1. Conduct Disorder & Oppositional Defiant Disorder

2. Notice you 4 symptoms from the any of the above categories
Notice you 4 symptoms from the any of the above categories. This can be a tricky diagnosis-why? Because it is sometimes hard to make a distinction between normative and atypical behavior. For example, children are supposed to tantrum!!!! An important part of development is trying to find a way to manage emotions. Another example, most children do not listen all of the time. Again this is an important developmental process, it is normal for children to try to find out what they can get away with, to test limits, and to try to develop a sense of independence.

4. Oppositional Defiant Disorder
Oppositional Defiant Disorder (ODD)
Usually appears during the preschool years & rarely later than adolescence.
High percentage of clinic referrals
Most commonly diagnosed in elementary school or preschool. A very high percentage of clinic referrals. Even if they do not meet diagnostic criteria, children not listening or losing temper are probably the most common complaints given by parents.

5. Notice, these symptoms are considered much more serious when relative to ODD. They are also harder to treat. As mentioned later, most typically identified and diagnosed in adolescence.

6. Notice and review the specifiers: age of onset and severity.

7. When assessing conduct problems, it is important to consider the nature of the problems. Overt symptoms and aggression tend to go together. Cover symptoms tend include less aggression. Overt, aggressive behavior is typically associated with a poorer prognosis (poorer long-term outcome).

8. Another prognostic indicator of outcome, especially in relation to CD is limited prosocial emotions (think empathy). Limited prosocial emotions is associated with aggressive and cruel behavior.

9. Prevalence One year prevalence rates:
Conduct disorder median rate is approximately 4%.
Oppositional-defiant disorder, median rate is approximately 3.3%
Rates vary depending on study, these are median rates across studies. ODD may be higher, especially considering more “mild cases.”

10. Age of onset Typical Age of onset Oppositional-Defiant Disorder
Early to middle childhood
Most cases observed by the age of 8
Conduct Disorder
Most typically diagnosed in adolescence.
Can be diagnosed in elementary-school- aged children. Earlier diagnosis relates to a poorer prognosis.

11. ODD and CD appear to be more prevalent in boys
Gender Differences
Gender differences
ODD and CD appear to be more prevalent in boys
Possible gender differences in behaviors exhibited.
It is possible that the rates of CD are underestimated in females.
OCC and CD seem to be more likely in boys. However, some researchers have pointed out that there may be some biases in diagnosis (clinicians less likely to identify ODD or CD in females). Another idea is that females show more covert behavior and less overt behavior. For example, males may be more likely to exhibit overt aggression, whereas females may be more likely to exhibit relational aggression (social aggression).

12. Course & Outcomes (ODD)
Course is variable, but many children, epically with more “mild” ODD may either outgrow or show mild to moderate symptoms in adolescence.
However, ODD is a risk factor for CD, and most cases of CD were preceded by ODD. Those with angry, vindictive symptoms at the greatest risk for developing CD.
In addition to CD, children & adolescents are at risk for a number of psychiatric difficulties later in life.
ODD is generally considered very treatable. Most children with ODD to not go on to develop CD but the risk is elevated.

13. Course & Outcomes (conduct disorder)
Conduct disorder symptoms are typically considered stable & difficult to treat.
Risk for a range of negative outcomes in adulthood
Antisocial personality disorder (40% of youth with CD develop this)
Criminal behavior
Family instability
Negative health
Poor academic functioning
Females: Pregnancy & internalizing disorders
The prognosis for CD is often considered poor and it is difficult to treat. For example, once a parent has lost control of an adolescent (e.g., he or she leaves for 3 days at a time, has been arrested, etc…), it is hard to regain that control. May parents of children of CD have their own psychiatric issues. As you may have noticed the symptoms of CD are similar to antisocial personality disorder. In fact, antisocial PD requires a pattern of antisocial behavior in adolescence (the only PD that has this type of requirement).

14. Course & Outcomes (conduct disorder)
Factors that appear to be predictive of negative prognosis.
Age of onset (early onset, more negative outcome) (see following slides)
Limited prosocial emotions (see slide 8)
Aggression (see slide 17).
Three prognostic indicators. See following slides.

15. Course & Outcomes (conduct disorder)
CD “Early starter pathway” (before 10)
early onset, progression of symptoms
More likely to exhibit aggressive symptoms
Behaviors often escalate over time.
Early starters are more likely to be aggressive and to exhibit continued difficulties into adulthood.

