Presentation on theme: "Marcia Jensen, Ph.D., NCSP 3/2/2010"— Presentation transcript:
1 Marcia Jensen, Ph.D., NCSP 3/2/2010 email@example.com Development of Disruptive Behavior Disorders: Implications for Prevention & TreatmentMarcia Jensen, Ph.D., NCSP3/2/2010I’m going to start this presentation by describing normative and non-normative development of behavior to prepare you to understand effective ways to prevent and treat disruptive behavior disorders.
2 Plan for Presentation What are Disruptive Behavior Disorders? Why are DBD problematic?What causes DBD?Who has DBD?What are implications for prevention & treatment of DBD?
3 What are Disruptive Behavior Disorders? Attention-Deficit/Hyperactivity DisorderOppositional Defiant DisorderConduct DisorderDisruptive Behavior Disorder, NOS
4 Attention-Deficit/Hyperactivity Disorder (ADHD) ADHD-I: > 6 symptoms of inattention occurring often for 6+ months causing significant impairment in social, academic, or occupational fxningADHD-H-I: > 6 symptoms of hyperactivity-impulsivity for 6+ months causing significant impairmentADHD-C: > 6 symptoms of inattention & > 6 symptoms of hyperactivity-impulsivity with impairmentBelow developmental level and some symptoms before age 7
5 Oppositional Defiant Disorder (ODD) > 4 criteria occurring often for 6+ months causing significant impairment in social, academic, or occupational fxningLoses temperArgues with adultsActively defies/refuses to comply with adults’ requests/rulesDeliberately annoys peopleBlames others for own mistakes/behaviorTouchy/easily annoyed by othersAngry/resentfulSpiteful/vindictive
6 Conduct Disorder (CD)> 3 criteria occurring in 12 months, > 1 in past 6 months causing significant impairment in social, academic, or occupational fxningAggression to people/animalsOften bullies, threatens, or intimidates othersOften initiates physical fightsUsed a weapon than can cause serious physical harm to othersHas been physically cruel to peopleHas been physically cruel to animalsStolen with confrontationForced someone into sexual activityDestruction of propertyFire setting with intent to cause serious damageDestruction of property other than fire settingDeceitfulness or theftBroken into someone’s house, building, or carOften lies to obtain goods/favors (i.e., cons others)Stolen items of nontrivial value without confrontationSerious violations of rulesStays out all night despite parent prohibition (before age 13)Run away from home overnight > twice or once for lengthy periodOften truant (before age 13)Childhood onset if > 1 symptom prior to age 10; Adolescent onset if no criteria before 10; Unspecified if age of onset unknownDBD NOS is used when
7 Why are DBD problematic? High association with comorbid psychiatric diagnosisHigh association with negative life course outcomes
9 Life Course Outcomes of DBD Higher rates of violence, arrest/conviction, substance abuse/dependence, unemploymentPoor school performance, low educational attainmentProblems with peers, social isolationMental & physical health problemsViolent, coercive parentingChildren with problem behaviorsDe Genna et al., 2007; Farrington, 1991; Jaffee et al., 2006; Offord & Bennett, 1994; Offord, Boyle, & Racine, 1991; Temcheff et al., 2008
11 Developmental Trajectory of Self-Control AgeTypicalAggressiveInfant/ToddlerEasy temperamentManageable negative behaviorsIrritable, fussy, unresponsive to parentTantrums/whinesPreschoolObeys most caregiver directionsFollows rulesDisobeys caregiver directionsFails to follow rulesContinued tantrumsElementary SchoolUsually reflective & thinks before actingCan calm down when upsetOften impulsive & acts before thinkingGets upset & overreacts to stressAdolescenceCopes with strong emotionsAware of behavior & impacts on othersFrequent intense anger outburstsUnaware of behavior & impact on others
12 Theories on Developmental Trajectory of Aggressive Behavior 2 pathways to later criminalityEarly onset; life-course persistentLater onset; adolescence-limitedPatterson, DeBaryshe, Ramsey, 1989; Moffitt, 19935 pathways2 life-course persistent groupsEarly onset w/ ADHDMiddle childhood onset w/o ADHD2 limited duration aggression groupsHigh aggression subsides in middle childhood‘’ late teens1 late onset groupLoeber & Stouthamer-Loeber, 1998Moffitt characterizes life-course persistent CD as psychopathology & adolescence-limited as normative (due to gap between biological and social maturity social mimicry of deviant peers – and resolved by healthy adaptation to shifting contingencies). Life-course persistent impacts small proportion of population; 1/3 of males arrested for a serious crime and 4/5 for minor infringement.
