1. What We Know About Acting Out Teens
Diagnosis, etiology, risk assessment, the role of the Department of Juvenile Services, and treatment

2. Conduct Disorder
Diagnosis

3. Conduct Disorder: What is it?
A repetitive and persistent pattern 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 past 6 months:
Aggression to people and animals
Often bullies, threatens, or intimidates others
Often initiates physical fights
Has used a weapon that can cause serious harm to others
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity

4. Conduct Disorder: What is it?(Continued)
Destruction of property
Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed other’s 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
Has stolen items of nontrivial value without confronting a victim
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 time).
Is often truant from school, beginning before age 13 years.

5. Diagnostic Mistakes
Symptoms cause harm to others, so clinicians don’t ask about symptoms
Don’t get outside sources of data
Diagnosing someone with Conduct Disorder labels them as “bad” and “untreatable”
They have experienced trauma, so it’s just PTSD
They have an “underlying” depression, so it’s not Conduct Disorder

6. Conduct Disorder: A Serious Problem
Cost to the Individual:
Difficulties in relationships
Difficulties at school and work
Most common treatment referral (1/3)
Boys:Girls (5:1)
1 to 4% of 9-17 year olds
Costs to Society
Violence
Property Loss
Cost of Incarceration
As adults:
High risk for becoming career criminals-35 to 40%
Substance abuse
Vocational Difficulties/Financial difficulties
Inability to sustain relationships
Child abuse and neglect

7. Conduct Disorder
Etiology

8. What causes Conduct Disorder?
Genetics/Temperament
Environmental Factors
Family
Peers
Neighborhood

9. Genetic Predisposition
Temperament (Lahey, 2003)
Negative Emotionality
Daring
Lack of Prosociality
Cognitive Problems
Low Verbal IQ
Executive Deficits

10. Negative Emotionality
They experience negative emotions frequently, intensely, and with little provocation
Aggression
Low frustration tolerance
Can’t delay gratification
Frequent temper tantrums
Overwhelmed by normal demands of life
Can’t handle disappointments
Poor coping skills
DSM-V may call this Temper Dysregulation Syndrome with Dysphoria

11. Daring Sensation-seeking behaviors Low harm avoidance
Autonomic nervous system doesn’t respond to punishment
Lack of anxiety
Head injuries
Impulsivity

12. Lack Of Prosociality Less sympathy and concern for others Don’t share
Don’t help
Unkind behaviors
Lack of guilt or remorse

13. Environmental Factors
Parents poor behavior as youths
Born to teenage parent
Physical abuse and neglect
Absence of same sex role model
Witnessed violence
Access to other antisocial kids
Lack of monitoring
Antisocial or alcoholic parents
Lower SES
Family hostility

14. Genetic-Environment Correlations
Passive-the same genes that give the kid a bad temperament account for the bad parenting
Evocative-genes that create the temperament lead to behavior that evokes bad parenting, which then increases the likelihood of conduct disorder
Active-genes lead kid to seek out antisocial social environment

15. The Path to Conduct Disorder
Aggressive kids gets lots of negative feedback
School failure
Physical abuse
Peer rejection
Sometimes aggressive behaviors get reinforced
Parents give in to intense kid
Allowed to bully other kids in places where there is poor monitoring

16. The Path To Conduct Disorder
Constant negative feedback from parents, teachers, and peers intensifies the kids anger
At puberty, he finds other antisocial kids
Suddenly, he’s popular
Behavior problems worsen

17. Life Course-Persistent Versus Adolescent-Limited Conduct Disorder
Adolescent-Limited-well-behaved child becomes rebellious teen with unconventional values and connects with antisocial peers.
Life Course-Persistent-chronically aggressive child becomes antisocial teen

18. Longitudinal Studies of Conduct Disordered kids
Life-Course Persistent Conduct Disorder
Weak bonds with family
Callous-unemotional
Impulsive
Negative emotionality
Aggressive
Adolescent-Limited Conduct Disorder
Unconventional values
Were well-behaved as children

19. Features of Life-Course Persistent Conduct Disorder (Moffitt, et. al
Individual Risk factors
Under controlled temperament at age 3
Neurological abnormalities and delayed motor development at age 3
Low intellectual abilities
Reading difficulties
Poor memory
Hyperactivity
Slow heart rate
Parenting Risk Factors
Teenage single parent
Mothers with poor mental health
Harsh or neglectful mothers
Family conflict
Changes in caretaker
Low SES
Rejection by peers
Childhood onset antisocial behavior nearly always predicts poor adult adjustment

