Disruptive Behavior Disorders Creating an understanding for elementary

Disruptive Behavior Disorders Creating an understanding for elementary and middle school teachers by piecing together the puzzle of disruptive behavior disorders. Amelia Weishaar

Learner Objectives Participants in this seminar will be able to: • Identify symptoms and characteristics of disruptive behavior disorders (DBDs) • Recognize the potential causes of DBDs • Describe risk and protective factors for DBDs.

Identification and Characteristics of Disruptive Behavior Disorders “DBDs are the most common mental health disorder among children with a rate of 4 -9% of all children from birth to 18 years old. ” 1 (Journal of the American Academy of Child & Adolescent Psychiatry, Official Action, Jan 2007)

What is a Disruptive Behavior Disorder? The main category in the DSM-IV-TR that Disruptive Behavior Disorders fall into is: Attention-Deficit Disorder and Disruptive Behavior Disorders Disruptive Behavior disorders are split into three more specific diagnoses: • Oppositional Defiant Disorder • Conduct Disorder • Disruptive Behavior Disorder (NOS)

Oppositional Defiant Disorder (ODD) 2 DSM-IV-TR Definition “A pattern of negativistic, hostile, disobedient and defiant behaviors. Children display four or more of these behaviors for more than 6 months • • Loses Temper Easily Argues with Adults Actively Defies Adults Requests or Rules Deliberately Tries to Annoy Others Blame others for their own misbehavior and mistakes Seems touchy or is annoyed easily Angry and resentful Spiteful or Vindictive”

Oppositional Defiant Disorder • Average of onset is 6 years old, symptoms can be seen in children as early as 3 years old 3 • Symptoms usually manifests by 8 years old, with most children diagnosed during preadolesence 1 • Children with ODD have a significantly higher rate of having more that one psychiatric disorder 4 • Most children, 67%, will ultimately exit from the diagnosis after a 3 -year follow-up 5 • Early onset of ODD is more likely to persist and lead to subsequent development of CD 6

Conduct Disorder (CD) 1 DSM-IV-TR Definition “Repetitive and persistent pattern of behaviors in which the basic rights of others or rules of society are violated. Three or more of the following behavior will have occurred within the last 12 months. • Aggression Toward People and Animals • Destruction of Property • Deceitfulness or Theft • Serious Violation of the Rules”

Conduct Disorder Childhood-onset vs. Adolesent-onset 7 Childhood-onset – - Average is 9 years old - Males more likely to be affected - Prognosis is poor as the earlier the age of CD syptom onset, the more severe the disorder is likely to be Adolescent-onset – - Usually less severe - Tends to coincide with family or peer problems. - Aggression may or may not be present. - Males = females for prevalence rates. - Adolescent-onset of CD has a much better progonsis

Disruptive Behavior Disorder Not Otherwise Specified 1 (DBD NOS), DSM-IV Definition This category of DBD was created for children who demonstrate similar behaviors as children with ODD or CD but do not display the same frequency /severity and only met one or two of the behavior criteria for this disorder. Like ODD and CD, this disorder causes significant impairment in the child’s life.

How many children are diagnosed with DBDs? • A summary of 34 studies suggested the prevelance rate for children 4 – 18 years old is: 8 ODD – range 3% to 22. 5% with median of 3. 2% CD – range 0% to 11. 9% with a median of 2. 0% • • Another study indicated that ODD has a wide range of prevelance from 1% -16% of children, depending on which criteria and assessment methods are used 9 Research presents evidence that the prevelence and the severity of this disorder are increasing 10

Overlapping of disorders It is rare for ODD/CD to occur outside the context of other psychiatric disorders 11 - Most common is ADHD 65% of children diagnosed with ADHD also had ODD 80% of children diagnosed with ODD also had ADHD - Anxiety disorders 45% of children diagnosed with an anxiety disorder also had ODD - Severe depression 70% of children diagnosed with severe depression also had ODD - Bipolar 85% of children diagnosed with bipolar disorder also had ODD - Language processing disorder (LPD) 55% of children diagnosed with LPD also have ODD

What causes Disruptive Behavior Disorders? • It is thought that children with severe behavior disorders may be more influenced by neurological and genetic factors 12 • However mild to moderate DBDs are believed to appear in children who have an accumulation of a high number of risk factors and a low number of protective factors in all contexts of their lives 7 • This imbalance of risk to protective factors may determines the presence and severity of a child’s DBD. 5 6 7

Risk Factors A risk factor is a characteristic within the individual or a circumstance of the individual that increases the probability of a Disruptive Behavior Disorder.

