oppositional defiant and conduct disorder james h. johnson, ph.d. university of florida © james h....

Oppositional Defiant and Conduct Disorder

James H. Johnson, Ph.D.

University of Florida© James H. Johnson, Ph.D. 2008

The Nature of Conduct Disorder

• The term conduct disorder has traditionally been used to characterize children who display a broad range of behaviors that bring them into conflict with their environment.

• These include behaviors that are probably best described as coercive or oppositional;– temper tantrums, – defiance,– noncompliance

The Nature of ConductDisorder

• Also included under this general heading have been behaviors of a more serious nature (e.g., cruelty to people or animals, aggressiveness, stealing) .

• These are more serious in that they– represent a greater threat to those the child interacts with and/or

– have the potential of bringing the child into contact with the juvenile justice system

Empirical Support for the Construct of Conduct Disorder

• Empirical support for conduct disorder, as a meaningful dimension of psychopathology, has come from many factor analytic studies.

• Characteristics like the one’s listed here are often found to occur together in child and adolescent samples.

• The clinical significance of this problem is highlighted by the fact that conduct disordered behavior is one of the more common reasons for referral for mental health services.

Types of “Conduct” Problems

• Although clinicians have used the term “conduct disorder” to refer to a general pattern of disruptive behaviors, like those cited here, it has also been been used for purposes of classification.

• For example, in DSM IV, features usually associated with the general label of conduct disorder are subdivided in order to provide for the diagnosis of two specific patterns of behavior;– Oppositional Defiant Disorder (ODD)– Conduct Disorder (CD)

Oppositional Defiant Behavior as A DSM IV Diagnostic Category

• Oppositional Defiant Disorder (ODD), is defined as "a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures".

• The disorder is reflected in behaviors such as frequent temper tantrums, arguing, defiance, non-compliance, externalizing blame, vindictiveness, and a range of other problem behaviors.

Specific DSM IV ODD Criteria

• For at least 6 months, shows defiant, hostile, negativistic behavior; (4 or more of the following):-Losing temper-Arguing with adults-Actively defying or refusing to carry out the rules or requests of adults-Deliberately doing things that annoy others-Blaming others for own mistakes or misbehavior-Being touchy or easily annoyed by others-Being angry and resentful-Being spiteful or vindictive

DSM IV ODD Criteria

• The symptoms:– cause clinically significant distress or impair work, school or

social functioning. – do not occur in the course of a Mood or Psychotic Disorder. – do not fulfill criteria for Conduct Disorder.

• If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder.

• Coding Note – Symptoms do not presently have to be found across situations; although it is being suggested that perhaps DSM V should require presence of symptoms across situations (First, 2007)

• *Characteristics should occur more often than expected for age and developmental level.

Conduct Disorder as a DSM IV Diagnostic Category

• The essential features of Conduct Disorder (CD) involve "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated“, resulting in a clinically significant impairment in functioning.

• This includes– aggressive behaviors, – behaviors that result in property loss or damage,

– deceitfulness or theft, – other serious rule violations (e.g., running away from home, truancy).

DSM IV Conduct Disorder Criteria

• For 12 months or more has repeatedly violated rules, age-appropriate societal norms or the rights of others.

• Shown by 3 or more of the following, with at least one of the following occurring in the past 6 months:

•Aggression against people or animals– Frequent bullying or threatening– Often starts fights– Used a weapon that could cause serious injury– Physical cruelty to people– Physical cruelty to animals– Theft with confrontation – Forced sex upon someone


• Property destruction-Deliberately set fires to cause serious damage-Deliberately destroyed the property of others (except fire-setting)Lying or theft-Broke into building, car or house belonging to someone else-Frequently lied or broke promises for gain or to avoid obligations ("conning")-Stole valuables without confrontation (burglary, forgery, shoplifting)


• Serious rule violation- Beginning by age twelve, frequently stayed out at night against parents' wishes- Runaway from parents overnight twice or more (once if for an extended period)- Frequent truancy before age 13

• These symptoms cause clinically important job, school or social impairment.

• If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder.