20. Are Two Groups Enough? Possible Third Groups
Substance abuse driven conduct disorder
Antisocial behaviors are non-aggressive and revolve around substance use
Low level chronic offenders
Socially isolated-less contact with antisocials
Anxious
Unmarried, unemployed, mental health needs

21. Gray’s Biobehavioral Theory of Brain Function
Behavioral Activating System
Activates when there are signals for rewards
Escape from punishment
Instrumental aggression
Hope and relief
Behavioral Inhibiting System
Inhibits behavior when signals of punishment, frustration, or novelty
Anxiety and apprehension
Conduct Disordered kids have overactive BAS and underactive BIS

22. Support for Gray’s Theory
Daugherty and Quay, 1991
Computerized card game
Subjects get money for correct responses, but lose money for incorrect.
As the game goes on, the probability of correct responses decreases.
Most subjects stop playing. Conduct Disordered kids keep playing.
Conduct Disordered kids are reward dominant

23. Support for Gray’s Theory
Walker, et. Al., 1991
Conduct Disordered youth with co-occurring anxiety disorder-less deviant and less aggressive
Kerr, Tremblay, Pagani, and Vitaro, 1997
Followed kids in high crime urban area.
Kids who showed anxiety in new situations were protected against the later development of antisocial behaviors

24. Support for Gray’s Theory
Raine, Venables, and Williams, 1995
14 year longitudinal study of CD kids
Measured electrodermal activity (measure of ANS arousal)
Kids with higher ANS arousal ceased their antisocial behaviors
Sequin, Pihl, Boulerice, Tremblay, and Harden, 1996
Measured sensitivity to pain at age five and followed kids
Persistently aggressive teens had least sensitivity to pain at age five

25. Other Problems Associated with CD
ADHD
Learning Disabilities
Substance Abuse
Trauma and Abuse Issues
Unstable self-esteem
Anger Management

26. Deficits related to Conduct Disorder
Low IQ (especially Verbal)-language processing and communication
Executive functions
Social skills
Emotion regulation
Cognitive flexibility

27. Low IQ
Moffitt (1993)-reviewed 47 studies. CD kids score 8 points lower, even after you control for other risk factors. Persistently aggressive kids score 17 points lower.
Kids can’t express feelings
Language development helps us regulate emotions
Kids have difficulty listening to and comprehending instructions
Kids can’t express their point of view in a conflict situation
Language development may play a role in the development of empathy
Sets them up for social interactions full of tension

28. Executive Functions Self-regulation
Maintaining a problem-solving mental set in pursuit of a goal
Inhibition
Planning
Interference control
Allocation of attention
Lack of persistence
Initiation
Abstraction
Cognitive flexibility

29. Emotion Regulation Grouchy, irritable
Difficulty being calm enough to think clearly when frustrated
Get upset and stay upset-minor things can ruin their day
Over-react, making their coping efforts ineffective

30. Social Skills and Conduct Disorder
Difficulty collaborating
Refusal to ask for help
Unable to be in a non-dominant role
Difficulty accepting limits
Unaware of others/ surprised by their response
Inaccurate self-perception
Difficulty taking the others point of view
Afraid they will be perceived as “soft”
Egocentric
Examples
Youth who doesn’t want to sit near another kid in class
Youth on an outing from a facility expects to be able to walk around without escort

31. Cognitive Inflexibility
All-or-none thinking
Problems with ambiguity, uncertainty
Insistence on sticking with the original plan
Can’t take another’s perspective
Problems with transitions

32. Families and Conduct Disorder

33. Families of Conduct Disordered Kids
Lack of monitoring
Lack of family rituals
Lack of affection
Don’t comfort distress-lock kids out
Lack of mirroring
Violence
Coercive family environment (Patterson)

34. Coercive Family Environment
Parents don’t reinforce prosocial behaviors, they use negative reactions to exert influence on kids
Parents are inconsistent in addressing antisocial behaviors
Children use aversive behaviors to terminate intrusions by family members
Irritable fathers have explosive reactions
Mothers chronic nagging

35. Families of Conduct Disordered Kids
Absent father-insecure mother
Create closed system
Hide the dysfunction
Teens need to go through phase of devaluing parents, who don’t respond by rejecting
Us against the world
“I won’t hold you accountable for your behavior, if you don’t hold me accountable for mine.”
Moms don’t cooperate with authorities-threatened by kids acting up
CD Kids-”mom’s always been there for me.”
CD Moms-”He’s always been good for me.”

