when caught and/or facing punishment).
2. Callous-Lack of Empathy:
   * Disregards and is unconcerned about the feelings of others.
3. Shows 2 or more of the following characteristics persistently over at least 12 months and in more than one relationship or setting.
   a. Unconcerned about Performance: Does not show concern about poor/problematic performance at school, work, or in other important activities.
   b. Shallow or Deficient Affect: Does not express feelings or show emotions to others, except in ways that seem shallow or superficial (e.g., emotions are not consistent with actions; can turn emotions “on” or “off” quickly) or when they are used for gain (e.g., to manipulate or intimidate others).

Question 11

Signs of conduct disorder (7)

Answer 11

1. Aggressive behavior that harms or threatens other people or animals
2. Destructive behavior that damages or destroys property
3. Lying or theft
4. Truancy or serious violations of rules
5. Antisocial behavior
6. Early tobacco, alcohol, and substance use and abuse
7. Precocious sexual activity

Question 12

Other conduct disorder issues (6)

Answer 12

1. Higher rates of depression, suicidal thoughts, suicide attempts, and suicide
2. Academic difficulties
3. Poor relationships with peers or adults
4. Sexually transmitted diseases
5. Difficulty staying in adoptive, foster, or group homes
6. Higher rates of injuries, school expulsions, and problems with the law

Question 13

Conduct disorder severity (3)

Answer 13

Mild: few if any conduction problems present in excess of those required to make the diagnosis with minor harm to others (lying, staying out late)

Moderate: The number of conduct problems are intermediate and include stealing without confronting victim

Severe: In excess of number causing considerable harm (forced sex, physical cruelty, use of weapon, stealing

Question 14

Conduct disorder associated features (3)

Answer 14

1. Aggressive individuals misperceive the intentions of others as more hostile and threatening and respond with aggression that they feel is reasonable and justified
2. Substance misuse is associated in adolescent females
3. Suicidal attempts and suicidal ideation occur more

Question 15

Conduct disorder: childhood (4) vs. adolescent onset (2)

Answer 15

Childhood Onset

1. Tend to exhibit more aggressive behaviors
2. Tend to exhibit antisocial and criminal behavior as they get older
3. More likely correlated with impulsivity and family dysfunction
4. More likely to be a severe and chronic disorder

Adolescent Onset

1. More likely exaggerated process of adolescent rebellion
2. More likely to be a result from peer pressure (e.g. gangs)

Question 16

Conduct disorder interventions (6)

Answer 16

1. Assess severity and refer to specialist for treatment if needed
2. Treat substance abuse first if applicable
3. Training for parents on how to handle child or adolescent behavior and offer feedback
4. Family therapy
5. Training in problem solving skills for children or adolescents
6. Community-based services that focus on the young person within the context of family and community influences

Question 17

Conduct disorder: Practical Guidance for Parents (7)

Answer 17

1. Structure child’s activities and be consistent with rules
2. Monitor child’s activities (especially after school)
3. Enforce curfews consistently
4. Encourage child to become involved in structured after school activities (e.g. school sports)
5. Clearly communicate with child and give specific instructions
6. Establish rewards for good behavior for positive reinforcement
7. Clearly communicate consequences for breaking rules

Question 18

Conduct disorder Pharmacotherapy (6 with examples)

Answer 18

1. Currently no medications are approved specifically for Conduct Disorder
2. Used in combination with behavioral and psychosocial interventions
3. Primary care can refill these prescriptions provided they have checked labs, but cannot initiate these drugs
4. First Line:
   a. Mood stabilizer (Lithium) -/plus
   * Should not refill lithium; psychiatry should do this
   b. Atypical anti-psychotics (e.g. Olanzapine)
   * Can renew anti-psychotics
5. Second line
   a. Ability
   b. Olanzapine
   c. Risperdal
6. Third line
   a. Valproic Acid

Question 19

Conduct disorder behavioral interventions (6)

Answer 19

1. Behavioral interventions are non-pharmacologic techniques, which can be effective in changing behaviors with or without pharmacologic interventions.
2. A simple example of a behavioral intervention is a time out, commonly used for the same number of minutes as the child’s age. So for a child of 4-years-old, the time out would be 4 minutes.
3. Teach parents to be consistent when using time outs.
4. It is not recommended to force the child to sit in a corner facing the wall
5. The notion here is that unwanted behaviors have consequences, but not to shame the child.
6. The parent should maintain emotional control when applying time outs.

Question 20

Relaxation Therapy (5)

Answer 20

1. Relaxation therapy is a skill, which can easily be taught to both children and adolescents.
2. The most common of these is diaphragmatic deep breathing exercises.
   * The youth is taught to take a slow deep inhalation in through the nose to fill the lungs completely with air causing the chest to rise, and then to hold their breath to the mental count of 4 (slowly), then to gently blow the breath out through pursed lips very slowly, while counting backwards, slowly to the mental count of 8.
3. Patients are taught to do this slowly, taking a slow cleansing breath after the exercise. This can be repeated one or two times as needed.
4. The important thing to teach the youth is to avoid doing this exercise too quickly to avoid dizziness.
5. This exercise puts gentle pressure on the diaphragm, which can gently induce parasympathetic innervation.