13 Developmental Trajectory & Outcomes Juvenile Arrest %Adult Arrest %CD %ASPD %Nonaggressive12916Moderate422620Increasing72466962Chronic High73487471Control group from larger universal prevention study in BaltimoreWhole Sample:19.2% CD; 15.5% ASPD; 35.4% Juvenile Court involvement; 24.6% Adult Court involvementSchaeffer et al., 2003
14 Genetic Biomarkers of DBD? Genetic studies evaluate main effects of genes (G), environment (E), and GxE interactionsConclusive evidence of main effects for ESome evidence of main effects for GWithin serotonin & dopamine transmitting systems, but far from definitive markers to reliably diagnose or predict treatment outcomesSome evidence of interaction effects for GxEPolymorphism on MAOA gene moderates impact of childhood maltreatmentMoffitt et al., 2008
15 Gender Differences in DBD Few differences in rate of conduct problems during infancy/toddlerhoodMales exhibit more conduct problems than females between the ages of 4 & 13 and post-pubertySmaller differences between males & females around pubertyMales more likely to be on LCP trajectory; similar prevalence for AL trajectoryLahey et al., 2006
16 Gender Differences in DBD Differences in early childhood conduct problems may be result of differential socializing responses from adultsKeenan & Shaw, 1997Differential response patterns by males & females to same experienceGirls shift from physical to relational aggressionCrick & Zahn-Waxler, 2003Insufficient evidence to create female-specific diagnostic criteria for CDMoffitt et al., 2008
17 Synthesis of Developmental Models DBD associated with increased risk for negative life-course outcomesLCP = psychopathology & is relatively uncommon (3-16%)Worst prognosis for high stable aggression, problems associated with low & moderate stable aggressionLCP vs. AL model applies to males and females, but DBD & LCP more prevalent in malesTrajectory determined by a combination of genetic & environmental influencesThere may be both main effects & interaction effects for G & E influences
19 Risk & Protective Factors Risk FactorsChildBehavioral/emotional regulationSocial skills> Average IQAcademic skillsBehavioral/emotional dysregulation/problemsPoor social skillsLow IQAcademic difficultiesParent/familyClose relationship w/ stable adultSupportive, authoritative parentingPredictable routines/ritualsPositive parent-child interactionsPositive/stable family environmentMiddle/high SESProblems w/ parent-child attachmentPermissive, inconsistent parentingFamily lacks routines/ritualsCoercive parent-child interactionsFamily problems/instabilityParent personal problemsLow SESRisk and protective factors are used to help explain how individuals achieve expected or unexpected outcomes.