36. CD Families Sexual and physical abuse Neglect Abandonment
Parents are burdened by kids needs
Teach kids feelings are unimportant
Secrets-hide our dysfunction, defensiveness
Difficult to address family’s faults-a task of adolescence
Out of touch with feelings
CD kids-skewed notion of what parenting is-leads to unwanted children

37. The Psychology of CD
Antisocial behaviors help person avoid helplessness.
Invulnerability.
Omnipotence.
Protect self-esteem.
Little tolerance for bad feelings.
Externalize blame.
Introspection is painful.
Impulsivity/immediacy.
Thrill-seeking-turn the volume up.
Hate boredom.

38. The Psychology of CD Externalizing disorder Moral judgment is impaired
Empathy feels like pity
Competitiveness
Self-esteem is bolstered by destroying others
Seems self-serving, but is self-destructive
Difficulty cooperating
Difficulty tolerating delays
Experience limits as excessive

39. Conduct Disorder and Social Cognition

40. Social Cognition Human beings are social beings
We attend to important social stimuli.
We interpret those stimuli in meaningful ways
We use memory to associate these interpretations with possible behavioral responses
We evaluate those responses
We decide which response is best

41. Social Cognition
We selectively attend to certain aspects of the stimulus field.
We differ as to:
what we attend to
the attributions we make to other’s behavior
the goals we have
the responses we generate
the evaluations we make of our response.
Example-some people are hypervigilant to threat cues, whereas others interpret events in a way that maintains harmony.

42. Social Cognition Examples
Teacher yells at kids to “quiet down.”
One kid gets mildly irritated and sits quietly, thinking “Boy, she’s having a bad day.”
Another kid feels disrespected, and yells back at her, “You can’t talk to me that way.”
Another kid feels sorry for the teacher, and feels annoyed with the kids in the class who she sees as rude.

43. Social Cognition and Aggression
Aggressive kids have been found to:
Make hostile attributions regarding others intent
Attribute anger to teachers
Generate fewer potential responses in situations
Tend to evaluate aggressive responses favorably whatever the outcome (especially callous-unemotional kids)
Boys tend to make more hostile attributions and evaluate aggression favorably

44. What Causes Biased Social Information Processing?
Dodge (2001)-found kids exposed to early maltreatment had biased social information processing styles in kindergarten, and continued to have the same response pattern in grades 8 and 11.
Peer rejection may result from and lead to biased social information processing style.
Hostile attributional bias explains reactive aggression. It does not account for the aggression of the callous-unemotional.

45. Is This An Avenue For Intervention?
Several studies targeting hostile attributional bias have found that reducing it leads to less aggressive behavior.
Clinically, it’s important to understand the way your patient interprets situations.
We can offer non-hostile attributions (i.e., perhaps the teacher wasn’t trying to humiliate you, perhaps she told you to quiet down because she was frustrated with the class)

46. Is This An Avenue For Intervention?
We can get kids to reevaluate their goals in social situations (i.e., “does everyone have to respect you”, “some kids have no respect”)
We can help kids more critically evaluate their aggressive responses.

47. Aggression in Conduct Disorder

48. The Biology of Aggression
Testosterone levels are correlated with aggression.
Low cortisol levels are indicative of low autonomic nervous system arousal, and are correlated with increased aggression.
Aggressive kids have lower heart rates.
SSRI’s decrease cortisol levels.

49. The Development of Aggression
At 17 months (Tremblay, et. Al., 1999)
50% of children push others
25% kick others
15% have bitten others
Aggression increases to age three or four and then declines
Aggression is a natural behavior that children learn to inhibit
Language helps kids problem solve non-aggressively
Middle class kids have thousands more words in their vocabulary than poor kids at age five.
Low Verbal IQ is associated with poor outcome among Conduct Disordered boys

50. Conduct Disorder and Aggression
The aggressive symptoms of the disorder concern us the most
Do the most harm
Create the most countertransference
Most useful predictor of outcome in boys
Least popular third grade boy is the most likely to be an adult offender
Aggression is fairly stable for boys from third grade on.

