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

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Presentation on theme: "What We Know About Acting Out Teens Diagnosis, etiology, risk assessment, the role of the Department of Juvenile Services, and treatment."— Presentation transcript:

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: 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 Aggression to people and animals Often bullies, threatens, or intimidates others Often bullies, threatens, or intimidates others Often initiates physical fights Often initiates physical fights Has used a weapon that can cause serious harm to others Has used a weapon that can cause serious harm to others Has been physically cruel to people Has been physically cruel to people Has been physically cruel to animals Has been physically cruel to animals Has stolen while confronting a victim Has stolen while confronting a victim Has forced someone into sexual activity Has forced someone into sexual activity

4 Conduct Disorder: What is it?(Continued) Destruction of property Destruction of property Has deliberately engaged in fire setting with the intention of causing serious damage Has deliberately engaged in fire setting with the intention of causing serious damage Has deliberately destroyed others property (other than by fire setting) Has deliberately destroyed others property (other than by fire setting) Deceitfulness or theft Deceitfulness or theft Has broken into someone elses house, building or car. Has broken into someone elses house, building or car. Often lies to obtain goods or favors or to avoid obligations Often lies to obtain goods or favors or to avoid obligations Has stolen items of nontrivial value without confronting a victim Has stolen items of nontrivial value without confronting a victim Serious violations of rules Serious violations of rules Often stays out at night despite parental prohibitions, beginning before age 13 years. 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). 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. Is often truant from school, beginning before age 13 years.

5 Diagnostic Mistakes Symptoms cause harm to others, so clinicians dont ask about symptoms Symptoms cause harm to others, so clinicians dont ask about symptoms Dont get outside sources of data Dont get outside sources of data Diagnosing someone with Conduct Disorder labels them as bad and untreatable Diagnosing someone with Conduct Disorder labels them as bad and untreatable They have experienced trauma, so its just PTSD They have experienced trauma, so its just PTSD They have an underlying depression, so its not Conduct Disorder They have an underlying depression, so its not Conduct Disorder

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

7 Conduct Disorder Etiology

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

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

10 Negative Emotionality They experience negative emotions frequently, intensely, and with little provocation They experience negative emotions frequently, intensely, and with little provocation Aggression Aggression Low frustration tolerance Low frustration tolerance Cant delay gratification Cant delay gratification Frequent temper tantrums Frequent temper tantrums Overwhelmed by normal demands of life Overwhelmed by normal demands of life Cant handle disappointments Cant handle disappointments Poor coping skills Poor coping skills DSM-V may call this Temper Dysregulation Syndrome with Dysphoria DSM-V may call this Temper Dysregulation Syndrome with Dysphoria

11 Daring Sensation-seeking behaviors Sensation-seeking behaviors Low harm avoidance Low harm avoidance Autonomic nervous system doesnt respond to punishment Autonomic nervous system doesnt respond to punishment Lack of anxiety Lack of anxiety Head injuries Head injuries Impulsivity Impulsivity

12 Lack Of Prosociality Less sympathy and concern for others Less sympathy and concern for others Dont share Dont share Dont help Dont help Unkind behaviors Unkind behaviors Lack of guilt or remorse Lack of guilt or remorse

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

14 Genetic-Environment Correlations Passive-the same genes that give the kid a bad temperament account for the bad parenting 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 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 Active-genes lead kid to seek out antisocial social environment

15 The Path to Conduct Disorder Aggressive kids gets lots of negative feedback Aggressive kids gets lots of negative feedback School failure School failure Physical abuse Physical abuse Peer rejection Peer rejection Sometimes aggressive behaviors get reinforced Sometimes aggressive behaviors get reinforced Parents give in to intense kid Parents give in to intense kid Allowed to bully other kids in places where there is poor monitoring 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 Constant negative feedback from parents, teachers, and peers intensifies the kids anger At puberty, he finds other antisocial kids At puberty, he finds other antisocial kids Suddenly, hes popular Suddenly, hes popular Behavior problems worsen 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. 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 Life Course-Persistent-chronically aggressive child becomes antisocial teen