20 Risk & Protective Factors Risk FactorsSocial/Peer GroupAcceptance by positive peer role modelsAssociations/acceptance by positive-influence peersRejection by positive peer role modelsAssociations/acceptance by negative-influence peersCommunityAttending effective schoolSafe, organized neighborhoodOpportunities of positive influence: school, religious, community activitiesNonviolent media influencesAttending ineffective schoolNeighborhood problemsCommunity violence & crimePovertyViolent media influencesBloomquist & Schnell, 2002
21 Social Information Processing Theory PEER EVALUATION & RESPONSEDatabaseModel developed for children 9-12 yrs and extends up, not downChildren have a biologically limited set of responses to behavior; in their database is their memory of previous experiences; incoming cues are used to select & implement a behavioral response.1 & 2 Selective attention to situational and internal cues during Encoding & Interpretation of cues3 Goals are focused arousal states functioning as orientation toward producing an outcome brought to situation but also possible to revise given current social stimuli4 Access from memory behavioral response or construct in the moment5. Evaluation of responses includes outcome expectancies, self-efficacy, & appropriateness of response.6) Behavior is enacted producing a social response which provides more cues to drive the recursive process.As development continues, increased rigidity in adherence to already acquired processing patterns & tendencies.Adapted from Crick & Dodge, 1994
22 Social Info Processing & Aggression Hostile attribution bias: aggressive children more likely to attribute hostile intent to neutral interactions; linked to reactive aggressionDeficits in response selection: aggressive children generate fewer responses, have & choose more aggressive & less prosocial responses≈ 40% of children have SIP problems, boys and African Americans at greater riskLansford et al., 2006
23 Who has DBD? Children of delinquent parents Children of substance abusing parentsLow SES associated with increased risk for DBDRacial/ethnic differences not observed when SES controlledMore prevalent in boys than girls; boys age have steeper increase in delinquent behavior than girlsGirls may manifest in different ways (e.g., relational aggression)Note: These statements are summarized from data presented across many studies.
24 Prevention & Treatment UniversalEntire population prior to onset; $SelectedAt-risk population; $$Indicated/IntensiveHigh risk individuals showing early warning signs; $$$Treatment/recurrence preventionIndividuals who have already demonstrated problem to reduce symptoms/recurrence; $$$$Before we get into a discussion of prevention and treatment of DBD, I want to talk about what prevention and treatment are.Prevention of heart disease:U: regular check-ups, healthy diet, and regular exerciseS: increase monitoring, restrict food intake, more regimented exercise programI: more frequent monitoring, medication to reduce cholesterol plus restricted diet, increased exerciseT: Hospital stay, frequent and intensive monitoring, Heart surgery, medication, major lifestyle changes (e.g., restrict food, increase exercise)
25 Effective Prevention Strategies Should be based on theory about developmental course of a conditionAnalyze problemDevelop intervention to enhance protective factors or minimize risk factorsTest, evaluate, & refineDumka et al., 1995
26 Why DBD are a good candidate for prevention? We have a lot of information about developmental trajectories, risk, & protective factorsLargely influenced by environmental factorsMany, expensive, negative life-course outcomes associated with DBD
27 Prevention of DBD through RTI Logic Level IVSpecial Education IEP DeterminationHIGHLevel IIIIntensive InterventionsLevel IISelected InterventionsIntensity of TreatmentLevel IUniversal InterventionsLOWDegree of Unresponsiveness to InterventionHIGH
28 Multiple Tiers of Behavior Support Targeted/Intensive(High-risk students)Individual Interventions(3-5%)Selected(At-risk Students)Classroom & SmallGroup Strategies(10-20% of students)Multiple Tiers of Behavior SupportUniversal(All Students)Schoolwide, Culturally RelevantSystems of Support(75-85% of students)Adapted from:Sprague & Walker, 2004
29 Tier I Menu: Schoolwide PBS SEL Curriculum Good Behavior Game Tier 3 Menu:Assessment-based Behavior Intervention PlanReplacement Behavior TrainingIN AN IDEAL WORLD:Menu of a continuum of evidence-based supportsTargeted/Intensive(High-risk students)Individual Interventions(3-5%)Tier 2 Menu:Behavioral ContractingSelf MonitoringSchool-Home NoteMentor-Based ProgramDifferential ReinforcementPositive Peer ReportingSelected(At-risk Students)Classroom & SmallGroup Strategies(10-20% of students)Tier I Menu:Schoolwide PBSSEL CurriculumGood Behavior GameProactive ClassroomManagementUniversal(All Students)School/classwide, Culturally RelevantSystems of Support(75-85% of students)
30 Tier 1 for All: Recommended Complementary Services Schoolwide Positive Behavior SupportTeach, model, and reinforce behavioral expectations in all settingsSocial Emotional Learning CurriculumTeach self-regulatory behaviors and expose students to big picture conceptsPeer Mediation ProgramTeach students to reduce interpersonal conflict through mediation strategiesProactive Classroom ManagementSeating, rules, instructional activities, transitions, proactive strategyGood Behavior GameClassroom-based behavior management systemThese interventions can be implemented individually or as a comprehensive package. They are complementary.At the back of your handouts, there are references and resources for obtaining information about all of the strategies that I’m describing. Many of these are probably familiar to you and/or in use in your school settings. In addition, I’m certain that there are full presentations going on here at NASP about these topics. I would like to highlight the GBG as it is both extremely effective and relatively easy to set up and maintain.