51. Conduct Disorder in Girls

52. Boys, Girls, and Antisocial Tendencies
For life-course persistent Conduct Disorder, boys outnumber girls 10:1.
For adolescent limited Conduct Disorder, boys outnumber girls 1.5:1.
Among adults, male criminals far outnumber females.
Adolescence is a brief period in which girls engage in antisocial behaviors.
Severe CD is girls predicts teen pregnancy
Antisocial girls are a key link in the intergenerational transmission of male criminality. They are romantically involved with antisocial boys, become teenage mothers, and are unable to function as parents. Their offspring are at increased risk for behavior problems.

53. Conduct Disordered Girls
Girls represent 28% of juvenile arrests, up from 23% a decade ago.
Study in Maryland found much of this increase resulted from domestic disputes
Typically girls show a non-aggressive pattern-lying, running away, truancy, substance abuse, and non-confrontational stealing.
Aggressive girls are a small percentage of all conduct disordered girls.
Highly dependent on their choice of mates.
Aggressive acts, if present, are perpetrated on people they know.
Most likely victim of a teenage girls assault-mother
Most likely victim of a teenage girls murder-her newborn

54. Gender Differences in Aggression
Peaks at age three, with boys and girls both exhibiting aggressive behaviors.
By age four, aggression is uncommon among girls. It takes longer for boys to reduce aggression.
Aggression in kindergarten can be used to predict adolescent behavior problems.
Aggression in young boys is a highly effective red flag-it predicts later conduct problems. It underidentifies later conduct disorder in girls.
To predict antisocial behavior in teenage girls, you need to add oppositional and inattentive behaviors to the predictive model.

55. Aggression and Adult Criminality
In males, adult criminality can be predicted from aggression in kindergarten
In females, aggression at age 13 predicts adult criminality.
Physical aggression is uncommon among elementary school girls.

56. Socialization and Gender
Boys are under-socialized and girls are over-socialized.
Mothers disapprove of girls displays of anger. They encourage girls to resolve anger.
Mothers are more lax with boys misbehavior. This is correlated with behavior problems.
Parental depression is related to conduct problems is boys and care-giving in girls.

57. Gender Differences in Play
Boys are more likely to engage in collaborative play (several boys engaging in a coordinated group activity).
However, boys are more likely to fight because they don’t appreciate the other’s point of view and misattribute hostile intent to others.
Boys fights are more likely to become physical, but boys make up quicker after a fight.
Girls are better able to take each others point of view, reducing the risk of fights.
However, girls interpersonal sensitivity reduces their amount of collaborative play.
Girls friendships are more exclusive.
When girls are aggressive, their victims is likely someone they know. This is not necessarily true for boys.

58. Parenting and Antisocial Behavior
Harsh parenting and lack of affection were related to boys antisocial behavior, but not girls in early childhood.
Parenting was more important for girls than boys in adolescence.
Family dinners, checking homework, and family support are more strongly correlated with outcomes in girls than boys.
DJS girls have more dysfunctional families than DJS boys.
It appears girls are more sensitive to family factors.

59. Socialization and Antisocial Behaviors
Choice of a mate is important in predicting later behavior problems for girls, but not boys.
Greater negative environmental factors are necessary to elicit antisocial behavior in girls.

60. Sexual Abuse and Antisocial Behaviors
Sexually abused girls are at risk for a variety of psychiatric problems
Sexually abused girls exhibit more antisocial behaviors than a matched control group following the revelations of abuse.
More severe abuse is correlated with worse outcomes.
The differences in antisocial behaviors disappear after 7-8 years, except for girls abused by their biological fathers, who remain at increased risk for antisocial behaviors.

61. Relational Aggression
Threatening to end a relationship unless the friend complies with a request.
Using social exclusion to punish others.
The silent treatment.
Spreading nasty rumors.

62. Girls Who Bully More alienated from peers. More conflict with friends
Less trust in romantic relationships
Less committed in their friendships
Among girls, bullying increases during the transition between grades eight and nine.

