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CONDUCT DISORDERCONDUCT DISORDER
Jeanette E. Cueva, M.D.Jeanette E. Cueva, M.D.Associate Clinical Professor of Psychiatry, Columbia Associate Clinical Professor of Psychiatry, Columbia
University College of Physicians and Surgeons; University College of Physicians and Surgeons; Adjunct Associate Professor of Clinical Psychiatry, Adjunct Associate Professor of Clinical Psychiatry,
New York Medical CollegeNew York Medical College
Normal Behavior (1)Normal Behavior (1)((McFarland et. Al., 1970)McFarland et. Al., 1970)
• Longitudinal study: ages < 2 yo – 14 yoLongitudinal study: ages < 2 yo – 14 yo• lying at 6 yo: lying at 6 yo:
• boys 53%; girls 48%boys 53%; girls 48%
• lying at 11 yo:lying at 11 yo:• boys 10%; girls 0%boys 10%; girls 0%
Normal Behavior (2)Normal Behavior (2)(Achenbach and Edelbrock, 1981)(Achenbach and Edelbrock, 1981)
Cross-sectional StudyCross-sectional Studyage: 4 yo- 16 yoage: 4 yo- 16 yodisobedience, destruction of own property:disobedience, destruction of own property:
50% and 26% at 4-5 yo50% and 26% at 4-5 yo20% and 0% at 16 yo20% and 0% at 16 yo
Normal Behavior (3)Normal Behavior (3)
Antisocial behaviors are frequent at Antisocial behaviors are frequent at different points in normal development different points in normal development (toddler age; adolescence)(toddler age; adolescence)
These behaviors These behaviors declinedecline over time over timeStabilityStability of these behaviors over time = of these behaviors over time =
clinically significant departure from the clinically significant departure from the normal patternnormal pattern
HUMAN AGGRESSIONHUMAN AGGRESSION
Behaviors by one person intended to Behaviors by one person intended to cause physical pain, damage or cause physical pain, damage or destruction to othersdestruction to others
Aggression in Animals Aggression in Animals (Moyer, 1971)(Moyer, 1971)
PredatoryPredatory
Intramale Intramale
Fear inducedFear induced
Irritable Irritable
TerritorialTerritorial
MaternalMaternal
InstrumentalInstrumental
Aggression SubtypesAggression Subtypes (Flynn et. al., 1970)(Flynn et. al., 1970)
Predatory/covert: instrumentalPredatory/covert: instrumental
Affective/overt: intermale, fear Affective/overt: intermale, fear induced, irritable, territorial, maternalinduced, irritable, territorial, maternal
Overt AggressionOvert Aggression
Overt/Affective: high autonomic arousalOvert/Affective: high autonomic arousalPiloerectionPiloerectionPupillary dilationPupillary dilationThreatening behaviorsThreatening behaviors Increase BPIncrease BP
Covert AggressionCovert Aggression
Covert/Predatory: Low autonomic arousalCovert/Predatory: Low autonomic arousalNot associated with intense increase in BPNot associated with intense increase in BP
e.g. Animals silently stalking preye.g. Animals silently stalking prey
CONDUCT DISORDERCONDUCT DISORDER
RULE BREAKING AND ILLEGAL RULE BREAKING AND ILLEGAL ACTIVITYACTIVITY
VIOLATION OF BASIC RIGHTS OF VIOLATION OF BASIC RIGHTS OF OTHERSOTHERS
PRE- REQUISITE FOR ANTISOCIAL PRE- REQUISITE FOR ANTISOCIAL PERSONALITY DISORDERPERSONALITY DISORDER
Areas to ConsiderAreas to Consider
Pattern Pattern of antisocial behaviorsof antisocial behaviorsDegree Degree of impairmentof impairmentDegreeDegree ofof unmanageabilityunmanageability
