Presentation is loading. Please wait.

Presentation is loading. Please wait.

Behaviour Disorders in Adolescents: Clinical and Psychopathological Assessment Mª.C. Ballesteros (Hospital Clínico Universitario de Valladolid) J.L. Pedreira.

Similar presentations


Presentation on theme: "Behaviour Disorders in Adolescents: Clinical and Psychopathological Assessment Mª.C. Ballesteros (Hospital Clínico Universitario de Valladolid) J.L. Pedreira."— Presentation transcript:

1 Behaviour Disorders in Adolescents: Clinical and Psychopathological Assessment Mª.C. Ballesteros (Hospital Clínico Universitario de Valladolid) J.L. Pedreira (Hospital Infantil Universitario Niño Jesús, Madrid)

2 Behaviour Disorders and International Systems of Mental Disorders Classification/1 DSM-III (1980): Basic conditions are sociabilization: –Undersocialized, aggressive or not aggressive –Socialized, aggressive or not aggressive DSM-III-R (1987): Basic conditions are individual or grupal behaviour disorder or aggressiveness

3 Behaviour Disorders and International Systems of Mental Disorders Classification/2 DSM-IV (1994): Basic conditions are disocial behaviour and age: –Aggression on people and animals –Destruction of property –Deceitfulness or theft and serious violations rules ICD-10 ( ): Basic condition is context of disocial disorder: –Disocial disorder only on family context –Disocial disorder undersocialized children –Disocial disorder socialized children –Oppositional defiant disocial disorder

4 HOLLISTIC AND COMPREHENSIVE CLINICAL ASSESSMENT IN BEHAVIOUR DISORDERS IN ADOLESCENCE Vulnerability + Risk factors SymptomsPronogsisTretment Clinical diagnosis Therapeutic and Preventive Interventions

5 GLOBAL AND DEVELOPMENTAL ASSESSMENT OF BEHAVIOUR DISORDERS IN ADOLESCENCE VULNERABILITY + RISK FACTORSSYMPTOMSPROGNOSIS Genetic factors Temperament mediators Personality traits Cognitive patterns Neuropsychology Neurophysiology Neurotransmission * Unspecific * Especific: - Sex - Family - School - Social *Developmental symptoms *Clinical symptoms - Diagnostic criteria - Subtypes - Comorbidity * Clinical features * Protective factors * Temperament Mª C. Ballesteros-Alcalde & J.L. Pedreira-Massa (1999)

6 Comprehensive and Developmental Assessment of Behaviour Disorders in Adolescence/2 Vulnerability Genetic and Temperament factors as mediators –Personality traits: Aggressiveness Socialization disorders Impulsiveness Hyperactivity –Cognitive patterns: Hostile attributions Egocentric Low and inconsistent problem-solving skills Inadequate aims

7 Comprehensive and Developmental Assessment of Behaviour Disorders in Adolescence/3 Vulnerability: Genetic and Temperament factors as mediators –Neuropsychology: Low IQ Language disorders Attention disorders –Neurophysiology: Low dermal conductivity Loe cardiac rating –Neurotransmissions: Dopamine, noradrenaline Serotonine

8 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/3 Risk Factors Parental Factors: –Antisocial and criminal behaviour –Alcoholism –Untoward parent-child interaction: Harsh punishment Inconsistent punishment Poor supervision Coercitive exchanges (escalted aversive interactions) Less parental warmth, support and comunication with children

9 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/4 Risk Factors Family Factors: –Marital discord –Large family size –Birth order –Older siblings with antisocial behaviour –Few family activities

10 Disruptors of effective parenting Grand parental Traits Antisocial behaviour Poor family management Family Demographics Income Parent education Neighborhood Ethnic group Parental Traits Antisocial behaviour Susceptible to stressors Family Stressors Unemployement Marital conflict Divorce Disrupted family-management practices Child antisocial behaviour B. Lahey & R. Loeber (1994)

11 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/5 Risk Factors Child Factors: –Child temperament –Neuropsychological deficits (in verbal and executive” functions) –School (academic deficiencies, attendance, peers and teacher relationship) –Signs of antisocial behaviour: Early onset, frequency (number of episodes), diversity (range of different antisocial behaviours), breadth across situations, seriousness

12 A visual heuristic describing the developmental levels model Mug Truant Cruel Steal Force sex Run away Break, enter Use weapon Lie Bully Vandalize Fight Set fires Hurt animals Temper tantrums Irritable Defiant Spiteful Blame others Annoy others Angry Argumentative Oppositional Intermediate CD Advanced CD B. Lahey & R. Loeber (1994)