• Childhood-Onset Type: at least one problem with conduct before age 10

• Adolescent-Onset Type: no problems with conduct before age 10

• Note. Age of onset subtypes have been supported using trajectory analyses in longitudinal cohorts by finding that those with childhood-onset type typically continue to meet criteria up to their late 20’s (Mofitt, 2007)

• Severity:– Mild (both are required):

There are few problems with conduct more than are needed to make the diagnosis, and Problems cause little harm to others.

– Moderate. Number and effect of conduct problems is between Mild and Severe

– Severe. Many more conduct symptoms than are needed to make the diagnosis, orSymptoms cause other people considerable harm.

Support for the CD/ODD Distinction

• While there is some empirical support for the distinction between CD and ODD– this categorization may fail to capture the patterning of conduct disordered features found in the clinical population.

• Most relevant to this issue are the results of an ambitious study conducted by Lahey, Frick, Loeber, Tannenbaum, Van Horn, and Christ, 1990.

Empirically Defined Dimensions of Conduct Disordered Behavior

• These authors conducted a meta-analysis of 64 factor analytic studies involving 23,401 children/adolescents on whom data had been obtained regarding substance use & oppositional defiant/conduct disorder symptoms.

• Subjecting this data to multidimensional scaling techniques resulted in the extracting of an initial bipolar scale where

– oppositional defiant and aggressive characteristics were located on one end of the dimension (overt symptoms).

– Substance use and other non-aggressive conduct disorder symptoms were located on the other (covert symptoms).


• These results are generally consistent with the findings of earlier studies, highlighting the distinction between overt/covert conduct disordered behavior.

• Subsequent analyses also resulted in the extraction of a second bipolar dimension.

– Symptoms on one end of this second dimension related to the presence of destructive behavior directed toward property or persons.

– Those on the other end were reflective of non-destructive behaviors (e.g., status offenses, substance use)


• These findings provide general support for the distinction between oppositional defiant and conduct disorder.

• They also suggest that conduct problems may be more meaningfully grouped into four, rather than two, general categories.

• These include– "overt & nondestructive behaviors reflecting symptoms of ODD;

– overt & destructive symptoms of aggression;– covert & destructive behaviors, such as lying and stealing; and

– covert & nondestructive behaviors such as truancy and running away from home (status offenses)

Four Dimensions of Conduct Disordered Behavior

• OVERT/DESTRUCTIVE OVERT/NONDESTRUCTIVE• (Aggressive Behaviors) (Oppositional

Features)• Fights

Annoys• Bullies

Defies• Assault

Stubborn• Spiteful

Angry• • COVERT/DESTRUCTIVE COVERT/NONDESTRUCTIVE• (Property Violations) (Status

Offenses)• Cruel to Animals

Runaway• Vandalism

Truancy• Steals

Substance Use• Fire setting

Breaks Rules

• Adapted from Frick, et al., (1993).

Relevance of Dimensions for the Juvenile Justice System

• These four categories of conduct disordered behavior appear to correspond to categories of antisocial behavior often used by the Juvenile Justice system.

• They are also consistent with other systems for classifying conduct disordered and delinquent behavior (e.g., oppositional behavior, aggressive behavior, property violations, status offenses).

On the Breadth of the Conduct Disorder Construct

• However defined, the general term conduct disorder refers to a heterogeneous group of problem behaviors.

• Some are aversive, disruptive and problematic for parents and teachers.

• Others involve aggression toward property or persons.

• Others involve actual violations of the law which might result in the child being labeled as delinquent if the behavior were to come to the attention of legal authorities.

Prevalence of Oppositional Defiant and Conduct Disorder

• Epidemiological studies of children displaying more general conduct disordered features have suggested that somewhere between 3.2 and 6.9% of the general child/adolescent population may be affected .

• When children meeting specific DSM criteria for diagnoses of ODD and CD are considered together, research suggests general population prevalence rates of somewhere between 8 and 12%

Sex Ratio of ODD/CD

• Generally sex differences in disruptive behavior disorders do not emerge prior to age 6.

• At later ages, however, males referred for disruptive behavior disorders significantly outnumber females anywhere from 4:1 to 6:1.

• These children account for somewhere between one-third and two-thirds of all child mental health referrals.

Comorbidity of ODD/CD

• As with ADHD, children with ODD and CD frequently display other types of problems. – Between 34.7 and 48 % of children and adolescents with ODD/CD also show evidence of ADHD.

