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Marcia Jensen, Ph.D., NCSP 3/2/2010

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1 Marcia Jensen, Ph.D., NCSP 3/2/2010
Development of Disruptive Behavior Disorders: Implications for Prevention & Treatment Marcia Jensen, Ph.D., NCSP 3/2/2010 I’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 Disorder Oppositional Defiant Disorder Conduct Disorder Disruptive 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 fxning ADHD-H-I: > 6 symptoms of hyperactivity-impulsivity for 6+ months causing significant impairment ADHD-C: > 6 symptoms of inattention & > 6 symptoms of hyperactivity-impulsivity with impairment Below 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 fxning Loses temper Argues with adults Actively defies/refuses to comply with adults’ requests/rules Deliberately annoys people Blames others for own mistakes/behavior Touchy/easily annoyed by others Angry/resentful Spiteful/vindictive

6 Conduct Disorder (CD) > 3 criteria occurring in 12 months, > 1 in past 6 months causing significant impairment in social, academic, or occupational fxning Aggression to people/animals Often bullies, threatens, or intimidates others Often initiates physical fights Used a weapon than can cause serious physical harm to others Has been physically cruel to people Has been physically cruel to animals Stolen with confrontation Forced someone into sexual activity Destruction of property Fire setting with intent to cause serious damage Destruction of property other than fire setting Deceitfulness or theft Broken into someone’s house, building, or car Often lies to obtain goods/favors (i.e., cons others) Stolen items of nontrivial value without confrontation Serious violations of rules Stays out all night despite parent prohibition (before age 13) Run away from home overnight > twice or once for lengthy period Often 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 unknown DBD NOS is used when

7 Why are DBD problematic?
High association with comorbid psychiatric diagnosis High association with negative life course outcomes

8 Comorbidity of DBD DSM-IV-TR Diagnosis Comorbid Conditions (%) ADHD
Internalizing (13-51) Externalizing (43-93) ODD ADHD (35); Anxiety (62); Mood (46) Conduct Disorder ADHD (80); Anxiety (40); Depression (50) Ollendick et al., 2008

9 Life Course Outcomes of DBD
Higher rates of violence, arrest/conviction, substance abuse/dependence, unemployment Poor school performance, low educational attainment Problems with peers, social isolation Mental & physical health problems Violent, coercive parenting Children with problem behaviors De Genna et al., 2007; Farrington, 1991; Jaffee et al., 2006; Offord & Bennett, 1994; Offord, Boyle, & Racine, 1991; Temcheff et al., 2008

10 What Causes DBD? Physiological influences Environmental influences
Genes Temperament Neurological functioning Environmental influences Risk factors Protective factors

11 Developmental Trajectory of Self-Control
Age Typical Aggressive Infant/Toddler Easy temperament Manageable negative behaviors Irritable, fussy, unresponsive to parent Tantrums/whines Preschool Obeys most caregiver directions Follows rules Disobeys caregiver directions Fails to follow rules Continued tantrums Elementary School Usually reflective & thinks before acting Can calm down when upset Often impulsive & acts before thinking Gets upset & overreacts to stress Adolescence Copes with strong emotions Aware of behavior & impacts on others Frequent intense anger outbursts Unaware of behavior & impact on others

12 Theories on Developmental Trajectory of Aggressive Behavior
2 pathways to later criminality Early onset; life-course persistent Later onset; adolescence-limited Patterson, DeBaryshe, Ramsey, 1989; Moffitt, 1993 5 pathways 2 life-course persistent groups Early onset w/ ADHD Middle childhood onset w/o ADHD 2 limited duration aggression groups High aggression subsides in middle childhood ‘’ late teens 1 late onset group Loeber & Stouthamer-Loeber, 1998 Moffitt 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 % Nonaggressive 12 9 16 Moderate 42 26 20 Increasing 72 46 69 62 Chronic High 73 48 74 71 Control group from larger universal prevention study in Baltimore Whole Sample: 19.2% CD; 15.5% ASPD; 35.4% Juvenile Court involvement; 24.6% Adult Court involvement Schaeffer et al., 2003

14 Genetic Biomarkers of DBD?
Genetic studies evaluate main effects of genes (G), environment (E), and GxE interactions Conclusive evidence of main effects for E Some evidence of main effects for G Within serotonin & dopamine transmitting systems, but far from definitive markers to reliably diagnose or predict treatment outcomes Some evidence of interaction effects for GxE Polymorphism on MAOA gene moderates impact of childhood maltreatment Moffitt et al., 2008

