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

IDENTIFY CHILDREN AT RISKIDENTIFY CHILDREN AT RISK

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

TREATMENT AND PROGNOSISTREATMENT AND PROGNOSIS