Behaviour%20Disorders%20in%20Adolescents:%20Clinical%20and%20Psychopathological%20Assessment

1
Behaviour Disorders in Adolescents Clinical and
Psychopathological Assessment

• Mª.C. Ballesteros (Hospital Clínico Universitario
  de Valladolid)
• J.L. Pedreira (Hospital Infantil Universitario
  Niño Jesús, Madrid)

2
Behaviour Disorders and International Systems of
Mental Disorders Classification/1

• DSM-III (1980) Basic conditions are
  sociabilization
• Undersocialized, aggressive or not aggressive
• Socialized, aggressive or not aggressive
• DSM-III-R (1987) Basic conditions are individual
  or grupal behaviour disorder or aggressiveness

3
Behaviour Disorders and International Systems of
Mental Disorders Classification/2

• DSM-IV (1994) Basic conditions are disocial
  behaviour and age
• Aggression on people and animals
• Destruction of property
• Deceitfulness or theft and serious violations
  rules
• ICD-10 (1992-94) Basic condition is context of
  disocial disorder
• Disocial disorder only on family context
• Disocial disorder undersocialized children
• Disocial disorder socialized children
• Oppositional defiant disocial disorder

4
HOLLISTIC AND COMPREHENSIVE CLINICAL ASSESSMENT
IN BEHAVIOUR DISORDERS IN ADOLESCENCE
Vulnerability Risk factors
Symptoms
Pronogsis
Tretment
Clinical diagnosis
Therapeutic and Preventive Interventions
5
GLOBAL AND DEVELOPMENTAL ASSESSMENT OF BEHAVIOUR
DISORDERS IN ADOLESCENCE
VULNERABILITY RISK FACTORS
SYMPTOMS
PROGNOSIS

• Genetic factors
• Temperament
• mediators 
• Personality traits
• Cognitive patterns
• Neuropsychology
• Neurophysiology
• Neurotransmission

Unspecific Especific - Sex - Family -
School - Social
Developmental symptoms Clinical symptoms -
Diagnostic criteria - Subtypes - Comorbidity
Clinical features Protective factors
Temperament
Mª C. Ballesteros-Alcalde J.L. Pedreira-Massa
(1999)
6
Comprehensive and Developmental Assessment of
Behaviour Disorders in Adolescence/2Vulnerability

• Genetic and Temperament factors as mediators
• Personality traits
• Aggressiveness
• Socialization disorders
• Impulsiveness
• Hyperactivity
• Cognitive patterns
• Hostile attributions
• Egocentric
• Low and inconsistent problem-solving skills
• Inadequate aims

7
Comprehensive and Developmental Assessment of
Behaviour Disorders in Adolescence/3

• Vulnerability Genetic and Temperament factors as
  mediators
• Neuropsychology
• Low IQ
• Language disorders
• Attention disorders
• Neurophysiology
• Low dermal conductivity
• Loe cardiac rating
• Neurotransmissions
• Dopamine, noradrenaline
• Serotonine

8
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/3Risk Factors

• Parental Factors
• Antisocial and criminal behaviour
• Alcoholism
• Untoward parent-child interaction
• Harsh punishment
• Inconsistent punishment
• Poor supervision
• Coercitive exchanges (escalted aversive
  interactions)
• Less parental warmth, support and comunication
  with children

9
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/4Risk Factors

• Family Factors
• Marital discord
• Large family size
• Birth order
• Older siblings with antisocial behaviour
• Few family activities

10
Disruptors of effective parenting
Family Demographics Income Parent
education Neighborhood Ethnic group 
Grand parental Traits Antisocial behaviour Poor
family management
Parental Traits Antisocial behaviour Susceptible
to stressors
Disrupted family-management practices
Child antisocial behaviour
Family Stressors Unemployement Marital
conflict Divorce
B. Lahey R. Loeber (1994)
11
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/5Risk Factors

• Child Factors
• Child temperament
• Neuropsychological deficits (in verbal and
  executive functions)
• School (academic deficiencies, attendance, peers
  and teacher relationship)
• Signs of antisocial behaviour Early onset,
  frequency (number of episodes), diversity (range
  of different antisocial behaviours), breadth
  across situations, seriousness

12
A visual heuristic describing the developmental
levels model
Mug Truant Cruel
Steal Force sex Run away
Break, enter Use weapon Lie Bully
Vandalize Fight Set fires
Hurt animals Temper tantrums
Irritable Defiant Spiteful Blame
others Annoy others Angry
Argumentative 
Advanced CD
Intermediate CD
Oppositional
B. Lahey R. Loeber (1994)
13
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/6Risk Factors

• Social Risk Factors
• Poverty
• Unemployed
• Marginal behaviours or life styles
• Migration
• Low culture