– Comorbidity estimates ranging from 12 to 17.6 % have been found for depressive disorders.

– As many as 19% of children/adolescents with ODD/CD qualify for a diagnosis of anxiety disorder.

Comorbidity of ODD/CD

• While findings of multivariate studies have provided some support for making a distinction between Oppositional Defiant and Conduct Disorder, it is interesting to note that

– over half of children with ODD appear to meet criteria for a diagnosis of CD,

– almost half of children with CD also meet criteria for a diagnosis of ODD.

The Course of Disruptive Behavior Disorders

• Conduct disorders are usually not diagnosed prior to school entry

• However, non-compliance, defiance and other symptoms of ODD may begin during the preschool years.

• These less severe disruptive behavior disorder features are can be the precursors of full blown conduct disorder symptoms - although most with ODD do not progress to CD (Moffitt, 2007).

• The suggested sequence of progression in children who develop early symptoms and go on to develop more serious disruptive behavior disorders is suggested by cross-sectional research conducted by Achenbach and Edelbrock.


• These investigators studied 2,600 children age 4 and 16 whose mothers provided data (Child Behavior Checklist: CBCL) on conduct disordered behavior displayed at different ages.

• The youngest children tended to display characteristics such as a tendency to argue, stubbornness and temper tantrums - followed by other oppositional behaviors.

• At later ages there was an increase in behaviors such as stealing and fire setting.

• These were followed by other serious conduct disordered behaviors such as truancy, vandalism, and involvement in substance abuse.


• This type of developmental progression is consistent with that often seen when working with older conduct disordered children and adolescents.

• It fits with the generally accepted view that oppositional defiant behavior often (but not always) precedes the development of more serious conduct disordered behavior.

Relationship of ODD to CD

• Some research findings suggest the risk of CD is four times higher in children with ODD than in children without prior ODD (Cohen & Flory, 1998).

• It’s unclear, however, if ODD represents as much of a stepping stone to CD for girls, as late onset of CD is more common females.

• It’s deems likely that many girls with a late onset do not have a history of ODD

• For girls there may be an alternate pathway to the development of Conduct Disorder.

Prognosis:Who is at greatest risk?

• Not all children with early disruptive behavior problems, like ODD, develop more serious conduct disorders.

• Some do not develop more serious antisocial behavior.

• The poorest outcome are for children who show high levels of conduct disordered behavior at an early age.

• This type of information highlights the importance of secondary prevention efforts (e.g., PCIT)

Prognosis of Conduct Disorder

• Robins, et al. (1991) found that 71% of children who displayed severe conduct disorder (eight or more symptoms) at age 6 showed evidence of antisocial personality disorder in adulthood.

• 53 % of children whose symptoms began between the ages of 6 and 12 displayed antisocial personality disorder in adulthood.

• 48 % of those who developed symptoms after age 12 showed evidence of this disorder as adults.

What is Antisocial Personality Disorder?

• “Pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.”

• For diagnosis, must have a history of some Conduct Disorder symptoms before age 15.

• Not actually diagnosed prior to age 18.

What is Antisocial Personality Disorder?

• Three or more of the following:– Failure to conform to social norms (behaviors warranting

arrest)

– Deceitfulness (lying, conning, deceit)

– Impulsivity

– Irritability and aggressiveness

– Reckless disregard for safety of others or self

– Consistent irresponsibility

– Lack of remorse (indifference or rationalization)

Prognosis of Conduct Disorder

• In general, the literature suggests that– children who develop conduct disordered behavior later in childhood have a somewhat better prognosis.

– the severity and variety of early antisocial behavior is a powerful predictor of serious antisocial behavior in adulthood.

– the prognosis may be worse for those who also have comorbid disorders.

Etiological Factors in Childhood Conduct Disorder

• While the etiology of Conduct disorder is not fully understood it has been shown to be related to a range of psychosocial factors including;– living in environments with high crime rates.– marital conflict & broken homes, – dysfunctional and rejecting family environments,

– inconsistent and severe discipline, – Physical and sexual abuse– social learning experiences (e.g., the learning of problem behavior through observation and/or its reinforcement by parents, siblings and others).