Biological Risk Factors • Difficult Temperament at birth – irritable, easily frustrated, angry and hard to soothe 13 • Aggression is highly influenced by genetic factors in boys and girls. 12 • In severe cases of DBDs neurological factors may cause the brain to function differently compared to how an average child’s brain may function. 12 • Children diagnosed with both ODD/CD and ADHD (ADHD being highly genetic) are likely to have greater symptom severity and increased risk of future disorders 11

Individual Risk Factors • • • Underdeveloped emotional regulation skills Low tolerance of frustration Little to no problem solving capabilities Inability to adapt to new situations Language development impairment 11

Family Risk Factors • Young age of the mother at birth of first child • Insecure Parental Attachment • Coercive parent – child interactions Parental behaviors include inconsistent/harsh discipline, poor monitoring/ supervision, low levels of warmth/nurturance, high numbers of negative verbalizations towards the child. • Depressed or “distressed” mother • High levels of substance abuse and antisocial behaviors in parents 7 14

Contextual Risk Factors • Living in urban, low-socioeconomic settings. As the magnitude of poverty increases, so too does the severity of aggression and conduct problems 7 • Living in a disadvantaged neighborhood Characterized by dilapidated housing, high crime rates, isolation, lack of economic resources and unsafe conditions. 15 • • Witness of violence or being the victim of violence or abuse 7 Stressful live events 16

School Risk Factors • • • Zero-tolerance discipline which is highly punitive and erratic, escalating with little or no attention to students’ good behaviors or efforts to achieve 10 17 Negative interactions with adults, typical school experience for these students is highly negative 10 Discipline including punishments that takes students away from the academic environment 17 Deficits in social skills lead to rejection by prosocial peers 7 Affiliation with “deviant” peers 7 10

Non – Factors • • No significant evidence has been found that demonstrates increased occurrence of DBDs in relation to race and ethnicity 7 18 19 Although controversial, most researchers have concluded that there are no IQ differences between children with and without CD. 7 19

Protective Factors Protective factors reduce the likelihood of children confronted with risk factors to develop maladaptive behaviors associated with Disruptive Behavior Disorders.

Resilience in Childhood Resilience, a positive adjustment occurring in children at-risk, seems to result from a combination of internal and external resources that function as protective factors. 7

Child Protective Factors • • • Easy Temperament Good intellectual functioning Self-confidence Empathy Talents 3 7

Family Protective Factors • • Good supportive relationship with a parent Close supervision by parents when not in school Positive parent-child relationships: warmth, structure, high expectations Connection to extended supportive family networks 5 7 8

School Protective Factors • • Children with ODD/CD who had a positive teacher-child relationship showed a decrease in aggression. 20 Friendship with prosocial peers 7 Bonds to prosocial adults outside the family 7 17 Attending effective school 3

Interventions will be more successful if they not only reduce the risk factors, but also promote the protective factors observed in resilient children. 7

School-wide Interventions • • Create a positive school climate Define behavioral expectations - Small set of general expectations and specific expectations for different locations in the school • Support positive behavior - Monitor behavior especially during common problem times, acknowledge and reward positive behavior, use reminders and review of behavior expectations. • Respond to problem behavior consistently and effectively - Use consistent procedures in responding to minor and serious problem behaviors. Institute procedures for problems solving meetings.

Classroom Interventions • Establish and teach the classroom rules and procedures - Classroom rules and procedures need to be established and clearly stated, explicitly taught, closely monitored and consistently followed. • • • Manage common problem times: transition, seat work, other unstructured times of the day Promote social and emotional functioning Use rewards effectively Use mild punishment effectively Manage angry/acting out behavior

Three-level: Triangle Approach Green-Zone School-Based Interventions Red-Zone Positive behavior support interventions that are school-wide will support all children. This foundational level is sufficient for promoting positive behavior for approximately 80% of students Comprehensive and individualized interventions that focuses on 5% of children with significant difficulties Yellow-Zone Early interventions for children at risk, will affect 15% of children

Individual Interventions • • Consistently reinforce good behavior Use of proactive and instructive teaching strategies to teach adaptive behaviors and problem solve with the student Train student to self-monitor disruptive behaviors Use positive reinforcement when students reaches behavior goals.

IDEA Classification Special Education Interventions • If a student with DBDs is labeled “emotionally disturbed” they are included under and given all protections under the Individuals with Disabilities Education Act (IDEA) • But, if a student with DBDs is labeled “socially maladjusted but not emotionally disturbed”, they are denied any protection under IDEA and special education services 10

Piecing it all together: What does all of this mean for a teacher?