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

19 Features of Life-Course Persistent Conduct Disorder (Moffitt, et. al., 2001) Individual Risk factors Individual Risk factors Under controlled temperament at age 3 Under controlled temperament at age 3 Neurological abnormalities and delayed motor development at age 3 Neurological abnormalities and delayed motor development at age 3 Low intellectual abilities Low intellectual abilities Reading difficulties Reading difficulties Poor memory Poor memory Hyperactivity Hyperactivity Slow heart rate Slow heart rate Parenting Risk Factors Parenting Risk Factors Teenage single parent Teenage single parent Mothers with poor mental health Mothers with poor mental health Harsh or neglectful mothers Harsh or neglectful mothers Family conflict Family conflict Changes in caretaker Changes in caretaker Low SES Low SES Rejection by peers Rejection by peers Childhood onset antisocial behavior nearly always predicts poor adult adjustment Childhood onset antisocial behavior nearly always predicts poor adult adjustment

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

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

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

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

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

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

26 Deficits related to Conduct Disorder Low IQ (especially Verbal)-language processing and communication Low IQ (especially Verbal)-language processing and communication Executive functions Executive functions Social skills Social skills Emotion regulation Emotion regulation Cognitive flexibility 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. 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 cant express feelings Kids cant express feelings Language development helps us regulate emotions Language development helps us regulate emotions Kids have difficulty listening to and comprehending instructions Kids have difficulty listening to and comprehending instructions Kids cant express their point of view in a conflict situation Kids cant express their point of view in a conflict situation Language development may play a role in the development of empathy Language development may play a role in the development of empathy Sets them up for social interactions full of tension Sets them up for social interactions full of tension

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

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

30 Social Skills and Conduct Disorder Difficulty collaborating Difficulty collaborating Refusal to ask for help Refusal to ask for help Unable to be in a non-dominant role Unable to be in a non-dominant role Difficulty accepting limits Difficulty accepting limits Unaware of others/ surprised by their response Unaware of others/ surprised by their response Inaccurate self-perception Inaccurate self-perception Difficulty taking the others point of view Difficulty taking the others point of view Afraid they will be perceived as soft Afraid they will be perceived as soft Egocentric Egocentric Examples Examples Youth who doesnt want to sit near another kid in class Youth who doesnt want to sit near another kid in class Youth on an outing from a facility expects to be able to walk around without escort Youth on an outing from a facility expects to be able to walk around without escort

31 Cognitive Inflexibility All-or-none thinking All-or-none thinking Problems with ambiguity, uncertainty Problems with ambiguity, uncertainty Insistence on sticking with the original plan Insistence on sticking with the original plan Cant take anothers perspective Cant take anothers perspective Problems with transitions Problems with transitions

32 Families and Conduct Disorder

33 Families of Conduct Disordered Kids Lack of monitoring Lack of monitoring Lack of family rituals Lack of family rituals Lack of affection Lack of affection Dont comfort distress-lock kids out Dont comfort distress-lock kids out Lack of mirroring Lack of mirroring Violence Violence Coercive family environment (Patterson) Coercive family environment (Patterson)

34 Coercive Family Environment Parents dont reinforce prosocial behaviors, they use negative reactions to exert influence on kids Parents dont reinforce prosocial behaviors, they use negative reactions to exert influence on kids Parents are inconsistent in addressing antisocial behaviors Parents are inconsistent in addressing antisocial behaviors Children use aversive behaviors to terminate intrusions by family members Children use aversive behaviors to terminate intrusions by family members Irritable fathers have explosive reactions Irritable fathers have explosive reactions Mothers chronic nagging Mothers chronic nagging

35 Families of Conduct Disordered Kids Absent father-insecure mother Absent father-insecure mother Create closed system Create closed system Hide the dysfunction Hide the dysfunction Teens need to go through phase of devaluing parents, who dont respond by rejecting Teens need to go through phase of devaluing parents, who dont respond by rejecting Us against the world Us against the world I wont hold you accountable for your behavior, if you dont hold me accountable for mine. I wont hold you accountable for your behavior, if you dont hold me accountable for mine. Moms dont cooperate with authorities-threatened by kids acting up Moms dont cooperate with authorities-threatened by kids acting up CD Kids-moms always been there for me. CD Kids-moms always been there for me. CD Moms-Hes always been good for me. CD Moms-Hes always been good for me.