14
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/7Symptoms

• Diagnostic criteria (symptoms type, number and
  frequency)
• DSM-IV
• ICD-10

15
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/8Clinical
Symptoms

• The subtypes of the Disorders
• Subtypes based on age at onset
• Subtypes based on aggression
• Subtypes based on socialization
• Subtypes based on comorbid conditions

16
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/9Clinical
Symptoms

• Subtypes based on age at onset
• Childhood onset vs. Adolescence onset
  (Longitudinal follow-up study Farrington, 1979
  Dunedin Longitudinal Study Moffit, 1990 McGee,
  1992)

17
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/10Clinical
Symptoms

• Subtypes based on aggression
• Overt vs. Covert (1st Bipolar Dimensional Type
  Loeber et al, 1985)
• Destructive vs. Nondestructive (2nd Bipolar
  Dimensional Type Frick et al., 1993)
• Proactive vs. Reactive (theoretical model based
  dichotomy Dodge et al., 1991)
• Affective vs. Predatory (connection with
  Autonomous/neurotransmission Vitello et al.,
  1990)
• Constraint

18
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/11Clinical
Symptoms

• Subtypes based on Sociabilization
• Socialized vs. undersocialised (Biological
  functioning is different Quay et al., 1987)

19
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/12Clinical
Symptoms

• Subtypes based on Comorbid Conditions
• ADHD
• Cognoscitive Disfuctions
• Emotional Disorders

20
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/13Clinical
Symptoms

• Comorbidity
• ADHD
• Impulse-control Disorders
• Alcohol or Drug abuse
• Anxiety, Depression
• Sociabilization Disorders

21
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/14Pronogsis

• Clinical Features associated with bad pronogsis
• Age at onset Childhood
• Subtypes of aggression
• Destructive
• Proactive
• Predatory
• Sociabilization Undersocialized
• Comorbid conditions ADHD and/or Cognitive
  Disfuctions

22
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/15Pronogsis

• Protective Factors
• Higher self-esteemand locus of control
• Family support and supervission
• Continuity in therapeutic intervention
• Early diagnosis and therapeutic intervention
• Good accessibility to Child and Adolescent
  Psychiatric Services
• Social support (peer and social context)
• School support

23
Hollistic and Developmental Assessment of
Behaviour Disorders in Adolescence/16Pronogsis

• Individual Factors
• Temperament
• Personality traits
• Perception disorder by himself/herself

24
Assessment of Behaviour Disorders in Adolescence/1

• Diagnostic Assessment
• Obtain patients history
• Obtain family history
• Interview with patient
• School information
• Physical evaluation
• AACAP (1997)
• MªC. Ballesteros JL Alcázar JL Pedreira A de
  los Santos (1998)

25
Assessment of Behaviour Disorders in Adolescence/2

• Diagnostic Formulation
• Identify ICD-10/DSM-IV target symptoms
• Biopsychosocial stressors, enviromental and
  developmental factors
• Subtype of the Behaviour Disorders
• Comorbidity
• AACAP (1997)
• MªC. Ballesteros J.L. Alcázar J.L. Pedreira
  A. De los Santos (1998)

26
Assessment of Behaviour Disorders in Adolescence/3

• Obtain patients history
• Prenatal ahd birth history (substance abuse by
  mother, maternal infections or medications)
• Developmental history (attachment diosrders e.g.
  Parental depression, substance abuse
  temperament, oppositionality, aggression,
  attention, socialization, impulse control)
• Physical/sexual abuse history
• History of symptoms development (impact on family
  and peer relationship, academic problems)
• Medical history (CNS pathology, chronic
  illnesses, somatizations)
• AACAP (1997) MªC. Ballesteros J.L. Alcázar
  J.L. Pedreira A. De los Santos (1998)

27
A developmental progression for antisocial
behavior
Rejection by normal peers
Poor parental discipline and monitoring
Commitment to deviant peer group
Child conduct problems
Deliquency
Academic failure
Late Childhood and Adolescence
Middle Childhood
Early Childhood
28
Multidimensional causal models Longitudinal model
Prior Delinquent Behaviour

Family
-
Delinquent Behaviour
Delinquent Peers

School
-
Elliot, Huizinga Ageton (1985) (Condensed
adapted)
29
Median Age of Onset Reported by Parent of
Symptoms of oppositional Defiant Disorder and
Conduct Disorder ª
ª This combines retrospective and prospective
ages of onset over four annual assessment in the
Developmental Trends Study.
B. Lahey R. Loeber (1994)
30
The families of adolescents The strop cycle
Harsh criticism from others
Identity definition by opposition
Precarious self-esteem
P. Hill (1992)
31
Assessment of Behaviour Disorders in Adolescence/4

• Obtain family history
• Family coping style, stressors, resources
  -socioeconomic status, social support/isolation,
  problem- solving skills, conflict-resolution
  skills, parenting skills, limit-setting,
  abuse/neglect, permissiveness, inconsistency,
  management childs aggression, parents and
  patients coercitive interaction cycles leading
  to reiforcement of noncompliance
• AACAP (1997)
• MªC. Ballesteros J.L. Alcázar J.L. Pedreira
  A. De los Santos (1998)