13 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/6 Risk Factors Social Risk Factors: –Poverty –Unemployed –Marginal behaviours or life styles –Migration –Low culture

14 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/7 Symptoms Diagnostic criteria (symptoms: type, number and frequency) –DSM-IV –ICD-10

15 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/8 Clinical Symptoms The subtypes of the Disorders –Subtypes based on age at onset –Subtypes based on aggression –Subtypes based on socialization –Subtypes based on comorbid conditions

16 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/9 Clinical Symptoms Subtypes based on age at onset –Childhood onset vs. Adolescence onset (Longitudinal follow-up study: Farrington, 1979; Dunedin Longitudinal Study; Moffit, 1990 & McGee, 1992)

17 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/10 Clinical Symptoms Subtypes based on aggression –Overt vs. Covert (1st Bipolar Dimensional Type; Loeber et al, 1985) –Destructive vs. Nondestructive (2nd Bipolar Dimensional Type; Frick et al., 1993) –Proactive vs. Reactive (theoretical model based; dichotomy; Dodge et al., 1991) –Affective vs. Predatory (connection with Autonomous/neurotransmission; Vitello et al., 1990) –Constraint

18 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/11 Clinical Symptoms Subtypes based on Sociabilization –Socialized vs. undersocialised (Biological functioning is different; Quay et al., 1987)

19 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/12 Clinical Symptoms Subtypes based on Comorbid Conditions –ADHD –Cognoscitive Disfuctions –Emotional Disorders

20 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/13 Clinical Symptoms Comorbidity –ADHD –Impulse-control Disorders –Alcohol or Drug abuse –Anxiety, Depression –Sociabilization Disorders

21 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/14 Pronogsis Clinical Features associated with bad pronogsis: –Age at onset: Childhood –Subtypes of aggression Destructive Proactive Predatory –Sociabilization: Undersocialized –Comorbid conditions: ADHD and/or Cognitive Disfuctions

22 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/15 Pronogsis Protective Factors: –Higher self-esteemand locus of control –Family support and supervission –Continuity in therapeutic intervention –Early diagnosis and therapeutic intervention –Good accessibility to Child and Adolescent Psychiatric Services –Social support (peer and social context) –School support

23 Hollistic and Developmental Assessment of Behaviour Disorders in Adolescence/16 Pronogsis Individual Factors: –Temperament –Personality traits –Perception disorder by himself/herself

24 Assessment of Behaviour Disorders in Adolescence/1 Diagnostic Assessment: –Obtain patient’s history –Obtain family history –Interview with patient –School information –Physical evaluation AACAP (1997) MªC. Ballesteros; JL Alcázar; JL Pedreira & A de los Santos (1998)

25 Assessment of Behaviour Disorders in Adolescence/2 Diagnostic Formulation: –Identify ICD-10/DSM-IV target symptoms –Biopsychosocial stressors, enviromental and developmental factors –Subtype of the Behaviour Disorders –Comorbidity AACAP (1997) MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

26 Assessment of Behaviour Disorders in Adolescence/3 Obtain patient’s history: –Prenatal ahd birth history ( substance abuse by mother, maternal infections or medications) –Developmental history (attachment diosrders e.g. Parental depression, substance abuse; temperament, oppositionality, aggression, attention, socialization, impulse control) –Physical/sexual abuse history –History of symptoms development (impact on family and peer relationship, academic problems) –Medical history (CNS pathology, chronic illnesses, somatizations) AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

27 A developmental progression for antisocial behavior Poor parental discipline and monitoring Child conduct problems Rejection by normal peers Academic failure Commitment to deviant peer group Deliquency Early Childhood Late Childhood and Adolescence Middle Childhood

28 Multidimensional causal models: Longitudinal model Family School Prior Delinquent Behaviour Delinquent Peers Delinquent Behaviour Elliot, Huizinga & Ageton (1985) (Condensed & adapted)

29 Median Age of Onset Reported by Parent of Symptoms of oppositional Defiant Disorder and Conduct Disorder ª Median ageOppositional defiant disorderConduct disorder Stubborn Defies adults, temper tantrums. Irritables, argues. Blames others. Annoys others. Spiteful. Angry. Swears. Lies. Fights. Bullies, sets fires. Uses weapon. Vandalizes. Cruel to animals. Physical cruelty. Steals, runs away from home. Truant, mugs. Breaks and enters. Forces sex. B. Lahey & R. Loeber (1994) ª This combines retrospective and prospective ages of onset over four annual assessment in the Developmental Trends Study.