Question 21

Conduct disorder: solution-focused therapy (6)

Answer 21

1. Also called Solution-Focused Brief Therapy (SFBT), was developed by Steve de Shazer and Insoo Kim Berg and colleagues in the late 1970s.
   a. Not Freudian
   b. Finding solutions to calm-self down
2. SDBT is future focused, focusing on solutions rather than on the problems that brought to patient in for treatment.
3. Therapy was developed inductively in an inner city outpatient mental health setting.
4. One of the leading schools of brief therapy.
5. SFBT is a practical, goal-driven model
6. Emphasizes clear, concise, realistic, goal negotiations.

Question 22

Conduct disorder social skills training (5)

Answer 22

1. Teach children and teens how to interact with others in socially and developmentally appropriate ways.
2. Often, therapists use Cognitive Behavioral Techniques in working with patients both individually and in group settings.
3. Social Skills Training is often used with children who suffer from Autism, Asperger’s Disorder and other disorders.
4. Several books are available on the subject
5. Focused on the developmental level of the child to help bridge children from where they are to a more developmentally appropriate level of interpersonal functioning.

Question 23

Conduct disorder educational support services (2)

Answer 23

1. Educational support services occur in the school.
2. Since school systems are often under budgetary restrictions, they often do not offer special education services unless asked to do so.

Question 24

Conduct disorder parent management training (2)

Answer 24

1. Refers to therapies or programs that train parents to manage their child’s behavioral problems in the home and at school.
2. PMT ‘s origins include maladaptive parent- child interaction study (especially regarding discipline practices which have been shown to foster and sustain behavioral problems in children) and also from social learning theory, with an emphasis on principles of operant conditioning

Question 25

Conduct disorder: psychoeducational approach (4)

Answer 25

1. Inform the patient and the family about the mental illness, its possible etiologies, and the available treatments, be they pharmacological, non-pharmacological or a combination of both
2. Setting realistic goals for treatment as a means of staying focused on desired outcomes.
3. Goal setting also provides a means to measure outcomes of treatment as part of the nursing process.
4. Once a course of action is agreed upon and goals have been agreed to, treatment commences.

Question 26

Conduct disorder: problem solving (9)

Answer 26

1. Identify the problem
2. Promote discussion of desired change
3. Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively.
4. Discuss alternative strategies for creating changes the patient and family desires to make
5. Weigh benefits and consequences of each alternative
6. Help the patient and family select an alternative
7. Encourage the patient and family to implement change
8. Provide positive feedback for the patient and family’s attempts to create change
9. Help the patient and family evaluate outcomes of the change and make modifications as required.

Question 27

Principles of cognitive behavioral therapy (5)

Answer 27

1. The cognitive postulates that the way an individual perceives situations influences how they feel emotionally. In the cognitive model, “it is not the situation that directly affects how people feel emotionally, but rather their thoughts in that situation”
2. The cognitive model also says that when individuals are in distress, their perceptions are often in accurate and their thoughts may be unrealistic.
3. Helps people identify distressing thoughts and evaluate how realistic these thoughts are.
4. They then learn to change their distorted thinking. As individuals think more realistically, they tend to feel better.
5. Emphasis is placed on problem solving and initiating behavioral change.

Question 28

What are the CBT Principles? (10)

Answer 28

1. Built on a therapeutic relationship
2. Begins with development of a cognitive formulation
3. Requires planning treatment and structuring sessions
4. Guide the patient during sessions, engaging them as active participants
5. Involves making collaborative decisions
6. Focused on problem solving
7. Focused on the here and now
8. Seeks to identify automatic thoughts
9. Involves identifying emotions
10. Includes homework for the patient/family with self- help assignments

Question 29

Structural Family Therapy That Emerged from Systems Theory (7)

Answer 29

1. Circular causation (causation is circular)
2. Equipotentiality (every part of a system maintains another)
3. Compementarity (every behavior is the complement to every other)
4. Homeostasis (systems have a steady state) change is slow
5. Structure “family structure is the invisible set of functional demands that organizes the ways in which family members interact.
6. A family is a system that operates through transactional patterns.
7. Repeated transactions establish patterns of how, when, and with whom to relate, and these patterns underpin the system.”

Question 30

Techniques for conduct behavior (12)

Answer 30

1. Enactment
2. Use of Self
3. Goals of therapy
4. Joining
5. Regulating Intensity
6. Searching for Competence
7. Constructions
8. Use of Paradox
9. Education
10. Boundary Making
11. Unbalancing
12. Working with Complementarity