16. Course & Outcomes (conduct disorder)
CD Later onset
Non-aggressive conduct problems common
Often “adolescent-limited”
May be similar rate of girls & boys
If an adolescent shows onset in adolescence AND does not exhibit overt aggression and a lack of empathy, outcome may be more favorable. They may outgrow the symptoms. You can think if it from a number of perspectives, they may get into the wrong crowd, be going though a rebellious phase, and/or need time for more frontal lobe development.

17. Aggression should be treated even if noticed at an early age. Why
Aggression should be treated even if noticed at an early age. Why? It shows a high level of continuity (tends not to go away on its own), it is harder to treat later in development, and is a predictor of negative outcome.

18. Course & Outcomes (conduct disorder)
Limited prosocial emotions specifier
Two of the following:
Lack or remorse or guilt
Callous-lack of empathy
Unconcerned about performance
Shallow or deficient affect
Here is a more detailed description of the characteristic of those who exhibit limited prosocial emotions. Again, a negative prognostic indicator.

19. Etiology (ODD)
Temperament- problems with emotional regulation even at a young age.
Parenting- ODD can be associated with harsh or inconsistent parenting (see coercive cycle next slide).
Note that etiology can come from a number of factors. Parenting relates to the presence or absence of ODD; however, the diagnosis of ODD is not always due to “bad” parenting. Try to avoid the blame the parent idea. Sometimes temperament plays a strong role. In other words, some children, seem to have a more difficult, challenging temperament even at a young age.

20. Etiology (Conduct Disorder)
Parenting & family environment- harsh, inconsistent , or neglectful parenting practices.
Genetic- moderate influence, seems to be most consistent for aggressive behaviors
Neuropsychological factors
Executive functioning deficits common
Lower IQ (verbal functioning)
Those with early-onset CD- psychophysiological/
cortical arousal, & low reactivity of ANS
The parenting issue is interesting. It may be a common belief that families of children or adolescence are chaotic and abusive and come from rough environments. This is often the case. However, sometimes the pattern is seen in children and adolescents who have overly permissive, overly indulgent, or uninvolved parents. As an example, when you get a chance, read about the “affluenza teen”. He killed 4 people in a drunk driving accident with apparently little remorse.

21. Coercive cycle, how would you get the family out of this cycle?

22. Notice, harsh discipline may be a risk factor, but this lower monitoring may be of greater importance.
Low parental monitoring predicts children’s conduct problems. Based on Rowe and colleagues (2002).

23. Treatment (ODD)
The first line of treatment for oppositional defiant disorder is behavioral training, including parent training (see next slide for topics often discussed in parent training).
Skills training with the child may also be helpful, but should probably be used to enhance parent training.
Medication is not effective!
Parent training and behavioral management training in other settings (e.g., school) is the most effective intervention. This can be a hard sell to parents who enter treatment with the perspective that goes something like “there is something wrong with my kid and I want you to fix it.” It is important to work in a tactful way with a family to get them on board with treatment.

24. Skills commonly used in parent training
Skills commonly used in parent training. Notice much if it is behavioral and also includes psychoeducation. Most parent training programs include these components.

25. Additional skills addressed
Additional skills addressed. Many parents don’t know how to give timeouts (even if they have tried it). It is important to disengage when the child is in timeout. It should be negative punishment (sending them to timeout takes them away from a more enjoyable task). Make sure it does not serve as negative reinforcement (the child avoids something) or positive reinforcement (the child gets attention).

26. Treatment (CD) Intensive intervention typically needed.
Effective treatments typically include efforts to improve parenting practices and monitoring of the adolescent’s behavior.
In more severe cases, intervention may occur through juvenile justice system (if the adolescent commits a crime) or through alternative placement (group home and/or therapeutic schools).
Intervention often needs to be intensive, caregivers need to begin to set limits and sometimes address their own issues with functioning. Many CD cases end up in the juvenile justice system.

27. Treatment (CD)
Multisystemic therapy has demonstrated some promise (see following slides)
Generally, medication is not effective. Sometimes atypical antipsychotic medications are prescribed (off label) to treat extremely aggressive behavior.
MST and some related treatments have shown some promise. See next slide.

28. MultiSySTEMIC FAMILY THERAPY
Intensive, home-based therapy
Can include intervention on the individual, family, or community level
Multisystemic means that treatment occurs at a number of levels, it may include addressing parenting, adolescent mental health, community engagement, etc.

29. Efficacy of Multisystemic therapy (MST)
Efficacy of Multisystemic therapy (MST). Researchers compared the behavioral outcomes of adolescents with conduct problems who participated in MST versus interpersonal therapy (IT), a non-behavioral form of treatment. Adolescents who participated in MST were less likely to show future antisocial behavior. Based on Schaeffer and Borguin (2005).