31 Good Behavior Game as “Behavioral Vaccine” Provides an inoculation against the development of physical, mental or behavior disorderse.g., antiseptic hand washing to reduce childbed feverHigh need for low-cost, widespread strategy as simple as antiseptic hand washingLittle time and effort = high likelihood of useEmbry, 2002
32 Good Behavior GameShort term benefits: Improved discipline practices by teacher, decreased discipline problems, more behavioral successLonger term benefits: Decreased smoking, substance abuse/dependence, reduced risk of development of mental health problems & later arrestPractical considerations: Need for adoption by school personnel; monitoring & mentoring to insure effective delivery & positive outcomes; cost per child/year ≈ $200Estimated cost/year to deliver to all 1st & 2nd graders in WY: $1,000,000Anticipated savings due to reduced special education placements (5%), legal problems (2%), substance use (4%): $15-20,000,000
33 Tier 2 for Some: Evidence-Based Interventions Behavioral contractingSelf-monitoringSystematic school-home note systemMentor-based support (e.g., Check & Connect; BEP)Differential reinforcement proceduresPositive peer reportingGroup contingenciesSocial skills trainingMulticomponent prevention program: Early RisersMany of these programs you might already be familiar with, but I’m going to tell you a little bit about the ER program because I am currently involved with research on several projects using this program through the U of MN where it was developed.
34 Early Risers Description: Program implemented in multiple settings Child Skills: Weekly group to develop social skills & reading enrichmentChild Monitoring & Mentoring: Systematic monitoring of child’s academic/school functioning, goal setting/attainment strategies, reading enrichment, teacher consultation, & facilitating involvement of parents around school issuesFamily Skills: Parent-focused education & skills training to enhance parent’s knowledge of child development and effective parenting strategies with special parent-child “bonding” activitiesFamily Support: Tailored monitoring of family functioning, goal setting/attainment strategies, assisting families in accessing community services, & intensive parent skills trainingSchool psychologists, counselors or school social workers would be effective practitioners to provide these services either as a team or individually if they were designated into the role of family advocate and their salary and time was allocated for that role.
35 Early Risers Short-term benefits: Longer-term benefits: Child improvements on academic and social/behavioral measures (greatest for most aggressive youth)Parent improvements in disciplinary practicesLonger-term benefits:Fewer symptoms of ODD for ER participantsPractical considerations:Requires extensive training, technical assistance, oversight, and resourcesParent participation & level of treatment fidelity must be sufficient to achieve positive outcomes.Cost per child/year ≈ $1750 (w/out cost of training & technical assistance included)August et al., 2002; Bernat et al., 2007; Bloomquist et al., 2008
36 Tier 3 for a Few: Functional Behavior Assessment (FBA) -Based Supports Examination of progress monitoring dataFBA-based supportConduct FBA to identify variables maintaining problem behaviorAlter environmental contingencies surrounding problem behaviorWeekly Replacement Behavior TrainingThis is used for about 3-5% of all students, those who were not responsive to prior tiers of supports.
37 Off the Pyramid, Tier 3 and Beyond: Specialized Supports for Persistent Non-responders Special Education evaluationWraparound services pursuedIncrease intensity of servicesUsed for 1-2% of students who have not responded to all prior tiers of supports.