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

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

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

39 Conduct Disorder and Social Cognition

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

41 Social Cognition We selectively attend to certain aspects of the stimulus field. We selectively attend to certain aspects of the stimulus field. We differ as to: We differ as to: what we attend to what we attend to the attributions we make to others behavior the attributions we make to others behavior the goals we have the goals we have the responses we generate the responses we generate the evaluations we make of our response. 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. 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. Teacher yells at kids to quiet down. One kid gets mildly irritated and sits quietly, thinking Boy, shes having a bad day. One kid gets mildly irritated and sits quietly, thinking Boy, shes having a bad day. Another kid feels disrespected, and yells back at her, You cant talk to me that way. Another kid feels disrespected, and yells back at her, You cant 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. 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: Aggressive kids have been found to: Make hostile attributions regarding others intent Make hostile attributions regarding others intent Attribute anger to teachers Attribute anger to teachers Generate fewer potential responses in situations Generate fewer potential responses in situations Tend to evaluate aggressive responses favorably whatever the outcome (especially callous- unemotional kids) Tend to evaluate aggressive responses favorably whatever the outcome (especially callous- unemotional kids) Boys tend to make more hostile attributions and evaluate aggression favorably 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. 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. 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. 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. Several studies targeting hostile attributional bias have found that reducing it leads to less aggressive behavior. Clinically, its important to understand the way your patient interprets situations. Clinically, its important to understand the way your patient interprets situations. We can offer non-hostile attributions (i.e., perhaps the teacher wasnt trying to humiliate you, perhaps she told you to quiet down because she was frustrated with the class) We can offer non-hostile attributions (i.e., perhaps the teacher wasnt 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 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. 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. Testosterone levels are correlated with aggression. Low cortisol levels are indicative of low autonomic nervous system arousal, and are correlated with increased aggression. Low cortisol levels are indicative of low autonomic nervous system arousal, and are correlated with increased aggression. Aggressive kids have lower heart rates. Aggressive kids have lower heart rates. SSRIs decrease cortisol levels. SSRIs decrease cortisol levels.

49 The Development of Aggression At 17 months (Tremblay, et. Al., 1999) At 17 months (Tremblay, et. Al., 1999) 50% of children push others 50% of children push others 25% kick others 25% kick others 15% have bitten others 15% have bitten others Aggression increases to age three or four and then declines Aggression increases to age three or four and then declines Aggression is a natural behavior that children learn to inhibit Aggression is a natural behavior that children learn to inhibit Language helps kids problem solve non-aggressively Language helps kids problem solve non-aggressively Middle class kids have thousands more words in their vocabulary than poor kids at age five. 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 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 The aggressive symptoms of the disorder concern us the most Do the most harm Do the most harm Create the most countertransference Create the most countertransference Most useful predictor of outcome in boys Most useful predictor of outcome in boys Least popular third grade boy is the most likely to be an adult offender Least popular third grade boy is the most likely to be an adult offender Aggression is fairly stable for boys from third grade on. 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 life-course persistent Conduct Disorder, boys outnumber girls 10:1. For adolescent limited Conduct Disorder, boys outnumber girls 1.5:1. For adolescent limited Conduct Disorder, boys outnumber girls 1.5:1. Among adults, male criminals far outnumber females. Among adults, male criminals far outnumber females. Adolescence is a brief period in which girls engage in antisocial behaviors. Adolescence is a brief period in which girls engage in antisocial behaviors. Severe CD is girls predicts teen pregnancy 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. 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. Girls represent 28% of juvenile arrests, up from 23% a decade ago. Study in Maryland found much of this increase resulted from domestic disputes 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. 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. Aggressive girls are a small percentage of all conduct disordered girls. Highly dependent on their choice of mates. Highly dependent on their choice of mates. Aggressive acts, if present, are perpetrated on people they know. 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 assault-mother Most likely victim of a teenage girls murder-her newborn 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. 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. 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 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. 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. 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 males, adult criminality can be predicted from aggression in kindergarten In females, aggression at age 13 predicts adult criminality. In females, aggression at age 13 predicts adult criminality. Physical aggression is uncommon among elementary school girls. Physical aggression is uncommon among elementary school girls.