Prevalence and EpidemiologyPrevalence and Epidemiology
ICD-9: (Esser et. al., 1990) prevalence of ICD-9: (Esser et. al., 1990) prevalence of less than 1% in a study of 8 y.o. in less than 1% in a study of 8 y.o. in GermanyGermany
DSM III: (Kashani et. al.,1987) prevalence DSM III: (Kashani et. al.,1987) prevalence of 8.7% in a group of teenagersof 8.7% in a group of teenagers
DSM IV: prevalence of 4-6% overall; 6-DSM IV: prevalence of 4-6% overall; 6-10% in males and 2-9% in females 10% in males and 2-9% in females
Up to 75% of clinic referralsUp to 75% of clinic referrals
DSM IV CRITERIA (1994)DSM IV CRITERIA (1994)
Aggression to people and animalsAggression to people and animalsDestruction of propertyDestruction of propertyDeceitfulness or theftDeceitfulness or theftSerious violation of rulesSerious violation of rules
RISK FACTORSRISK FACTORS
CHILD FACTORS: temperament, CHILD FACTORS: temperament, neuropsychological functioning, neuropsychological functioning, academic/intellectual performanceacademic/intellectual performance
PARENTAL FACTORS: pathology and PARENTAL FACTORS: pathology and criminal behavior, harsh disciplinary criminal behavior, harsh disciplinary practices, marital discordpractices, marital discord
SCHOOL RELATED: setting, low teacher SCHOOL RELATED: setting, low teacher student ratio etc.student ratio etc.
ETIOLOGYETIOLOGY
Biological: no clear genetic factorsBiological: no clear genetic factorsPsycho physiological: low autonomic Psycho physiological: low autonomic
arousal; stimulation seekersarousal; stimulation seekersLearning: aggression is reinforced, Learning: aggression is reinforced,
modelingmodeling
Kohlberg’s Moral Development Kohlberg’s Moral Development
PREMORAL LEVEL;PREMORAL LEVEL;STAGE 1: FEAR OF PUNISHMENTSTAGE 1: FEAR OF PUNISHMENT
STAGE 2: SATISFYING SELF-INTEREST STAGE 2: SATISFYING SELF-INTEREST REQUISITE FOR ANTISOCIAL REQUISITE FOR ANTISOCIAL PERSONALITYPERSONALITY
• UP TO APPROXIMATELY 14 YOUP TO APPROXIMATELY 14 YO
KOHLBERG’S MORAL KOHLBERG’S MORAL DEVELOPMENTDEVELOPMENT
• CONVENTIONALCONVENTIONAL LEVEL LEVEL
• Stage 3: Conforming to values of significant othersStage 3: Conforming to values of significant others
• Stage 4: Conforming to social order and its Stage 4: Conforming to social order and its maintenance for its own sakemaintenance for its own sake
• Up to about 20 y.oUp to about 20 y.o..
Kohlberg’s Moral DevelopmentKohlberg’s Moral Development
SELF ACCEPTED LEVELSELF ACCEPTED LEVELSTAGE 5: balance between human rights and STAGE 5: balance between human rights and
lawslawsSTAGE 6: recognition of valid universal STAGE 6: recognition of valid universal
ethical principals to which a person can ethical principals to which a person can choose to commit himself or herself tochoose to commit himself or herself to
From age 20 and upwardFrom age 20 and upward
Diagnostic EvaluationDiagnostic Evaluation
Clinical InterviewClinical InterviewFamily and developmental histories Family and developmental histories
(exposure to drugs in utero)(exposure to drugs in utero)History of physical or sexual abuseHistory of physical or sexual abuseCollateral information: include school Collateral information: include school
functioning functioning Rating Scales: CBCL, K-SADS, OASRating Scales: CBCL, K-SADS, OAS
