conduct disorder and oppositional defiant disorder：品行障礙對立違抗性障礙

CAROLYNR.FALLAHI,PH.D.ADDITIONALSLIDESPROVIDEDBYMASH&WOLFE(YOURTEXT)ConductDisorderandOppositionalDefiantDisorderIntroductiontoCDCasePresentationWhatisConductDisorder?ChronicpatternofbehaviorthatcausesharmtoothersChronicpatternofbehaviorthatviolatessocietalrulesConductDisorderandantisocialbehaviorinchildren.Actionsandattitudesthatareage-inappropriate.Violateexpectationsoffamilyandsociety.Damageothers’personalorpropertyrights.IssuesindefiningConductProblemsHistorically,wehavedefinedconductproblems:LegallyPsychologicallyDSM-IV-TRincludes:OppositionalDefiantDisorderConductDisorderChildrenwithconductdisordersshowawiderangeofbehaviors.EnvironmentalComponentCDandODDisassociatedwiththeperson’senvironmentPoverty/disorganizedneighborhoodViolencewithinthehome/neighborhoodAbuse/neglect/inadequatesupervisionpoorqualityschoolsCommunityFactorsTheHistoryofCDTheBostonboyfiend:1874JessePomeroy,age14.Adolescentgangsinlargecitiesduringthe1700sand1800s.Howshouldwehandlejuveniledelinquents?Ifaminorisfoundguiltyofanaggressiveact,howdowehandlethatinthecourtsystem?ConductDisorderCONDUCTDISORDERPersistentpatternofbehaviorwhererightsofothers/societalnormsviolated,shownby3ormoreoffollowinginlastyear,atleast1inpast6months:Aggressiontopeopleandanimals________oftenbullies,threatens,orintimidatesothers________ofteninitiatesfights________usedaweaponthatcancauseseriousphysicalharm________beenphysicallycrueltopeople________beenphysicallycrueltoanimals________stolenwhileconfrontingthevictim________forcedsexualactivityDestructionofproperty________deliberatelyfiresetwithintentofdoingseriousdamage________deliberatelydestroyedothers'propertyotherthanbyfireDeceitfulnessortheft________breakandentryintoacarorhouse________oftenliestoobtainthingsoravoidobligations("consothers")________stolenitemswithoutvictimconfrontationSeriousviolationsofrules________oftenstaysoutatnightdespiteparentalprohibitions________runawayfromhomeovernightatleasttwice(or1extended)________oftentruantbeginningbeforeage13TwoSubtypesofCDChildhood-Onsettype:1criterionofCDpresentbefore10yearsoldAdolescent-OnsettypeNoevidencepriorto10yearsoldSeverityMild,moderate,severeClusteranalysisofCDPropertyViolationsCrueltytoanimalsLiesSetsfiresStealsVandalismDestructiveAggressionAssaultsothersBlamesothersformistakesBulliesothersCrueltoothersPhysicalfightsSpiteful/vindictiveCovertStatusOffensesBreaksrulesRunsawayfromhomeSwearstruancyOppositionalOvertAngry-resentfulAnnoysothersArgueswithadultsDefiesadults’requestsStubbornTempertantrumsTouchy-easilyannoyedNondestructiveBasedonFricketal.(1993)OppositionalDefiantDisorderOPPOSITIONALDEFIANTDISORDERA.6monthpatternofnegativisticanddefiantbehaviorduringwhichatleast4offollowingpresent(consideredagainstwhatisnormalforagelevel):________oftenlosestemper________oftenargueswithadults________oftenactivelydefiesorrefusesadultrequestsorrules________oftendeliberatelyannoyspeople________oftenblamesothersforownmistakes________oftentouchy/easilyannoyedbyothers________oftenangryandresentful________oftenspitefulorvindictiveB.