56 Socialization and Gender Boys are under-socialized and girls are over- socialized. Boys are under-socialized and girls are over- socialized. Mothers disapprove of girls displays of anger. They encourage girls to resolve anger. 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. 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. 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). 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 dont appreciate the others point of view and misattribute hostile intent to others. However, boys are more likely to fight because they dont appreciate the others 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. 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. 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. However, girls interpersonal sensitivity reduces their amount of collaborative play. Girls friendships are more exclusive. Girls friendships are more exclusive. When girls are aggressive, their victims is likely someone they know. This is not necessarily true for boys. 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. 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. 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. 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. DJS girls have more dysfunctional families than DJS boys. It appears girls are more sensitive to family factors. 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. 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. 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 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. 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. 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. 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. Threatening to end a relationship unless the friend complies with a request. Using social exclusion to punish others. Using social exclusion to punish others. The silent treatment. The silent treatment. Spreading nasty rumors. Spreading nasty rumors.

62 Girls Who Bully More alienated from peers. More alienated from peers. More conflict with friends More conflict with friends Less trust in romantic relationships Less trust in romantic relationships Less committed in their friendships Less committed in their friendships Among girls, bullying increases during the transition between grades eight and nine. 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 Lack of family rituals Choice of a mate Choice of a mate Early onset puberty Early onset puberty Girls begin dating earlier Girls begin dating earlier More likely to date older boys, who involve them in antisocial activities More likely to date older boys, who involve them in antisocial activities Sexual abuse Sexual abuse Lack of school attachment Lack of school attachment High crime neighborhood High crime neighborhood

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

65 Conduct Disorder Risk Assessment

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

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

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

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

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

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

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

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

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

75 Data Gathering Cant rely on self-report alone Cant rely on self-report alone Assess established risk factors Assess established risk factors Assess protective factors-small body of research Assess protective factors-small body of research Identify things that might mitigate risk Identify things that might mitigate risk ADHD medication ADHD medication Family therapy Family therapy

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

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

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

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

80 Conduct Disorder The Role of the Department of Juvenile Services

81 Politics and DJS The Left The Left Rehabilitation Rehabilitation Sees kids as victims Sees kids as victims Anti-punishment Anti-punishment Crime results from poverty Crime results from poverty Kids need TLC Kids need TLC All kids are good inside All kids are good inside Pass judgment on the more powerful-The system failed him Pass judgment on the more powerful-The system failed him The Right 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-Hes just a bad kid

82 Politics Political views are deeply held beliefs about how the world works Political views are deeply held beliefs about how the world works We cling to them to simplify the world We cling to them to simplify the world They provide comfort They provide comfort We seek data to confirm our theory We seek data to confirm our theory Dont have a theory in search of data. Have data in search of a theory. Dont 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. 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. 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. 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 cant help these kids. Criminals are born. You cant help these kids. We need zero tolerance and harsh punishments or we will encourage crime. We need zero tolerance and harsh punishments or we will encourage crime. Things like trauma and ADHD are an excuse. They dont really matter. Things like trauma and ADHD are an excuse. They dont really matter.