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
ADHDADHDBIPOLAR DISORDERBIPOLAR DISORDERMAJOR DEPRESSIONMAJOR DEPRESSIONPSYCHOTIC DISORDERSPSYCHOTIC DISORDERS
TREATMENTTREATMENT
Individual PsychotherapyIndividual PsychotherapyGroup TherapyGroup TherapyBehavior TherapyBehavior TherapyProblem-solving Skills TherapyProblem-solving Skills TherapyRTCRTCFamily TherapyFamily TherapyParent Management TrainingParent Management TrainingPharmacothrepyPharmacothrepy
PHARMACOTHERAPYPHARMACOTHERAPY
LITHIUM: anti aggressive propertiesLITHIUM: anti aggressive propertiesCBZCBZBeta-blockersBeta-blockersNeurolepticsNeuroleptics
MEDICATION ALONE MEDICATION ALONE NOT NOT SUFFICIENT SUFFICIENT
COMBINATION OF COMBINATION OF INTERVENTIONSINTERVENTIONS
INCLUDE INDIVIDUAL, FAMILY AND INCLUDE INDIVIDUAL, FAMILY AND COMMUNITYH BASED TREATMENTSCOMMUNITYH BASED TREATMENTS
MEDICATION SOMETIMES HELPFUL IN MEDICATION SOMETIMES HELPFUL IN PARTICULAR FOR YOUTHS WITH PARTICULAR FOR YOUTHS WITH OVERT AGGRESSIONOVERT AGGRESSION
TREATMENT NEEDS TO BE TREATMENT NEEDS TO BE LONG-LONG-TERMTERM
““BIG BROTHER” OR “BIG SISTER” BIG BROTHER” OR “BIG SISTER” FOUND TO BE VERY HELPFULFOUND TO BE VERY HELPFUL
COMMUNITY BASED COMMUNITY BASED TREATMENTTREATMENT
““PROBLEM” YOUTH INTEGRATED WITH PROBLEM” YOUTH INTEGRATED WITH PROSICIAL PEERSPROSICIAL PEERS
PROMOTES GROUP INFLUENCES PROMOTES GROUP INFLUENCES FROM PROSOCIAL PEERSFROM PROSOCIAL PEERS
DECREASES STIGMATIZATIONDECREASES STIGMATIZATIONCAN BE DONE AT A LARGE SCALECAN BE DONE AT A LARGE SCALE
PROGNOSISPROGNOSIS
DEPENDS ON MANY FACTORS DEPENDS ON MANY FACTORS HOWEVER CURRENTLY GUARDED OR HOWEVER CURRENTLY GUARDED OR POORPOOR
““Kevin”Kevin”
Cc Cc :Evaluated at 10 yo due to “poor :Evaluated at 10 yo due to “poor progress at his current school setting”progress at his current school setting”
H/o maladaptive and aggressive behaviors H/o maladaptive and aggressive behaviors since toddlerhoodsince toddlerhood
H/o of special education placement since H/o of special education placement since 22ndnd grade due to LD (MIS IV); average grade due to LD (MIS IV); average cognitive functioningcognitive functioning
Currently in an “emotionally disturbed” Currently in an “emotionally disturbed” class setting (SIE VII) since 4class setting (SIE VII) since 4thth grade grade
““Kevin”Kevin”
Developmental History: exposed to crack Developmental History: exposed to crack in utero and born addictedin utero and born addicted
Milestones were normalMilestones were normalAdopted by foster family at 1 yo but has Adopted by foster family at 1 yo but has
contact with biological mothercontact with biological motherAdoptive family (consists of mother and Adoptive family (consists of mother and
two older adoptive sibs) overwhelmed: two older adoptive sibs) overwhelmed: have 6 children under 19 yo overallhave 6 children under 19 yo overall
Poor supervisionPoor supervision
““Kevin”Kevin”
Throws rocks from roof with and without Throws rocks from roof with and without other peersother peers
StealsStealsStays out late (until up to 11 pm or later)Stays out late (until up to 11 pm or later)Friends with older peers (16 yo and 18 yo) Friends with older peers (16 yo and 18 yo)
who are themselves delinquentwho are themselves delinquentSuspected of smoking MJ and dealind in Suspected of smoking MJ and dealind in
drugs drugs