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					Disruptive Behavior
  MAJ Suzin Whitten, MD
USAHC Baumholder, Germany
      15 FEB 2007
    Disruptive Behavior Disorders
   What is Normal Behavior?
   What Impacts the Development of Normal
   What is Temperament?
   Aggression and Stress
   Age Related Behavior Issues
   Oppositional Defiant Disorder
   Conduct Disorder
   When to Refer
             The Problem

 Psychosocialproblems in children and
 adolescents are on the RISE in Western

 Improved economic conditions and
 physical health
               The Problem
 Increasing   number of office visits

 Spansthe biological, psychosocial, social

 Numerous systems involved (medical,
 educational, legal)
    What is Normal Behavior?
 Society    defines what is pathological

 Social    rules are learned

        to incorporate social rules
 Ability
  developmentally over time
   What is Normal Behavior?
 DSM-IV-TR provides criteria to make
 diagnoses related to maladaptive behavior

 Considerthe influence of environment on
 behavior and behavior on environment

 Understand the social context of the
 aggressive behavior
What Impacts the Development of
       Normal Behavior?
   Homeostasis and adaptation

   Attachment and individuation

   Mastery and achievement

   Environmental supports and adversities

   Constitution and context
         What is Temperament?
   Set of individual predispositions

   Underlie and modulate expression of activity,
    emotionality, and sociability

   Reflection of baseline autonomic nervous
    system reactivity

   Threshold, dampening, reactivation
           Why Does it Matter?
 Impacts    development and behavior

 Impacts    mental and physical health

 Is   there a good fit?
 Stable   over time and may not “grow out”

 Earlyintervention is indicated for
 persistent aggressive behavior

 Bothgenetic factors and child rearing
 practices contribute
   Boys > girls

   Family unemployment, discord, criminality,
    psychiatric disorders and birth to teenage or
    unmarried mothers

   Exposure to aggressive models on TV, in play,
    in life
   Consider comorbid conditions
   This is Your Brain on Stress

 Corticotropin   releasing hormone system

 Locus    ceruleus norepinephrine system

 Limbic   system
         This is Your Brain on Stress
                                               Limbic system

        CRH                           Emotional Pain

                              Locus Ceruleus
Pituitary Gland
   ACTH and B endorphins

                                                      Increase BP and HR
 Adrenal Gland


      Increased glucose metabolism
           The Link to Behavior
   Reduction of autonomic responsiveness

   Lower pulse rate and skin conductance in
    presence of arousing stimuli

   Adaptive response to continual insults when
    exposed to stress at an early age

   Lower cortisol levels, NT dysfunction
     Behavior Issues: 2-4 yrs
 Need   for autonomy v dependence on
  parents, frustration and anger
 Lying, impulsiveness, breath holding,
  defiance, and temper tantrums
 Parental response is very important
 50% of preschoolers are brought to the
  attention of physicians for destructive and
  disobedient behaviors
  Behavior Issues: School Age
 School   achievement and acceptance by
 Lying and fantasy v lying and avoidance
 Aggressive play and fighting
 Stealing as impulsive, expression of anger
  and frustration, may be learned
 Truancy, running away, and unsupervised
  fire starting are never developmentally
    Behavior Issues: Adolescence
   Progressive individuation and separation from
    the family
   Importance of peer relationships
   Intense emotions and wide swings in mood are
   Abstraction, new mental power, omnipotence
   Rigid concepts of right and wrong, idealism
   Sexual activity (41% by 10th grade, 61% by 12th)
 Disruptive Behavior Disorders

 Oppositional   Defiant Disorder

 Conduct   Disorder

 Disruptive   Behavior Disorder NOS
       Assessment: History
 Several   sources (parent, patient, teacher)
 Abuse
 Trauma
 Substance   abuse
 Specific examples of problem behaviors
 Acute illness
 Chronicity
       Assessment: Physical
 Completeneurological exam and detailed
 age appropriate mental status exam

 Nospecific laboratory tests or radiological

 Consider   psychological testing
              “He’s ODD?”
9  y/o male with Type I DM and ADHD
  going “nuts” in the clinic
 “Uncontrollable”
 Wielded knife in kitchen, tried to hit Mom
 Cursing and yelling
 Not going to school and failing all classes
 Father is deployed
  Oppositional Defiant Disorder
   A pattern of negativistic, hostile, and defiant behavior
   lasting at least 6 mos, during which 4 or more of the
   following are present:
1) often loses temper
2) often argues with adults
3) often actively defies or refuses to comply with adults’
   requests or rules
4) often deliberately annoys people
5) often blames others for his/her mistakes
6) often touchy or easily annoyed by others
7) often angry or resentful
8) often spiteful or vindictive          DSM IV TR, 2000
  Oppositional Defiant Disorder
2  to 16 %
 Boys before puberty, equal after puberty
 NET age 3, evident before age 8, NLT
  than 11
 Gradual onset, emerge in home setting
 May be the antecedent to Conduct
  Disorder but usually does not persist after
              ODD: DDx
 Conduct  Disorder
 Mood Disorder
 Psychotic Disorder
 ADHD (may be co-occur)
 Mental Retardation
 Learning Disorder
 Normal individuation of adolescence
            Treatment: ODD
 Parent   training to manage child behavior

      individual therapy to develop efficient
 Child
 anger management, decrease negativity,
 and improve social skills