Coercive Family Behavior and Conduct Problems

• Conduct problems can evolve from ongoing patterns of coercive parent-child interactions that are characterized by;

– Escalating parent and child demands,

– Escalating negative consequences

– Where the person who dispenses the most negative consequence “wins”.

– Problems with “winning the battle” while “losing the war”.

Biological Factors in Childhood Conduct Disorder

• Genetics:– Some support for a genetic contribution to aggression

and the development of disruptive behavior disorders.– Difficult to disentangle the genetics from

environmental factors.• Frontal Lobe Involvement:

– Frontal lobe damage associated with aggression– Decreased glucose metabolism in frontal lobes

associated with violent behavior (lower levels of activation).

• Neurotransmitters:– High levels of blood serotonin related to aggression

in adolescence– As serotonin is related to mood regulation the link

with aggression may have to do with its impact on executive functions and behavioral dysregulation.


• Underarousal of the Autonomic Nervous System– Individuals with conduct disorders often display general

physiological underarousal (e.g., lower heart rate).– Low heart rate is associated with adolescent antisocial behavior.– Lower skin conductance associated with disruptive behavior in

males.

• Prenatal and Perinatal Problems– Maternal smoking predicts CD in boys, including early onset .– A range of pregnancy and birth complications have also been

shown to be related to behavior problems.


• Neurotoxins– High lead levels in children are related to higher parent/teacher ratings

of aggressiveness and higher delinquency scores on teacher rating scales.

• Child Temperament– Difficult child temperament may contribute to maladaptive parenting

which may facilitate the progression from simple behavior problems to CD

– Early temperament (negative mood, intense responding, inflexibility) has been found to be predictive of externalizing problems in childhood

– Inhibited temperament is associated with fewer externalizing problems.

Etiological Factors in Childhood Conduct Disorder

• While a range of factors has been implicated in the development of conduct disorders, no one factor has been determined to be “the cause”.

• Each of the factors listed here may contribute to conduct disordered and delinquent behavior in some instances.

• It’s likely that there are numerous possible combinations of contributing variables that can result in the clinical manifestations of these disorders.

Treatment of Oppositional Defiant and Conduct Disorders

• Although both insight‑oriented and client‑centered approaches have been employed with conduct disordered children, the current most popular approach is behavioral in nature.

• The work of Patterson and colleagues is most representative of this basic approach.

• The approach involves training parents to pinpoint problem behaviors (e.g. aggressive responses, noncompliant responses) as well as more appropriate modes of responding, & to utilize various child behavior management techniques to decrease problem behavior and increase desirable behavior


• Included among these behavioral procedures is– the reinforcement of appropriate behaviors,– the use of extinction (withdrawal of reinforcement)

and/or– time out procedures for dealing with undesirable

behavior– the reinforcement for incompatible behavior

• School personnel may be involved in order to deal with the child's behavior in that setting as well (School/Home Behavior Report Card).

• This multifaceted approach has been shown to be highly effective in treating a range of conduct problems.

• This approach is considered an Empirically-Supported/Well Established treatment for conduct problems (Eyberg, Nelson and Boggs, 2008).


• Other psychosocial approaches have been used to deal with specific behaviors (or classes of behaviors) displayed by behavior disordered children.

• Indeed, Eyberg, Nelson, and Boggs (2008) have highlighted 16 evidence based psychosocial treatment, 15 of which were designated probably efficacious.

• Examples involves group videotaped parent and child training approachs (Incredible Years Parent and Child Training) by Webster-Stratton and Reid (2003), developed at the University of Washington and the work of Forehand & McMahon (1981) with non-compliant children at Georgia.

• Of special note is the work of Eyberg and Boggs with Parent-Child Interaction Therapy, that is designed to modify oppositional/defiant behavior and the aggressiveness sometimes seen in ODD children.


• Kazdin (1993) has also developed another more cognitively oriented approach, Problem-Solving Skills Training, also appears to hold promise.

• This approach focuses on the modification of cognitions such as attributions of hostile intent, which may precipitate aggressive behavior, and maladaptive self-statements which may mediate other expressions of antisocial behavior.

• An additional focus is on helping the child learn and use effective problem solving skills in dealing with problematic interpersonal situations he/she may encounter.