Parent Involvement • • Home-school collaboration has the potential to significantly increase academic success for students with DBDs Teacher and parent use a “partnership approach” to child’s success in school Send daily report card home about the student’s behavior Encourage positive parental reinforcement of specific desired behaviors

What teachers should avoid • • Use of only reactive behavioral strategies Model antisocial behaviors by yelling or insulting student, instead teachers should model prosocial or problem solving behaviors. Use of harsh punishment Only coercive interactions with student

What teachers should do • • • Understand that teaching children with DBDs may take a “superhuman tolerance for interpersonal nastiness” 10 Directly teach adaptive behavior strategies Model and teach prosocial skills, problem solving, empathy and self-control Use individual interventions for students with DBDs Understand the teacher-student conflict cycle and how to avoid it

The Conflict Cycle Retrieved from: http: //cecp. air. org/interact/authoronline/april 98/3. htm

Questions?

Glossary • • • DSM IV - DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) An official manual of mental health problems developed by the American Psychiatric Association. Psychiatrists, psychologists, social workers, and other health and mental health care providers use this reference book to understand diagnose mental health problems. Insurance companies and health care providers also use the terms and explanations in this book when discussing mental health problems. (site is the Prosocial behavior -The term prosocial behavior describes acts that demonstrate a sense of empathy, caring, and ethics, including sharing, cooperating, helping others, generosity, praising, complying, telling the truth, defending others, supporting others with warmth and affection, nurturing and guiding. Antisocial behavior – The term anitsocial behavior describes behaviors that are unacceptable in our society. Examples are acts of aggression or malice, over-reactive displays of anger, inability to work or get along with others, disrespectful towards others, and abusive towards others.

References 1. AACAP Official Action, (2007). Practice parameters for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(1), 126 -141. 2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4 th text revision ed. ). Washington DC: Author. 3. Quay, H. C. , & Hogan, A. E. (1999). Handbook of disruptive behavior disorders. New York: Kluwer Academic/Plenun Publishers. 4. Angold, A. , Costello, E. J. & Erkanli, A. (1999). Co-morbidity. Journal of Child Psychological Psychiatry, 40: 1205 – 1212. 5. Lahey, B. B. , & Loeber, R. (1994). Framework for a developmental model of oppositional defiant disorder and conduct disorder. In D. K. Routh (Ed. ), Disruptive behaviors disorders in childhood. New York: Plenum. 6. Burke JD, Loeber R, & Birmaher, B. (2002) Oppositional defiant and conduct disorder: A review of the past 10 years, part II. American Academy of Child Adolescent Psychiatry, 41: 11, 1275 – 1293. 7. Bloomquist, M. L. & Schnell, S. V. (2002). Helping children with aggression and conduct problems: Best practices for intervention. New York: Guilford Press. 8. Lahey, B. B. , Miller T. L. , Gordon, R. A. and Riley, A. W. (1999). Developmental epidemiology of the disruptive behavior disorders. In H. C. Quay & A. E. Hogan (Eds. ), Handbook of disruptive behavior disorder (pp. 23 – 48). New York: Kluwer Academic/Plenum Press.

References 9. Loeber, R, Burke JD, Lahey BB, Winters A, Zera M. (2000) Oppositional defiant and conduct disorder: a review of the past 10 years, part I. American Academy of Child Adolescent Psychiatry, 39, 1468 -1484. 10. Kaufman, J. M. (2005) Characteristics of emotional and behavioral disorders of children and youth. New Jersey: Pearson Prentice Hall. 11. Greene, R. W. , Ablon, J. S. , Goring, J. C. , Fazio, V. , & Morse, L. R. (2004). Treatment of oppositional defiant disorder is children and adolescents. In P. M. Barrett & T. H. Ollendick (Eds. ), Handbook of interventions that work with children and adolescents: Prevention and treatment (pp. 369 – 393). New Jersey: John Wiley & Sons. 12. Pliszka, S. R. (1999). The psychobiology of oppositional defiant disorder and conduct disorder. In H. C. Quay & A. E. Hogan (Eds. ), Handbook of disruptive behavior disorder (pp. 371 – 396). New York: Kluwer Academic/Plenum Press. 13. Sanson, A. & Prior, M. (1999). Temperment and behavioral precursors to oppositional defiant disorder and conduct disorder. In H. C. Quay & A. E. Hogan (Eds. ), Handbook of disruptive behavior disorder (pp. 397 – 417). New York: Kluwer Academic/Plenum Press. 14. Loeber, R. , Wung, P. , Keenan, K. , Giroux, B. , Stouhamer-Loeber, M. Van. Kammern W. B. , & Maughan, B. (1993). Developmental pathways in disruptive child behavior. Development and Psychopathology, 5, 101 – 131.

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