85 DJS Facilities: A History DJS facilities were prisons without any treatment. DJS facilities were prisons without any treatment. They were run by correctional personnel with little training whose primary concern was security (dont let anyone run away). They were run by correctional personnel with little training whose primary concern was security (dont let anyone run away). Then, we brought in professionals to provide treatment. Then, we brought in professionals to provide treatment. But, the treatment personnel just ran a clinic, providing therapy. They didnt impact how the facility was run. But, the treatment personnel just ran a clinic, providing therapy. They didnt impact how the facility was run. Today, states differ in the degree to which trained professionals are involved in the running of facilities. 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. No accreditation body whose approval is attached to federal dollars. Some federal oversight through the Civil Rights of Institutionalized Persons Act (CRIPA) 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. Judges have typically relied on probation officers to make disposition. Probation officers tend not to have the training needed to determine a youths level of risk. Probation officers tend not to have the training needed to determine a youths level of risk. Probation officers personal feelings guide them. Probation officers personal feelings guide them. Psychological evaluations have helped. Psychological evaluations have helped. Actuarial instruments have also helped. Actuarial instruments have also helped.

87 Conduct Disorder and DJS DJS must recognize the heterogeneity of their population 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 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 Detention should be brief, used until placement can be made in a treatment-oriented facility Nothing good happens in detention Nothing good happens in detention Most kids will need community-based treatment 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. 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 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. 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. 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. Proximity to criminal models is a known risk factor for criminal activity. This influence is most powerful on marginally deviant youth and younger teens. This influence is most powerful on marginally deviant youth and younger teens. Highly deviant youth are beyond the influence of others. Highly deviant youth are beyond the influence of others. Well-adjusted kids are immune to the influence of deviance. 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. 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 Delinquency-more strongly influenced by the environment Aggression-a stable, heritable trait Aggression-a stable, heritable trait It is critical that we distinguish between aggression and delinquency. It is critical that we distinguish between aggression and delinquency. Kids with a long history of aggression should be treated separately from other kids. 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. 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 Longer term (12 to 18 months), locked residential program Strong behavioral component Strong behavioral component Interpersonal skills training Interpersonal skills training Anger management training Anger management training Confrontation of aggression, bullying, and other antisocial behaviors Confrontation of aggression, bullying, and other antisocial behaviors High number of direct care staff High number of direct care staff Highly structured athletic programs Highly structured athletic programs Social information processing training Social information processing training Seclusion Seclusion High recidivism should be expected High recidivism should be expected Gradual step down into the community Gradual step down into the community Kids may need to return to residential care for more treatment-preferably the same facility 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 Highly aggressive youngsters may spend major portions of their adolescence in residential care

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

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

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

94 Multisystemic Therapy Systems-based, strength-based treatment Systems-based, strength-based treatment In-home services, daily contact In-home services, daily contact Therapists have small caseload (3-6 cases) and are available 24/7 Therapists have small caseload (3-6 cases) and are available 24/7 Time-limited-3-5 months Time-limited-3-5 months Therapist work in teams of three or four with supervision from MST experts to promote adherence to the model 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 Average of 12 sessions over a three to four month period Sessions can be conducted in home, clinic, school, probation office Sessions can be conducted in home, clinic, school, probation office Strength-based Strength-based Focuses on risk and protective factors Focuses on risk and protective factors Engagement, motivation, relational assessment, behavior change, generalization Engagement, motivation, relational assessment, behavior change, generalization

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

97 Individual Therapy No evidence-based individual therapies No evidence-based individual therapies Weaknesses in evidence-based requirement Weaknesses in evidence-based requirement Conduct Disorder is more than one disorder Conduct Disorder is more than one disorder Evidence-based-often means that the recidivism rate was lower than treatment as usual. It doesnt mean it was zero. Evidence-based-often means that the recidivism rate was lower than treatment as usual. It doesnt mean it was zero. Many therapeutic surprises Many therapeutic surprises These kids need to build skills These kids need to build skills Social skills Social skills Anger management Anger management Hostile attributional bias Hostile attributional bias They need to process traumas They need to process traumas