• While such cognitive-behavioral procedures have been shown to be somewhat effective in dealing with older conduct disordered children, questions still remain regarding the clinical significance of observed treatment effects and the precise nature of those variables that contribute to effectiveness.

Brief Commentary on Juvenile Delinquency

• Some children not only show oppositional defiant behavior and features of conduct disorder – they also come into conflict with the juvenile justice system.

• The term “delinquency” may be applicable to such children and adolescents.

Delinquency: A Definition

• Delinquency is a legal term rather than a psychological construct.

• It refers to a juvenile (usually under 18 years) who is brought to the attention of the juvenile justice system for committing a criminal act or displaying a variety of other behaviors not specified under criminal law.

• These "other behaviors", are usually referred to as status offenses.

• They include truancy, curfew violations, running away from home and the use of alcohol.

• These are only violations of the law as a result of the child's age and his/her status as a minor.

Delinquency and Conduct Disorders

• Considered within the context of DSM IV, the concept of delinquency overlaps with the broader spectrum of conduct disorders. – While many delinquents do meet criteria for a diagnosis of

conduct disorder– Many youths who come into contact with the juvenile

justice system do not show the pattern of seriously antisocial behavior associated with the diagnosis of conduct disorder.

– Likewise, many conduct disordered youth are never considered delinquent as their illegal behaviors escape detection.

The Classification of Delinquency

• Given that juvenile delinquency is essentially a “legal” category used to designate those who have committed any of numerous offenses, one might expect delinquents to represent a very heterogeneous group.

• In spite of this, research studies have often focused on the causes, correlates, and treatment of delinquency without taking this variability into account.

• This tendency to treat delinquency as a unitary construct has often led to unreplicated findings and inconclusive results.

Assessing Dimensions of Delinquency

• As a result of the observed variability within this group, some researchers have considered the possibility that various dimensions of delinquency may exist and have attempted to assess and study correlates of these dimensions.

• Most prominent in this regard is the work of Herbert Quay (1964; 1987b), who is generally credited with developing the most widely cited, empirically based, classification scheme for delineating dimensions of delinquent behavior .

Empirically Dimensions of Delinquency

• In this early research, factor analyses of ratings of behavioral traits obtained from the case histories of institutionalized male delinquents yielded four independent groupings: – socialized-subcultural delinquency,

– unsocialized-psychopathic delinquency,

– disturbed-neurotic delinquency, and

– inadequate-immature delinquency

Dimensions of Delinquency: Characteristics

• Socialized-subcultural - Delinquents who scored high on the socialized-subcultural dimensions were defined by such traits as having strong allegiance to selected peers, being accepted by delinquent subgroup, having bad companions, staying out late at night, and having low ratings on shyness and seclusiveness.


• Unsocialized-psychopathic – These delinquents, in contrast, were described as solitary rather than group-oriented delinquents who were rated high on such traits as inability to profit from praise or punishment, defiance of authority, quarrelsomeness, irritability, verbal aggression, impudence, and assaultiveness.


• Disturbed-neurotic - These delinquents were described as unhappy, shy, timid and withdrawn, and prone to anxiety, worry, and guilt over their behavior.


• Inadequate – Immature - Quay (1987b) characterized this fourth group of youngsters as being relatively inadequate in their functioning and often unable to cope with environmental demands because of a poorly developed behavioral repertoire.

• Not usually accepted by delinquent peers, passive and preoccupied, picked on by others, and easily frustrated.

Dimensions of Delinquency

• Although, often given different labels by various researchers, these four dimensions have been replicated in a number of more recent factor analytic studies of delinquent behavior, using various measures, with data obtained obtained in various ways, and with both males and females.

• While there have been some studies that have documented significant differences between these groups there is still too little research that considers the variability in the delinquent population.

Treatment of Delinquents

• Treatment of children and adolescents who have become involved in actual delinquent activities has frequently been carried out in institutions or within community based programs.

• Research suggests that treatment within the context of standard institutional programs is often unsuccessful, with as many as 70 to 80 per‑cent being rearrested within a year or so after release.

• Despite these discouraging results, there are data to suggest that the inclusion of well‑conceived behaviorally‑based programs within this setting can result in positive outcomes.