39 Treatments for DBD Parent and family skills training Multisystemic therapyResidential TreatmentJail
40 Parent & Family Skills Training Description:Parent training about effective commands, contingent reinforcement, differential attention, & time out; persistent & consistent implementation improve outcomesUse modeling, role play, practice, & feedback in sessionSpecific CBT for youth targeting maladaptive social cognitive processes, improving anger control, social skills, & problem solving
41 Parent & Family Skills Training Short-term benefits:Reduce coercive interactions between parent & childConsistent & effective responses to child’s behaviorsLonger-term benefits:Reduced aggression/conduct problemsLower parent stress & increased parental sense of self-efficacyPractical considerations:Need to establish good relationship with family & provide structure when teaching skillsHarder to engage families with higher number of problemsMay need to begin with motivational interviewing> $1500 for 10 sessions of therapyBloomquist & Schnell, 2002; Offord & Bennett, 1994
42 Parent & Family Skills Training Topics Child Behavioral DevelopmentTeaching a child to obeyTeaching a child to follow rulesTeaching a child to avoid dishonest behaviorChild Social DevelopmentTeaching a child social behavior skillsTeaching a child social problem solving skillsTeaching a child to cope with bulliesPromoting positive peer affiliations
43 Parent & Family Skills Training Topics Child Emotional DevelopmentTeaching a child to understand & express feelingsTeaching a child to think helpful thoughtsTeaching a child to deal with stressPromoting a child’s self-esteemChild Academic DevelopmentHelping a child appreciate and enjoy readingTeaching a child self-directed academic behavior skillsBeing involved in your child’s schooling
44 Parent & Family Skills Training Topics Parent Well-BeingImproving parent stress management techniquesStaying calm with a stressful childChanging unhelpful parent thoughtsFamily RelationshipsImproving the parent-child bondImproving family interactionsDeveloping family routings & ritualsBloomquist, 2006, 2010
45 ReferencesAugust, G. J., Hektner, J. M., Egan, E. A., Realmuto, G. M., & Bloomquist, M. L. (2002). The early risers longitudinal prevention trial: Examination of 3-year outcomes in aggressive children with intent-to-treat and as-intended analyses. Psychology of Addictive Behaviors, 16,Baker, L.A., Raine, A., Liu, J., & Jacobson, K.C. (2008). Differential genetic and environmental influences on reactive and proactive aggression in children. Journal of Abnormal Child Psychology, 36,Bernat, D., August, G.J., Hektner, J.M., & Bloomquist, M.L. (2007). The Early Risers preventive intervention: Six year outcomes and mediational processes. Journal of Abnormal Child Psychology, 35(4),Bloomquist, M.L. (2006). Skills training for children with behavior problems: A parent and practitioner guidebook (Rev. ed.). New York : Guilford Press.Bloomquist, M.L., August, G. J., Horowitz, J., Lee, S.S., & Jensen, C. (2008). Moving from science to practice: Transposing and sustaining the “Early Risers” conduct problems prevention program in a community service system. The Journal of Primary Prevention.Bloomquist, M.L., & Schnell, S.V. (2002). Helping Children with Aggression and Conduct Problems: Best Practices for Intervention. New York: Guilford Press.Campbell, S.B., Spieker, S., Burchinal, M., Poe, M.D., & the NICHD Early Child Care Research Network (2006). Trajectories of aggression from toddlerhood to age 9 predict academic and social functioning through age 12. Journal of Child Psychology and Psychiatry, 47,Crick, N.R., & Dodge, K.A. (1994). A review and reformulation of social information-processing mechanisms in children’s social adjustment. Psychological Bulletin, 115,Crick, N.R., & Zahn-Waxler, C. (2003). The development of psychopathology in females and males: Current progress and future challenges. Development and Psychopathology, 15,