________DoesnotmeetcriteriaforConductDisorder,anddoesnotoccurexclusivelyduringpsychosisordepressionIssuessurroundingCDandODDAreODDandCDdistinctcategories?Wouldadimensionalviewbemoreappropriate?HowmightDSM-Vhandlethisissue?DoesourculturehelpdeterminewhoisdiagnosedwithODDandCD?Aregirlsunderdiagnosed?MightanenvironmentcreateODDorCD?AssociationswithCD&ODDIntelligenceandunderachievementinschoolLackofemotionalintelligencePersonalityfactors:impulsive,callous,unemotionalMultipleproblemsinrelationships:peers,family,teachers,authorityfigures.Co-occurringDisorders:ADHD,anxiety,depression,substanceabuse.EpidemiologyPrevalence:5-8%forCD.10.2%ODD.Genderdifferences:theratioofboystogirls10to1inchildhood;1.5to1inadolescence.Genderdifferencesinsymptomexpression.DevelopmentalpathwaysEarlyonsetversuslateronsetPeeraggressionFiresettingandcrueltytoanimalsPrecursorsandCourseofCDGeneralDevelopmentalCoursePg.161Patterson’sVileWeedCourseofChild-onsetContingenciestrainchildrentobecoercivetogetwhattheywantTwosocialfailuresDevelopmentalProgressionofConductProblemsBehaviors(ASBs)-ProbabilisticProgressionOppostitionalArguesBragggingDemandsattentionDisobeysathomeImpulsiveTemperTantrumsStubbornTeasesLoudOffensiveCrueltyDisobeysatschoolScreamsPoorPeerrelationsFightsSulksSwearsLyingDelinquentSetsfiresStealsoutsideAlcohol/DruguseTruancyRunsawayVandalismPreSchool Adolescence Overt(ofteninhome) BecomesmoreCovert EtiologyofConductProblemsEtiologicalTheoriesFamilyandtwinstudiesSharedenvironmentalfactorsNon-sharedenvironmentalfactorsTeratogenexposureprenatallyPerinatalstressorsAbnormalneurophysiologicalrespondingTemperamentIneffectiveparentingProblematicpeers/environmentalTreatmentWorkingwithParentsProblem-solvingTrainingFamilyTherapyPreventionIssuesThompsonHouseRules1.Nosettingeachotherup.Thismeansnonamecalling,notripping,andnoelbowing.2.Noviolenceagainstotherpeople.Thismeansnohitting,nothrowingthingsatothers,andnograbbingothers.3.Nopropertydestruction.ViolatinganyoftheserulesresultsinnoNintendo,TV,orGameboyfortherestoftheday.ViolatingeitherruleafterdinnermeansnoNintendo,TV,orGameboyfortherestofthedayANDthenextday.Additionalrules:4.MorningNintendo,TV,orGameBoyonlyafterreadyforschool(dressed,teethbrushed,bedmade).5.AfternoonandeveningNintendo,TV,orGameboyonlyafterthebedroomispickedupandallhomeworkisdone.MomwillinspecttomakesuretheserulesaremetandapprovebeforeTimorTomplaysNintendo,TV,orGameBoy.RewardcontingenciesandtokeneconomiesSusan’sAgreementwithStaffEachdayIearnatleasthalf(?)ofmyCommunityParticipationpoints(40pointstotal),Iwillbegiven15minutesofextraphonetime,or15minutesofextraWalkmantime,whicheverIchoose.Myextra15minutescanbeusedondayshiftonly,atatimedeterminedbystaff.ThingsIcandotoearnmorepoints:1.getupontime,after2promptsorless.2.attendunitmeetingsontime,after2promptsorless.3.attendschoolontime,aftertwopromptsorless.4.followdirectionsfromstaff.5.activelyparticipateinunitactivities.ThingsIshouldnotdoorIwillnotearnpoints:1.refusetogetoutofbed.2.stayinmyroomduringunitactivities.3.refusetoparticipateinunitactivities.IfIearn40CommunityParticipationpointsfor4daysoutof7,mymotherwillbeallowedtobringmydoginduringvisitinghoursonSaturdayorSunday.IfIearn50pointsfor5daysoutof7,mymotherwillalsobeallowedtobringpizzainformydinneronSaturdayorSunday.ParentbehavioraltrainingThreeparentingmistakestoavoidOver-reacting/personalizingVerbosity(Act,don'tyak!)InconsistencyInconsistencyInconsistencyInconsistencySocialSkillsTrainingMultisystemicTherapyTargetsmultiplesystemswithatreatment"team"Family,includingsiblingsSchoolPersonnelPeersJuvenileJusticeSystemEffectivebutveryexpensiveorisit?AdditionalTreatmentsPreventionInstitutionalizationMedicationEmpiricallySupportedTreatmentsAccordingtoChambless&Hollon,ESTsare: "...clearlyspecifiedpsychological treatmentsshowntobeefficaciousin controlledresearchwitha delineatedpopulation.”