Institutionally Based Treatments

• Illustrative of such an approach is the Cascadia Project, conducted in Tacoma, Washington by Irwin Sarason and his colleagues at the University of Washington.

• In this “skills based” program residents were provided with modeling and role‑play/discussion experiences where they were taught a variety of adaptive skills which were thought to decrease the likelihood of future delinquent behaviors.

• Among these were learning how to resist temptation from peers, to delay gratification, to apply for a job, how to behave appropriately when stopped by police, and so forth.

Institutionally Based Treatments

• Not only did those in treatment show gains at post treatment but, at five year follow up, recidivism rates for treated subjects was less than half that of residents who did not receive treatment.

• These findings suggest that skills‑based treatments that are designed to provide skills that promote a pro-social lifestyle may be of value in decreasing the likelihood of future delinquency.

• Despite the positive findings, since some residents showed evidence of later delinquency.

• It would seem desirable that such programs provide booster-sessions after release so as to maximize the durability of skills.

Community Based Treatments

• An good example of community, rather that institutionally, based program is the Teaching Family Model (Achievement Place) which was developed at the University of Kansas.

• Residents in this program live in a home‑like setting with up to seven or eight other residents and two house parents who are trained in behavior management skills.

Community Based Treatment: Family Teaching Model

• Residents attend school and have a variety of work responsibilities.

• An extensive token economy program serves as the basic focus of treatment.– Here, residents are rewarded for engaging in appropriate behaviors (e.g., completing homework assignments, increased academic performance, improving conversational skills with adults, modifying aggressive statements, improving problem solving skills with parents)

– Or fined for showing inappropriate behaviors.

Community Based Treatment: Family Teaching Model

• Reinforcement is with points which can be cashed in for a wide variety of back‑up reinforcers (e.g., allowance, snacks, TV viewing.

• The overall focus is on using the token economy to increase non‑delinquent modes of responding.

• Attention is given to insuring that behaviors generalize to the general environment so that they will be maintained after release from the program.

• A number of controlled studies have provided support for the general effectiveness of this program, although research has frequently questioned the durability of treatment effects once residents leave the program.

Multisystemic Treatment

• Another non-institutional approach to treatment is Multisystemic Therapy (MST), which is designed to address the role of multiple, interconnected systems in which the adolescent is embedded (Henggeler & Lee 2003).

• This approach recognizes– the effects of family, school, work, peer, community and

cultural institutions on the adolescents functioning and in the initiation and maintenance of delinquent behavior

– and seeks to intervene therapeutically on multiple levels, as needed.

Multisystemic Therapy

• The length of MST is between 13 and 17 sessions. • It is based on family-systems and social-ecological models of

behavior• Therapists employ empirically based treatment procedures to

tailor interventions to the needs and strengths of each family member (a good example of flexibility of manualized treatment efforts.

• Although specific therapeutic techniques are flexible, therapists abide by a number of clearly defuned treatment principles, such as “Focus on systemic strengths, and “Interventions should be developmentally appropriate, etc.


• In contrast to many past intervention approaches in which treatment gains have not held at follow-up, MST has been shown to result in long-term reduction in delinquent activity.

• For example, in a longitudinal investigation of treatment efficacy with chronic juvenile offenders, MST improved family cohesion, reduced the number of incarcerations at a 59-week follow-up, and significantly reduced peer-related aggression.

• Re-arrest rates were also reduced at a 2.4 year follow-up.


• In another study, MST was found to reduce violent and criminal activity at a 4-year follow-up ,

• Other promising aspects of this treatment include its documented efficacy with ethnic minority populations, and its cost-effectiveness in comparison to incarceration.

• This, family-and home-based treatment for serious juvenile offenders, appears to be one of the most promising, empirically supported treatment approaches for this extremely hard to treat population.

• This approach has been designated a probably efficacious treatment by Eyberg, Nelson, and Boggs (2008).

MST Brief Overview

Group Based Treatments of Delinquency

• Still other community‑based programs have also been used.

• These have usually involved the use of group treatment approaches in modifying delinquent behaviors (e.g., Reality Therapy, Guided Group Interaction).

• Less research related to these program has been done and their effectiveness is less well documented.

That’s all Folks!

oppositional defiant and conduct disorder james h. johnson, ph.d. university of florida © james h....

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