30 The families of adolescents: The “strop cycle” Harsh criticism from others Precarious self-esteem Identity definition by opposition P. Hill (1992)

31 Assessment of Behaviour Disorders in Adolescence/4 Obtain family history: –Family coping style, stressors, resources - socioeconomic status, social support/isolation, problem- solving skills, conflict-resolution skills, parenting skills, limit-setting, abuse/neglect, permissiveness, inconsistency, management child’s aggression, parent’s and patient’s coercitive interaction cycles leading to reiforcement of noncompliance AACAP (1997) MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

32 Assessment of Behaviour Disorders in Adolescence/6 Interview patient (may precede parental interview) : –Capacity for attachment, trust and empathy –Tolerance for and discharge of impulses –Capacity for showing restraint, accepting responsability for actions, experiencing guilt,user anger constructively, acknowleding negative emotions –Cognitive functioning AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

33 Assessment of Behaviour Disorders in Adolescence/7 Interview patient/2 (may precede parental interview) : –Mood, affect, self-esteem, suicide potencial –Peer relationship (loner, popular, drug-, crime-, or gang oriented friends) –Disturbances of ideation (suggestibility, disociation) –History of early, persistent use of tabacco, alcohol or other substances –Psychometric self-report instruments might provide AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

34 Assessment of Behaviour Disorders in Adolescence/8 School information : –Functioning (IQ, achievement test data, academic performance and behaviour) –Standard parent and teacher rating scales of the patient’s behaviour –Referral for IQ, speech and language and learning disability and neuropsychiatric testing if available test data are nor sufficient –Data may be obtained inperson, by phone or though written reports from appropiate staff, such as school principal, psychologist, teacher and nurse AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

35 Cross-Sectional model Parental Monitoring Behaviour problems/ Social Competence Academic Skills Deviant Peers Delinquent Behaviour a a: High behaviour problems and low social competence Patterson & Dishion (1985) (adapted)

36 Assessment of Behaviour Disorders in Adolescence/9 Physical examination : –Collaboration with family doctor, paediatrician or other health care providers –Vision and hearing screening –Evaluation of medical and neurological conditions (e.g. Head injury, chronic illness) –Urine and blood drugs screening as indicated, especially when clinical evidence suggest substance use AACAP (1997); MªC. Ballesteros; J.L. Alcázar; J.L. Pedreira & A. De los Santos (1998)

37 Selected Measures of Behaviour Disorders in Adolescents/1 In order to discriminate clinical and no clinical people: High discriminant reliability –Child Behavior Checklist, Achenbach, 1978 –Revised Behavior Problems Checklist, Quay, 1983 –Eyberg Child Behavior Inventory, Eyberg, 1978 –Conners Rating Scales (Parents and Teachers)

38 Achenbach-Connors-Quay Questionnaire (ACQ) delinquent and aggressive behaviour dimensions Delinquent behaviorAggressive behaviour Cheats Doesn’t feel guilty Hangs around kids who get in trouble Lies Runs away from home Sets fires Steals at home Steals outside home Swears; uses obscene language Talks or thinks about sex too much Truancy Uses alcohol Uses drugs Vandalizes older kids Argues Brags Bullies; is mean to others Destroys others’ things Demands attention Destroys own things Disobedient at school Jealous Irritable Loud Physically attacks people Screams Shows offor clowns Stars fights Stubborn Sudden mood changes Talks too much Teases other kids Temper tantrums Threatens

39 Selected Measures of Behaviour Disorders in Adolescents/2 In order to evaluate the treatment impact: High predictive reliability –Child Behavior Checklist, Achenbach, 1978 –Eyberg Child Behavior Inventory, Eyberg, 1978 –Conners Rating Scales (Parents and Teachers) In order to require shortness or treatment evaluation or developmental impact: Short Scales –Short’s Conners Rating Scale –Iowa-Conners Teacher Rating Scale –Eyberg Child Behavior Inventory

40 Selected Measures of Behaviour Disorders in Adolescents/3 In order to assess behaviour competences or adolescent behaviour profile: –Child Behavior Checklist, Achenbach, 1978 In order to consider the setting: –Child and Adolescent Psychiatric Services, or comorbidity screening: ABC, CBC, TBP and Conners Scales –Behaviour specific setting: Eyberg Child Behavior Inventory

41 Family Assessment of Behaviour Disorders in Adolescents/1 Parenting Profiles: –Parenting Scale (Arnold, 1993) –Parent Practices Scale (Stayhom & Widman, 1998) –Alabama Parenting Questionaire (Frick, 1991) Parent and Teacher Social Cognitions: –Parenting sense of Competende Scale (Johnston, 1989) –Cleminshaw-Guidubaldi Parent Satisfaction Scale (1985) –Parental Locus of Control Scale (Campis et al., 1986)