63. Risk Factors For Conduct Disorder That Are Unique To Girls
Lack of family rituals
Choice of a mate
Early onset puberty
Girls begin dating earlier
More likely to date older boys, who involve them in antisocial activities
Sexual abuse
Lack of school attachment
High crime neighborhood

64. Conduct Disorder and Social Class
More prevalent in poor communities
Can manifest differently depending on peer group
Kids moved from housing project to middle class communities
The presence of a particular behavior may mean something different in two different communities

65. Conduct Disorder
Risk Assessment

66. Risk Assessment
Must distinguish between risk for violence and risk for delinquency
Many factors lead to delinquency
Delinquency is complex, varies in severity
Chronic violence and aggression appears to have a strong heritable component

67. Biological Risk Factors
Neurochemical- serotonin facilitates inhibition
Hormonal-testosterone linked to aggression
Psychophysiological-lower heart rate, less galvanic skin response
Neuropsychological-executive function deficits

68. Actuarial Instruments
Youth Level of Service/Case Management Inventory (YLS/CMI)-risk for general delinquency
Assessment of risks and needs
Predicts re-offending
Washington State Juvenile Court Assessment
Looks at risk and protective factors
Scores are used to guide case management
Emphasis is on increasing protective factors and reducing risk factors

69. The SAVRY SAVRY (Borum)-risk for violence
24 risk factors, each rated as low, moderate, or high
6 protective factors
Structured professional judgment
Each risk factor is empirically associated with violence

70. Historical Risk Factors (SAVRY)
History of violence
History of non-violent offending
Early initiation of violence
Past supervision/intervention failures
History of self-harm or suicide attempts
Exposure to violence in the home
Childhood history of maltreatment
Parental/caregiver criminality
Early caregiver disruption
Poor school achievement

71. Social Risk Factors (SAVRY)
Peer delinquency
Peer rejection-not loner, they are actively disliked
Stress and poor coping
Poor parental management
Lack of social support
Community disorganization

72. Individual Risk Factors (SAVRY)
Negative attitudes-criminal attitudes, hostile attributional style
Risk taking/impulsivity
Substance abuse
Anger management problems
Low empathy/remorse
ADHD
Poor compliance
Low commitment to school

73. Protective Factors (SAVRY)
Prosocial involvement
Strong social support
Strong attachments and bonds
Positive attitude toward intervention and bonds
Strong commitment to school
Resilient personality traits

74. Risk Assessment in Practice
Ask about violence and antisocial behaviors
Injury
Weapon use
Context
Precipitants
Mental state
Substance use
Victims
Purpose
Patterns

75. Data Gathering Can’t rely on self-report alone
Assess established risk factors
Assess protective factors-small body of research
Identify things that might mitigate risk
ADHD medication
Family therapy

76. Theory-Based Risk Judgment (Borum)
Past behavior
Frequency
Recency
Multi-pathways
Peers
Delinquent associates
Gang activity
Peer rejection
Personality
Callous/unemotional
Aggressive egocentric
Impulsive/rule-breaking
Problematic attitudes
Antisocial attitudes
Anti-authority
Hostile hypersensitivity

77. Psychopathy Not in DSM, but has lots of construct validity (it exists)
Likely to be in DSM-V
We can measure the trait in youth
Scores not quite as stable among adolescents
It predicts violence
People don’t develop the capacity for empathy and then lose it

78. Psychopathy as a Predictive Construct
Wooten, Frick, Shelton, and Silverhorn, 1997
Looked at CD kids with and without psychopathic personality traits.
Ineffective parenting was only correlated with antisocial behavior in those without psychopathy

79. Psychopathy as a Predictive Construct
Applegate and McBurnett, 1993
Aggressive kids with psychopathic traits had less ANS arousal than aggressive kids without psychopathic traits
Fisher and Blair, 1998
CD kids with psychopathic traits showed a reward dominant response style and were unable to alter behavior in response to punishment

80. The Role of the Department of Juvenile Services
Conduct Disorder
The Role of the Department of Juvenile Services

81. Politics and DJS The Left The Right Rehabilitation
Sees kids as victims
Anti-punishment
Crime results from poverty
Kids need TLC
All kids are good inside
Pass judgment on the more powerful-”The system failed him”
The Right
Public safety
Sees kids as perpetrators
Lock them up
Criminals are born
Kids need consequences
Criminals are beyond help
Pass judgment on the less powerful-”He’s just a bad kid”

82. Politics
Political views are deeply held beliefs about how the world works
We cling to them to simplify the world
They provide comfort
We seek data to confirm our theory
Don’t have a theory in search of data. Have data in search of a theory.

83. How Politics Mislead Us: The Left
Studies show that incarcerated kids have the highest recidivism rates, so we should not incarcerate kids.
Measures used to combat aggression (i.e., seclusion, restraint) will only re-traumatize the children and are unnecessary.
If you treat them for their trauma experience, the behavior problems will go away.