46 ReferencesDumka, L.E., Roosa, M.W., Michaels, M.L., & Suh, K.W. (1995). Using research and theory to develop prevention programs for high-risk families. Family Relations, 44,Embry, D.D. (2002). The good behavior game: A best practice candidate as a universal behavioral vaccine. Clinical Child and Family Psychology Review, 5,Farrington, D.P. (1991). Childhood aggression and adult violence: Early precursors and later life outcomes. In D.J. Pepler & K.H. Rubin (Eds.), Development and Treatment of Childhood Aggression (pp.5-30). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.Jaffee, S.R., Belsky, J., Harrington, H., Caspi, A., Moffitt, T.E. (2006). When parents have a history of conduct disorder: How is the caregiving environment affected? Journal of Abnormal Psychology, 115,Kellam, S.G., Brown, C.H., Poduska, J.M., Ialongo, N.S., Wang, W., Toyinbo, P., Petras, et al. (2008). Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes. Drug and Alcohol Dependence, 95S, S5-S28.Lahey, B.B., Van Hulle, C.A., Waldman, I.D., Rodgers, J.L, D’Onofrio, B.M., Pedlow, S., et al. (2006). Testing descriptive hypotheses regarding sex differences in the development of conduct problems and delinquency. Journal of Abnormal Child Psychology, 34,Lansford, J.E., Malone, P.S., Dodge, K.A., Crozier, J.C., Pettit, G.S., & Bates, J.E. (2006). A 12-year prospective study of patterns of social information processing problems and externalizing behaviors. Journal of Abnormal Child Psychology, 34,Moffitt, T.E. (1993). Adolescent-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100,
47 ReferencesMoffitt, T.E., Arseneault, L., Jaffee, S.R., Kim-Cohen, J., Koenen, K.C., Odgers, C.L., et al. (2008). Research review: DSM-V conduct disorder: Research needs for an evidence base. The Journal of Child Psychology and Psychiatry, 49, 3-33.Offord, D.R., & Bennett, K.J. (1994). Conduct disorder: Long-term outcomes and intervention effectiveness. Journal of the American Academy of Child and Adolescent Psychiatry, 33,Offord, D.R., Boyle, M.C., & Racine, Y.A. (1991). The epidemiology of antisocial behavior in childhood and adolescence. In D.J. Pepler & K.H. Rubin (Eds.), Development and Treatment of Childhood Aggression (pp.31-54). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.Ollendick, T.H., Jarrett, M.A., Grills-Taquechel, A.E., Hovey, L.D., & Wolff, J.C. (2008). Comorbidity as a predictor and moderator of treatment outcome in youth with anxiety, affective, attention deficit/hyperactivity, and oppositional/conduct disorders. Clinical Psychology Review, 28,Patterson, G.R., DeBaryshe, B.D., & Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44,Schaeffer, C.M., Petras, H., Ialongo, N., Poduska, J., & Kellam, S. (2003). Modeling growth in boys’ aggressive behavior across elementary school: Links to later criminal involvement, conduct disorder, and antisocial personality disorder. Developmental Psychology, 39,Sprague, J., Cook, C.R., Browning-Wright, D., & Sadler, C. (2008). Response to intervention for behavior: Integrating academic and behavior supports. Palm Beach: LRP Publications.Temcheff, C.E., Serbin, L.A., Martin-Storey, A., Stack, D.M., Hodgins, S., Ledingham, J. et al. (2008). Continuity and pathways from aggression in childhood to family violence in adulthood: A 30-year longitudinal study. Journal of Family Violence, 23,
48 Schoolwide PBS Programs Building Effective Schools Together (BEST; Sprague, 2004)Effective Behavior and Instructional Supports (EBIS; Sugai et al., 2006)Florida Positive Behavior Support Project (Kincaid -OSEP Technical Assistance Center Positive Behavior Interventions and Supports (
49 Resources on Schoolwide SEL Programs Collaborative for Academic, Social, and Emotional Learning (CASEL) at the University of Illinois at Chicago
50 Behavior Education Program Manuals Crone, Horner, & Hawken (2004). Responding to Problem Behavior in Schools: The Behavior Education Program. New York, NY: Guilford PressHawken, Pettersson, Mootz, & Anderson (2005). The Behavior Education Program: A Check-In, Check-Out Intervention for Students at Risk. New York, NY: Guilford Press.