15 Gender Differences in DBD
Few differences in rate of conduct problems during infancy/toddlerhood Males exhibit more conduct problems than females between the ages of 4 & 13 and post-puberty Smaller differences between males & females around puberty Males more likely to be on LCP trajectory; similar prevalence for AL trajectory Lahey et al., 2006

16 Gender Differences in DBD
Differences in early childhood conduct problems may be result of differential socializing responses from adults Keenan & Shaw, 1997 Differential response patterns by males & females to same experience Girls shift from physical to relational aggression Crick & Zahn-Waxler, 2003 Insufficient evidence to create female-specific diagnostic criteria for CD Moffitt et al., 2008

17 Synthesis of Developmental Models
DBD associated with increased risk for negative life-course outcomes LCP = psychopathology & is relatively uncommon (3-16%) Worst prognosis for high stable aggression, problems associated with low & moderate stable aggression LCP vs. AL model applies to males and females, but DBD & LCP more prevalent in males Trajectory determined by a combination of genetic & environmental influences There may be both main effects & interaction effects for G & E influences

18 Bronfenbrenner’s Ecological Theory

19 Risk & Protective Factors
Risk Factors Child Behavioral/emotional regulation Social skills > Average IQ Academic skills Behavioral/emotional dysregulation/problems Poor social skills Low IQ Academic difficulties Parent/family Close relationship w/ stable adult Supportive, authoritative parenting Predictable routines/rituals Positive parent-child interactions Positive/stable family environment Middle/high SES Problems w/ parent-child attachment Permissive, inconsistent parenting Family lacks routines/rituals Coercive parent-child interactions Family problems/instability Parent personal problems Low SES Risk and protective factors are used to help explain how individuals achieve expected or unexpected outcomes.

20 Risk & Protective Factors
Risk Factors Social/Peer Group Acceptance by positive peer role models Associations/acceptance by positive-influence peers Rejection by positive peer role models Associations/acceptance by negative-influence peers Community Attending effective school Safe, organized neighborhood Opportunities of positive influence: school, religious, community activities Nonviolent media influences Attending ineffective school Neighborhood problems Community violence & crime Poverty Violent media influences Bloomquist & Schnell, 2002

21 Social Information Processing Theory
PEER EVALUATION & RESPONSE Database Model developed for children 9-12 yrs and extends up, not down Children 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 cues 3 Goals are focused arousal states functioning as orientation toward producing an outcome brought to situation but also possible to revise given current social stimuli 4 Access from memory behavioral response or construct in the moment 5. 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 aggression Deficits 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 risk Lansford et al., 2006

23 Who has DBD? Children of delinquent parents
Children of substance abusing parents Low SES associated with increased risk for DBD Racial/ethnic differences not observed when SES controlled More prevalent in boys than girls; boys age have steeper increase in delinquent behavior than girls Girls may manifest in different ways (e.g., relational aggression) Note: These statements are summarized from data presented across many studies.

24 Prevention & Treatment
Universal Entire population prior to onset; $ Selected At-risk population; $$ Indicated/Intensive High risk individuals showing early warning signs; $$$ Treatment/recurrence prevention Individuals 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 exercise S: increase monitoring, restrict food intake, more regimented exercise program I: more frequent monitoring, medication to reduce cholesterol plus restricted diet, increased exercise T: 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 condition Analyze problem Develop intervention to enhance protective factors or minimize risk factors Test, evaluate, & refine Dumka et al., 1995

26 Why DBD are a good candidate for prevention?
We have a lot of information about developmental trajectories, risk, & protective factors Largely influenced by environmental factors Many, expensive, negative life-course outcomes associated with DBD

27 Prevention of DBD through RTI Logic
Level IV Special Education IEP Determination HIGH Level III Intensive Interventions Level II Selected Interventions Intensity of Treatment Level I Universal Interventions LOW Degree of Unresponsiveness to Intervention HIGH

28 Multiple Tiers of Behavior Support
Targeted/ Intensive (High-risk students) Individual Interventions (3-5%) Selected (At-risk Students) Classroom & Small Group Strategies (10-20% of students) Multiple Tiers of Behavior Support Universal (All Students) Schoolwide, Culturally Relevant Systems 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 Plan Replacement Behavior Training IN AN IDEAL WORLD: Menu of a continuum of evidence-based supports Targeted/ Intensive (High-risk students) Individual Interventions (3-5%) Tier 2 Menu: Behavioral Contracting Self Monitoring School-Home Note Mentor-Based Program Differential Reinforcement Positive Peer Reporting Selected (At-risk Students) Classroom & Small Group Strategies (10-20% of students) Tier I Menu: Schoolwide PBS SEL Curriculum Good Behavior Game Proactive Classroom Management Universal (All Students) School/classwide, Culturally Relevant Systems of Support (75-85% of students)