84. How Politics Mislead Us: The Right
Criminals are born. You can’t help these kids.
We need zero tolerance and harsh punishments or we will encourage crime.
Things like trauma and ADHD are an excuse. They don’t really matter.

85. DJS Facilities: A History
DJS facilities were prisons without any treatment.
They were run by correctional personnel with little training whose primary concern was security (don’t let anyone run away).
Then, we brought in professionals to provide treatment.
But, the treatment personnel just ran a clinic, providing therapy. They didn’t impact how the facility was run.
Today, states differ in the degree to which trained professionals are involved in the running of facilities.
No accreditation body whose approval is attached to federal dollars.
Some federal oversight through the Civil Rights of Institutionalized Persons Act (CRIPA)

86. DJS Disposition: A History
Judges have typically relied on probation officers to make disposition.
Probation officers tend not to have the training needed to determine a youth’s level of risk.
Probation officers personal feelings guide them.
Psychological evaluations have helped.
Actuarial instruments have also helped.

87. Conduct Disorder and DJS
DJS must recognize the heterogeneity of their population
Disposition should be based on the science of risk assessment and what we know about diagnostic distinctions within the group of kids meeting criteria for Conduct Disorder
Detention should be brief, used until placement can be made in a treatment-oriented facility
Nothing good happens in detention
Most kids will need community-based treatment
Kids who present a danger to the community should be housed in secure residential facilities that provide treatment.
Must have placements and community-based treatment for those with low IQ
We should avoid the use of treatments administered in groups. They bring deviant kids together.

88. Deviant Peer Influences in Programs
Dodge et. al. (2006) have summarized research showing that placing youth who engage in deviant behavior together in programs has harmful effects.
Proximity to criminal models is a known risk factor for criminal activity.
This influence is most powerful on marginally deviant youth and younger teens.
Highly deviant youth are beyond the influence of others.
Well-adjusted kids are immune to the influence of deviance.
This body of research suggests that we avoid placing younger, marginally deviant kids in programs where services are provided in a group format.

89. Aggression and Delinquency
Delinquency-more strongly influenced by the environment
Aggression-a stable, heritable trait
It is critical that we distinguish between aggression and delinquency.
Kids with a long history of aggression should be treated separately from other kids.

90. A Continuum of Care for Life-Course Persistent Conduct Disorder
The data suggests these will be hard kids to change, but we are not paid to give up.
Longer term (12 to 18 months), locked residential program
Strong behavioral component
Interpersonal skills training
Anger management training
Confrontation of aggression, bullying, and other antisocial behaviors
High number of direct care staff
Highly structured athletic programs
Social information processing training
Seclusion
High recidivism should be expected
Gradual step down into the community
Kids may need to return to residential care for more treatment-preferably the same facility
Highly aggressive youngsters may spend major portions of their adolescence in residential care

91. A residential program for highly impulsive, ADHD
Good psychiatric care
Family and youth education regarding ADHD
Small classroom, frequent breaks, rewards for on-task behaviors
Highly structured athletic program
Interpersonal skills training
Vocational emphasis with a real vocational program.
Lots of space, privacy

92. A program for substance abuse driven criminal involvement
Continuum of care
Solid month-long inpatient program
Longer term residential program
Intensive outpatient program

93. Community-Based, Evidence-Based Treatments for Conduct Disorder
Multisystemic Therapy
Functional Family therapy
Multidimensional Treatment Foster Care

94. Multisystemic Therapy
Systems-based, strength-based treatment
In-home services, daily contact
Therapists have small caseload (3-6 cases) and are available 24/7
Time-limited-3-5 months
Therapist work in teams of three or four with supervision from MST experts to promote adherence to the model

95. Functional Family Therapy
Average of 12 sessions over a three to four month period
Sessions can be conducted in home, clinic, school, probation office
Strength-based
Focuses on risk and protective factors
Engagement, motivation, relational assessment, behavior change, generalization

96. Multi-Dimensional Treatment Foster Care
Based on social learning theory (Patterson)
Mechanism of change is through relationships with others
Clear expectations and consequences delivered in a neutral, teaching manner
Point and level system
Weekly individual therapy
Weekly skill building
Close monitoring
Daily mentoring by MTFC parents
Weekly contact with parents and frequent home visits
Program supervisor on-call
Weekly family counseling-teach families behavior management

