1. Marcia Jensen, Ph.D., NCSP 3/2/2010 jens0692@umn.edu
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.