CriteriaforESTsThesetreatmentsareidentifiedbyaskingthefollowingquestions:Hasthetreatmentbeenshowntobebeneficialincontrolledresearch?Isthetreatmentusefulinappliedclinicalsettings,ifso,withwhatpatientsunderwhatcircumstances?Isthetreatmentcosteffectiverelativetoalternativeinterventions?TreatingConductProblemsIngeneral,thefurtheralongachildisintheprogressionofantisocialbehavior,thegreatertheneedforintensiveinterventionsandthepoorertheprognosisESTsforODDandCDParentManagementTreatmentMulti-SystemicTreatmentCognitiveProblemSolvingSkillsTreatmentPreventativeInterventionsMulti-SystemicTherapyAnintensivefamilyandcommunityapproachforadolescentswithsevereCPsDrawsonanumberoftechniquesandiscarriedoutwithallfamilymembers,schoolpersonnel,peers,juvenilejusticestaff,andotherindividualsinthechild’slifeCognitiveProblem-SolvingSkillsTrainingFocusesonthecognitivedeficienciesanddistortionsininterpersonalsituationsProvidesinstruction,practice,andfeedbacktoteachnewwaysofinteractingPreventativeInterventionsRecenteffortshavefocusedontryingtopreventCPsthroughintensiveprogramsofearlyinterventionExample:FastTrack(TheConductProblemsPreventionResearchGroup)TwoSpecificESTsforCP“TheIncredibleYears”–Webster-StrattonFastTrack–TheConductProblemsPreventionResearchGroupTheIncredibleYearsGroupParentingSkillsTrainingGroupTeacherClassroomManagementTrainingChildTrainingTheIncredibleYearsParentSkillTrainingFocuseson:Increasingpositiveparent-childinteractionsBehaviortrackingBehaviorTrackingTheIncredibleYearsParentSkillTrainingFocuseson:Increasingpositiveparent-childinteractionsBehaviortrackingUsing“time-out”todiscourageproblembehaviorsMakinghouseholdcontingenciesexplicitRewardcontingenciesRewards:StickerChartTheIncredibleYears

TheChildCurriculumfocuseson:emotionalliteracyempathyorperspectivetakingfriendshipskillsangermanagementinterpersonalproblemsolvingschoolruleshowtobesuccessfulatschoolOutcomeStudiesImprovesparentchildinteractionsReducesparentrelianceonviolentorcriticaldisciplinemethodsReduceschildconductproblemsAt3yearfollowup,2/3ofchildrencontinuedtoshowclinicallysignificantbehavioralimprovements(Webster-Stratton,1990b).

FastTrackFastTrackisamulti-site,comprehensive,10-yearinterventionprojectdesignedtopreventseriousantisocialbehavior.Beginswhenchildrenarein1stgradeSchool-wideprogramwithpulloutgroupsforchildrenhighinCD.FastTrackFocusesonimprovingchildcompetenciesparentingeffectivenessschoolcontextschool-homecommunicationsFastTrack:ComponentsTeacher-ledclassroomcurricula(calledPATHS)directedtowardthedevelopmentof:emotionalconceptssocialunderstandingself-control(includingweeklyteacherconsultationaboutclassroommanagement)FastTrack:ComponentsParenttraininggroupsdesignedtopromotethedevelopmentofpositivefamily-schoolrelationshipsandtoteachparentsbehaviormanagementskills,particularlyintheuseofpraise,time-out,andself-restraintHomevisitsforthepurposeoffosteringparents'problem-solving