98 Individual Therapy-Anger Management You must sell them on anger management You must sell them on anger management Look at thoughts-feelings-actions Look at thoughts-feelings-actions Teach about the hostile attributional bias Teach about the hostile attributional bias Explore the intent of others behavior Explore the intent of others behavior Re-evaluate the aggressive response-is it serving you? Do what works! Re-evaluate the aggressive response-is it serving you? Do what works! Dont expect empathy. Show them why non- aggression is in their best interest. Dont expect empathy. Show them why non- aggression is in their best interest. Look at the source of underlying anger-abuse, deprivation, neglect Look at the source of underlying anger-abuse, deprivation, neglect

99 Individual Therapy-Anger Management Real power comes from self-control Real power comes from self-control The least powerful citizens in our society are in prison The least powerful citizens in our society are in prison Your fists may help you on a street corner, but they wont put food on your table when you are an adult Your fists may help you on a street corner, but they wont put food on your table when you are an adult If you go into social interactions expecting problems, you will get them If you go into social interactions expecting problems, you will get them You dont have to be loud to stand up for yourself You dont have to be loud to stand up for yourself If I say Good Morning to someone I dont like, it doesnt make me weak or phony; it makes me polite If I say Good Morning to someone I dont like, it doesnt make me weak or phony; it makes me polite Give them the words to express the anger Give them the words to express the anger They will experience your words as soft They will experience your words as soft

100 Individual Therapy-Anger Management Encourage them to try new behaviors Encourage them to try new behaviors They have trouble taking advice from others-stirs up feelings of envy, you have things that they dont. Cant be in a one-down position. So, be amazed by them sometimes. They have trouble taking advice from others-stirs up feelings of envy, you have things that they dont. Cant 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) Youre either the Wizard of Oz, or they have no use for you Yet, you must convince them of your expertise (inject more of yourself than with other patients) Youre 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. I have keys to this facility. I want you to have keys too. Do you think people walk all over me? Do you think people walk all over me? Show them how much more relaxed your approach is-they like to think they are relaxed 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 peoples stuff? Ok to express moral discomfort-So, you take other peoples stuff? Why are you surprised that people are treating you so badly? 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 ladys purse, you are a thief. If you help nine old ladies across the street, but you take the tenth old ladys purse, you are a thief. Pro-social behaviors are in their best interest Pro-social behaviors are in their best interest 80% of people get their job through a social connection 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 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 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 Tough to work on abuse issues They deny abuse They deny abuse Dont want to appear weak Dont want to appear weak Feel they deserved the beatings Feel they deserved the beatings Boys fear sexual abuse makes them gay Boys fear sexual abuse makes them gay Hard for them to be vulnerable Hard for them to be vulnerable Experience empathy as pity Experience empathy as pity Do you know any children the same age you were when you were abused? 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 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 Relationship between depression and suicide attempts is not as strong in adolescents 70% of adolescent completers-Conduct Disorder 70% of adolescent completers-Conduct Disorder 15-33%-Substance Abuse 15-33%-Substance Abuse 40-50% are clinically depressed 40-50% are clinically depressed Attributional style- see negative events as their fault and pervasive in their life, positive events are happenstance Attributional style- see negative events as their fault and pervasive in their life, positive events are happenstance Poor problem-solvers Poor problem-solvers Impulsivity Impulsivity Poor relationship with parents Poor relationship with parents Precipitating Life Events Precipitating Life Events Loss of relationship Loss of relationship Sexual concerns Sexual concerns Achievement pressure Achievement pressure Family suicide 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? 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). 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? 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 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 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. 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. 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. 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. Monnica Williams, Ph. D., Co-Director of the Center for mental Health Disparities, on Psychotherapy With African Americans. New speakers coming soon!!! New speakers coming soon!!!

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


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