30 Tier 1 for All: Recommended Complementary Services
Schoolwide Positive Behavior Support Teach, model, and reinforce behavioral expectations in all settings Social Emotional Learning Curriculum Teach self-regulatory behaviors and expose students to big picture concepts Peer Mediation Program Teach students to reduce interpersonal conflict through mediation strategies Proactive Classroom Management Seating, rules, instructional activities, transitions, proactive strategy Good Behavior Game Classroom-based behavior management system These 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 disorders e.g., antiseptic hand washing to reduce childbed fever High need for low-cost, widespread strategy as simple as antiseptic hand washing Little time and effort = high likelihood of use Embry, 2002

32 Good Behavior Game Short term benefits: Improved discipline practices by teacher, decreased discipline problems, more behavioral success Longer term benefits: Decreased smoking, substance abuse/dependence, reduced risk of development of mental health problems & later arrest Practical considerations: Need for adoption by school personnel; monitoring & mentoring to insure effective delivery & positive outcomes; cost per child/year ≈ $200 Estimated cost/year to deliver to all 1st & 2nd graders in WY: $1,000,000 Anticipated 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 contracting Self-monitoring Systematic school-home note system Mentor-based support (e.g., Check & Connect; BEP) Differential reinforcement procedures Positive peer reporting Group contingencies Social skills training Multicomponent prevention program: Early Risers Many 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 enrichment Child Monitoring & Mentoring: Systematic monitoring of child’s academic/school functioning, goal setting/attainment strategies, reading enrichment, teacher consultation, & facilitating involvement of parents around school issues Family Skills: Parent-focused education & skills training to enhance parent’s knowledge of child development and effective parenting strategies with special parent-child “bonding” activities Family Support: Tailored monitoring of family functioning, goal setting/attainment strategies, assisting families in accessing community services, & intensive parent skills training School 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 practices Longer-term benefits: Fewer symptoms of ODD for ER participants Practical considerations: Requires extensive training, technical assistance, oversight, and resources Parent 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 data FBA-based support Conduct FBA to identify variables maintaining problem behavior Alter environmental contingencies surrounding problem behavior Weekly Replacement Behavior Training This 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 evaluation Wraparound services pursued Increase intensity of services Used 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 therapy Residential Treatment Jail

40 Parent & Family Skills Training
Description: Parent training about effective commands, contingent reinforcement, differential attention, & time out; persistent & consistent implementation improve outcomes Use modeling, role play, practice, & feedback in session Specific 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 & child Consistent & effective responses to child’s behaviors Longer-term benefits: Reduced aggression/conduct problems Lower parent stress & increased parental sense of self-efficacy Practical considerations: Need to establish good relationship with family & provide structure when teaching skills Harder to engage families with higher number of problems May need to begin with motivational interviewing > $1500 for 10 sessions of therapy Bloomquist & Schnell, 2002; Offord & Bennett, 1994

42 Parent & Family Skills Training Topics
Child Behavioral Development Teaching a child to obey Teaching a child to follow rules Teaching a child to avoid dishonest behavior Child Social Development Teaching a child social behavior skills Teaching a child social problem solving skills Teaching a child to cope with bullies Promoting positive peer affiliations

43 Parent & Family Skills Training Topics
Child Emotional Development Teaching a child to understand & express feelings Teaching a child to think helpful thoughts Teaching a child to deal with stress Promoting a child’s self-esteem Child Academic Development Helping a child appreciate and enjoy reading Teaching a child self-directed academic behavior skills Being involved in your child’s schooling

44 Parent & Family Skills Training Topics
Parent Well-Being Improving parent stress management techniques Staying calm with a stressful child Changing unhelpful parent thoughts Family Relationships Improving the parent-child bond Improving family interactions Developing family routings & rituals Bloomquist, 2006, 2010

45 References August, 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 References Dumka, 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 References Moffitt, 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 Press Hawken, Pettersson, Mootz, & Anderson (2005). The Behavior Education Program: A Check-In, Check-Out Intervention for Students at Risk. New York, NY: Guilford Press.

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