42 Family Assessment of Behaviour Disorders in Adolescents/2 Parental perceptions of personal and marital adaptation or emotional state: Screening of depressive and mood psychopathology, disocial behaviour and substance or alcohol abuses Family Stress: –Parenting Daily Hassles (Greener, 1990) –Parenting Stress Index (Abidin, 1995) Parental functioning in extrafamily context: –Community Interaction Checklist (CIC, Wahler, 1979)

43 Family Assessment of Behaviour Disorders in Adolescents/3 Parent conflicts: –O’Leary-Porter Scale (1980) –Conflict Tactics Scale (Partner-Strauss, 1979, 1990) –Parenting Alliance Inventory (Abidin, 1988) –Child Rearing Disagreements (Jouriles et al., 1991) –Parents Problems Checklist (Dadds & Powell, 1991) Parental satisfaction with treatment procedures: –Parent’s Consumer Satifaction Questionaire (Forehandy & McMahon, 1981; mcMahon, 1984)

44 Diagnostic Formulation of the Adolescents with Behaviour Disorders/1 Identify ICD-10/DSM-IV target symptoms When suggests BD consider the following: –Biopsychosocial stressors ( sexual and physical abuse, divorse or death or key attachment figures ) –Educational potential, disabilities, achievement –Peer, sibling and family problems and strengths –Enviromental factors ( disorganized home, lack of psychiatric illness or drug or alcohol abuse in parents, enviromental neurotoxins e.g. Lead ) –Adolescent or Child ego development, especially ability to form and maintain relationships AACAP (1997)

45 Diagnostic Formulation of the Adolescents with Behaviour Disorders/2 The subtype of the disorder: –Childhood onset vs. Adolescent onset –Overt vs. Covert versus authority –Under-restrained vs. Over-restrained –Socialized vs. Undersocialized AACAP (1997)

46 Diagnostic Formulation of the Adolescents with Behaviour Disorders/3 The syndromes may be confused or cuncurrent with: –ADHDOrganic Brain and seizure disorder –ODDSpecific developmental disorder –Intermittent explosive disorderSchizophrenia –Substance use disorderParaphilias –Mood disorder (bipolar and depressive) –PTSD and Disociative disorderMental retardation –Borderline personality disorder –Somatization disorderNarcisistic personality disorder –Adjustment disorder AACAP (1997)

47 Dimensional Assessment of Behaviour Disorders in Adolescents/1 Individual dimensions: –Developmental preocess and moral development –Aggressiveness’ subtypes –Self-esteem and self-likeness –Empathy and impulse control –Comorbility –Poor interpersonal relations –Cognitive and atttributional processes: Deficits and disttorsions in cognitive problem-solving skills, atributions or hostile intant to others, resentment and suspiciousness illustrate –Risk factor and vulnerability –Temperament –Clinical features (specially with sign of antisocial behaviour) AACAP (1997)

48 Dimensional Assessment of Behaviour Disorders in Adolescents/2 Family dimensions: –Parenting and attachment styles –Psychopathology (including drug and alcohol abuses) –Untoward parent-child interactions (physical and sexual abuses) –Poor or inconsistent supervision –Marital conflicts –Other family members with antisocial behaviour –Family risk factors –Genetic factors AACAP (1997)

49 Disruptors of effective parenting Grandparental Traits Antisocial behaviour Poor family management Family Stressors Unemployement Marital conflict Divorce Parental Traits Antisocial behaviour Susceptible to stressors Family Demographics Income Parent education Neighborhood Ethnic group Disrupted family-management practices Child antisocial behaviour B. Lahey & R. Loeber (1994)

50 Dimensional Assessment of Behaviour Disorders in Adolescents/3 School dimensions: –Acedemic deficiencies –Neuropsychological deficits (in verbal and “executive” functions) –Behaviour disorder in preschooler’s level –Peer’s relationship and perception of behaviour –Teacher’s supervision and authority AACAP (1997)

51 Dimensional Assessment of Behaviour Disorders in Adolescents/4 Social and contextual dimensions: –Identification with a subculture or group –Alienation of the individual from the wider social group –Delinquency areas –Poverty and marginalization behaviour –Legal problems –Social support AACAP (1997)

52 Cross-Sectional model Neighborhood Disorder Criminal Subculture Neighborhood organization Neighborhood Stability Age Family Stability School Delinquent Peers Severe Delinquent Behaviour a + + a: These parameters are counterintuitive and probably sampling and measurement limitations Simcha-Fagan & Schwartz (1986) (condensed and adapted)