 Family   therapy to improve communication
  Parent Behavior from AACAP
 Build on positives, give praise and
  reinforcement when child shows flexibility
  and cooperation
 Demo desired role model behavior by
  taking a time out when upset
 Pick battles and set priorities for what they
  want to do to minimize power struggles
 Parent Behavior from AACAP
 Establish  reasonable, age appropriate
  limits with consequences that are
  consistently enforced
 Maintain other interests
 Work with and obtain support from other
  adults who interact with child
 Manage own stress and use respite care
  when needed
        Conduct Disorder
A repetitive and persistent pattern of
behavior in which the basic rights of others
or major age appropriate societal norms or
rules are violated, as manifested by the
presence of 3 or more of the following
criteria for the past 12 mos with one
criterion present in the past 6 mos:
                    DSM IV TR, 2000
         Conduct Disorder
 15criterion that are broken down into 4

1) Aggression to people and animals
2) Destruction of Property
3) Deceitfulness or Theft
4) Serious Violation of Rules
                             DSM IV TR, 2000
Conduct Disorder: Childhood Onset
 Age < 10
 Male > female
 Frequently display physical aggression
 Have disturbed peer relationships
 ODD during early childhood
 Concurrent ADHD is common
 Greater risk for Antisocial Personality D/O
Conduct Disorder: Adolescent Type
   Age > 10

   Less likely to display physical aggression

   More normative peer relationships

   Less likely to persist beyond adolescence

   Less likely to develop ASPD
             Conduct Disorder
   More common in urban settings

   6-16% males, 2 to 9 % females

   More likely to die from homicide, suicide, violent
    accident, drug overdose

   Associated with lower than average intelligence,
    particularly verbal IQ
  Conduct Disorder: Comorbid
 ADHD   is common (30 - 50%)
 Learning disorders (10 – 90%)
 Anxiety d/o (15 - 24%)
 Depressive d/o (15 - 24%)
 Substance Related d/o (? >80%)
 25 to 40% of kids with CD go on to
  develop ASPD
        Conduct Disorder: DDx
   ODD                      Psychotic d/o
   ADHD                     Head Trauma
   Mood d/o (Bipolar)       Seizure Disorder
   Adjustment d/o           Birth Injury to the
   Child or Adolescent       Brain
    Antisocial Behavior      Encephalitis
   Mental Retardation
Conduct Disorder: Risk Factors
 Parental    rejection and neglect

 Difficult   infant temperament

 Inconsistent child rearing practices with
  harsh discipline

 Physical    or sexual abuse
Conduct Disorder: Risk Factors
   Lack of supervision

   Early institutional living

   Frequent change of caregiver

   Large family size

   History of maternal smoking during pregnancy
Conduct Disorder: Risk Factors
 Peer   rejection

 Association   with delinquent peer group

 Neighborhood       exposure to violence

        psychopathology (ASPD,
 Familial
 substance dependence)
             Treatment: CD
 Parent   management training

 SocialCognitive and problem solving skills

 Peer   and school based interventions

 Community    intervention strategies
                Treatment: CD
 Treatment     of comorbid disorders

 Individual,   psychodynamic therapy not

 Early   intervention > later intervention
             “Is he ODD?”
9  y/o male with Type I DM and ADHD
  going “nuts” in the clinic
 “Uncontrollable”
 Wielded knife in kitchen, hit Mom
 Cursing and yelling
 Not going to school and failing all classes
 Father is deployed
    Role of Pharmacotherapy

 Not   yet clearly defined

 Referral   to initiate pharmacotherapy

 Treatment    of concurrent disorders
                When to Refer
 Harm   to self or others

 Rapidly    escalating in severity

 Ineffective   interventions

 Multiple   domains of pathology
 A few words parting words about
 Most  commonly diagnosed behavioral
  disorder of childhood
 Inattention persists
 Consider COMORBID conditions!!!
 33% with ODD, 35% with CD, <20% with
  depressive d/o, 25% anxiety d/o, 12%
  learning d/o
    Resources for Parent/Clinician
 Taking Charge of ADHD: The Complete, Authoritative
  Guide for Parents by Russell A. Barkley
 Your Defiant Child: Eight Steps to Better Behavior by
  Russell A. Barkley
 1-2-3 Magic: Effective Discipline for Children 2-12 by
  Thomas W. Phelan
 Your Adolescent by AACAP edited by Dr. David B. Pruitt
 Your Child by AACAP edited by Dr. David B. Pruitt
 The Explosive Child by Ross W. Greene, Ph.D.
 Defiant Children, 2nd Ed: A Clinician’s Manual for
  Assessment and Parent Training by Russell A. Barkley
 Attention-Deficit Hyperactivity Disorder, 3rd Ed: A Clinical
  Workbook by Russell A. Barkley and Kevin R. Murphy

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