97. Individual Therapy No evidence-based individual therapies
Weaknesses in evidence-based requirement
Conduct Disorder is more than one disorder
Evidence-based-often means that the recidivism rate was lower than ‘treatment as usual.” It doesn’t mean it was zero.
Many therapeutic surprises
These kids need to build skills
Social skills
Anger management
Hostile attributional bias
They need to process traumas

98. Individual Therapy-Anger Management
You must sell them on anger management
Look at thoughts-feelings-actions
Teach about the hostile attributional bias
Explore the intent of other’s behavior
Re-evaluate the aggressive response-is it serving you? Do what works!
Don’t expect empathy. Show them why non-aggression is in their best interest.
Look at the source of underlying anger-abuse, deprivation, neglect

99. Individual Therapy-Anger Management
“Real power comes from self-control”
“The least powerful citizens in our society are in prison”
“Your fists may help you on a street corner, but they won’t put food on your table when you are an adult”
“If you go into social interactions expecting problems, you will get them”
“You don’t have to be loud to stand up for yourself”
“If I say ‘Good Morning’ to someone I don’t like, it doesn’t make me weak or phony; it makes me polite”
Give them the words to express the anger
They will experience your words as “soft”

100. Individual Therapy-Anger Management
Encourage them to try new behaviors
They have trouble taking advice from others-stirs up feelings of envy, you have things that they don’t. Can’t be in a one-down position. So, be amazed by them sometimes.
Yet, you must convince them of your expertise (inject more of yourself than with other patients) “You’re either the Wizard of Oz, or they have no use for you”
“I have keys to this facility. I want you to have keys too.”
“Do you think people walk all over me?”
Show them how much more relaxed your approach is-they like to think they are relaxed

101. Individual Therapy-Moral Development
Ok to express moral discomfort-”So, you take other people’s stuff?”
“Why are you surprised that people are treating you so badly?”
“If you help nine old ladies across the street, but you take the tenth old lady’s purse, you are a thief.”
Pro-social behaviors are in their best interest
80% of people get their job through a social connection
When I treat people with respect, even disrespectful people; other people notice this and respect me
By focusing on the harm others can do to you, you are missing out on the ways they can help you

102. Individual Therapy-Abuse Issues
Tough to work on abuse issues
They deny abuse
Don’t want to appear weak
Feel they deserved the beatings
Boys fear sexual abuse makes them gay
Hard for them to be vulnerable
Experience empathy as pity
“Do you know any children the same age you were when you were abused?”
Denial of affect can be a defense or a sign of the callous-unemotional quality found in psychopathy

103. Conduct Disorder and Suicide
Relationship between depression and suicide attempts is not as strong in adolescents
70% of adolescent completers-Conduct Disorder
15-33%-Substance Abuse
40-50% are clinically depressed
Attributional style- see negative events as their fault and pervasive in their life, positive events are happenstance
Poor problem-solvers
Impulsivity
Poor relationship with parents
Precipitating Life Events
Loss of relationship
Sexual concerns
Achievement pressure
Family suicide

104. Problems in the Conduct Disorder Literature
Is it really a single disorder or are we doing studies on kids with several different disorders?
Aggression can result from non-anxious psychopathic process (low ANS arousal) or from highly traumatized, defensive, hostile attributional bias (high ANS arousal).
What works for who?

105. Tzkseminars
Keith Hannan, Ph.D., consultant to juvenile facilities on “Conduct Disorder.” Dr. Hannan also does a Friday afternoon webinar series on juvenile delinquency
David Shapiro, Ph.D., the father of clinical forensic psychology on the “Fundamentals of Forensic Assessment.” Learn forensic assessment from the best.
David McDuff, M.D., consultant to the Baltimore Orioles and Ravens on “Sports Psychiatry.” This webinar is appropriate for all mental health clinicians interested in working with athletes. He also does “The Treatment of Complex Alcohol, Tobacco, and Drug Dependence.”
Heather Hartman-Hall, Ph.D., internship training director and talented clinician on “Making Sense of the Complexities of Trauma.”
Scott Hannan, Ph.D., seen on the show “Hoarders,” on “Cognitive Behavioral Therapy for School Refusal” and “The Treatment of Hoarding.”
Monnica Williams, Ph. D., Co-Director of the Center for mental Health Disparities, on “Psychotherapy With African Americans.”
New speakers coming soon!!!

106. To Get Your CEU Certificate
Go to our website: tzkseminars.com
Log in using your address and password
Complete the webinar evaluation
Download your certificate