53 Parents scales Yourself scales Clinical interview Peers and Social scales Teacher scales Any scales in Clinical range? Conclusion: No evidence of clinical deviance. check key items, e.g. Suicidal behaviour Is deviance confined to the same syndrome in all sources? Conclusion: Child’s problems correspond to a single Syndrome e.g. aggresive Are the same syndrome deviant in all sources? Conclusion: Child’s problems comprise multiple syndrome or profile pattern Does child’s behaviour actually differ much among contexts? Potential sources of data Initial screem Differential diagnosis Conclusion: Different behaviours may have to be targeted for changes in different contexts Conclusion: Some informants’ Perceptions may Have to be Targeted for change yes no yes no yes no yes no Taxonomic decision tree for using quantitative multi-informant data to make categorical decisions Achanbach (1993) (modified)

54 Treatment of Behaviour Disorders in Adolescents/1 General aims: –Treatment shold be provided in a continuum of care that allows flexible application of modelities by a cohesive treatment team –Outpatient’s treatment includes intervention in family, school and peer group –The predominance of externalizing symptoms in multiple domains of functioning call for interpersonal psychoeducational modalities –As a chronic condition requires extensive treatment and long-term follow-up –Patients with severe BD are likely to have comorbidities that requiare treatment AACAP (1997)

55 Treatment of Behaviour Disorders in Adolescents/2 Treat comorbid disorders Family interventions include parent guidance, training and family therapy: –Identify and work with parental strengths –Train parents to stablish consistent positive and negative consequences and well-defined –Arrange for treatment of parental psychopathology AACAP (1997)

56 Treatment of Behaviour Disorders in Adolescents/3 Individual and group psychotherapy with adolescent: –Technique of intervention (supportive vs. behavioural) depends on patient’s age, processing style and ability to engage in treatment –A combination of behavioural and explorative approaches is indicated, especially when there are internalizing and externalizing comorbidities Psychosocial skill-building training should supplement therapy AACAP (1997)

57 Conclussions/1 Behaviour disorder refers to instances when children or adolescent evince a pattern of antisocial behaviour, when there is significant impairment in everyday functioning at home or school, or when the behaviours are regarded as unmanageable by significant others BUT: –When are the behaviour problems a normal developmental variations? Or –Are the behaviour disorders an clinical syndrome with different clinical features and developmental expressions? And –When are the behaviour problems, the clinical symptom of disocial behaviour or antisocial personality disorder?

58 Conclussions/2 Behaviour disorder is multifaceted and symptomatic complex in so far as it includes many symptoms and effects many domains of functioning Although the disorder is discussed as a constellation of symptoms within the child, there are parent and family features often associated with the disorder The nature of the disfunction has important implications for assessment and intervention both in the context of clinical work and research

59 Conclussions/3 Behaviour disorder represents a special challenge given the multiple domains of functioning that are affected It is meaningful to consider alternative constellation of symptoms, various subtypes and developmental paths and trajectories Research identified differences among subtypes: Aggressive and delinquent types and childhood onset vs. Adolescent onset receiving major attention

60 Conclussions/4 We need longitudinal follow-up research based on developmental psychopathology methodology, in order to clarify the continuity vs. Discontinuity of the behaviour disorders Understanding the confluence of multiple factors (children’s characteristics, features of behaviour disorder, parent and family functioning and contextual influences) Peer influences have been implicated in the onset and maintenance of antisocial behaviours including substance use and abuse and deliquency Poor bonding to home and school were related to subsequent bonding to deviant peers

61 Conclussions/5 Assessment issues: –Assessment involves different sources of information, the challenges for research and clinical work consist to integrate multi-informant data –Although parents are in an excellent position to report on their children’s behaviour, the evaluation cannot be assumed to be free from systematic influences or basis –It is useful to mention the specificity of performance because in many cases symptoms are restricted to once or a few situations

62 Conclussions/6 Assessment issues/2: –The BDs are the “open door” in order to develop other psychopathological disorder –Evaluation of a symptom and set of symptoms needs to be developmentally based –In our opinion the assessment process includes an hollistic and comprehensive procedures: Vulnerability and risk factors, symptoms and clinical features and pronogsis in order to develop the treatment (therapeutic and preventive interventions)

63 Conclussions/7 The assessment of risk and protective factors has been relied upon to develop both therapeutic and preventive interventions Advances in understanding behaviour disorders have derived from trying to move to understanding the interrelation of factors and how they operate on a day-to-day basis in producing antisocial behaviour and its legal and/or ideological implications


Download ppt "Behaviour Disorders in Adolescents: Clinical and Psychopathological Assessment Mª.C. Ballesteros (Hospital Clínico Universitario de Valladolid) J.L. Pedreira."

Similar presentations


Ads by Google