32
Assessment of Behaviour Disorders in Adolescence/6

• Interview patient (may precede parental
  interview)
• Capacity for attachment, trust and empathy
• Tolerance for and discharge of impulses
• Capacity for showing restraint, accepting
  responsability for actions, experiencing
  guilt,user anger constructively, acknowleding
  negative emotions
• Cognitive functioning
• AACAP (1997) MªC. Ballesteros J.L. Alcázar
  J.L. Pedreira A. De los Santos (1998)

33
Assessment of Behaviour Disorders in Adolescence/7

• Interview patient/2 (may precede parental
  interview)
• Mood, affect, self-esteem, suicide potencial
• Peer relationship (loner, popular, drug-, crime-,
  or gang oriented friends)
• Disturbances of ideation (suggestibility,
  disociation)
• History of early, persistent use of tabacco,
  alcohol or other substances
• Psychometric self-report instruments might
  provide
• AACAP (1997) MªC. Ballesteros J.L. Alcázar
  J.L. Pedreira A. De los Santos (1998)

34
Assessment of Behaviour Disorders in Adolescence/8

• School information
• Functioning (IQ, achievement test data, academic
  performance and behaviour)
• Standard parent and teacher rating scales of the
  patients behaviour
• Referral for IQ, speech and language and learning
  disability and neuropsychiatric testing if
  available test data are nor sufficient
• Data may be obtained inperson, by phone or though
  written reports from appropiate staff, such as
  school principal, psychologist, teacher and nurse
• AACAP (1997) MªC. Ballesteros J.L. Alcázar
  J.L. Pedreira A. De los Santos (1998)

35
Cross-Sectional model
Parental Monitoring
-
Deviant Peers
-
Behaviour problems/ Social Competence

a
Delinquent Behaviour
Academic Skills
-
Patterson Dishion (1985) (adapted)
a High behaviour problems and low social
competence
36
Assessment of Behaviour Disorders in Adolescence/9

• Physical examination
• Collaboration with family doctor, paediatrician
  or other health care providers
• Vision and hearing screening
• Evaluation of medical and neurological conditions
  (e.g. Head injury, chronic illness)
• Urine and blood drugs screening as indicated,
  especially when clinical evidence suggest
  substance use
• AACAP (1997) MªC. Ballesteros J.L. Alcázar
  J.L. Pedreira A. De los Santos (1998)

37
Selected Measures of Behaviour Disorders in
Adolescents/1

• In order to discriminate clinical and no clinical
  people High discriminant reliability
• Child Behavior Checklist, Achenbach, 1978
• Revised Behavior Problems Checklist, Quay, 1983
• Eyberg Child Behavior Inventory, Eyberg, 1978
• Conners Rating Scales (Parents and Teachers)

38
Achenbach-Connors-Quay Questionnaire (ACQ)
delinquent and aggressive behaviour dimensions
39
Selected Measures of Behaviour Disorders in
Adolescents/2

• In order to evaluate the treatment impact High
  predictive reliability
• Child Behavior Checklist, Achenbach, 1978
• Eyberg Child Behavior Inventory, Eyberg, 1978
• Conners Rating Scales (Parents and Teachers)
• In order to require shortness or treatment
  evaluation or developmental impact Short Scales
• Shorts Conners Rating Scale
• Iowa-Conners Teacher Rating Scale
• Eyberg Child Behavior Inventory

40
Selected Measures of Behaviour Disorders in
Adolescents/3

• In order to assess behaviour competences or
  adolescent behaviour profile
• Child Behavior Checklist, Achenbach, 1978
• In order to consider the setting
• Child and Adolescent Psychiatric Services, or
  comorbidity screening ABC, CBC, TBP and Conners
  Scales
• Behaviour specific setting Eyberg Child Behavior
  Inventory

41
Family Assessment of Behaviour Disorders in
Adolescents/1

• Parenting Profiles
• Parenting Scale (Arnold, 1993)
• Parent Practices Scale (Stayhom Widman, 1998)
• Alabama Parenting Questionaire (Frick, 1991)
• Parent and Teacher Social Cognitions
• Parenting sense of Competende Scale (Johnston,
  1989)
• Cleminshaw-Guidubaldi Parent Satisfaction Scale
  (1985)
• Parental Locus of Control Scale (Campis et al.,
  1986)

42
Family Assessment of Behaviour Disorders in
Adolescents/2

• Parental perceptions of personal and marital
  adaptation or emotional state Screening of
  depressive and mood psychopathology, disocial
  behaviour and substance or alcohol abuses
• Family Stress
• Parenting Daily Hassles (Greener, 1990)
• Parenting Stress Index (Abidin, 1995)
• Parental functioning in extrafamily context
• Community Interaction Checklist (CIC, Wahler,
  1979)

43
Family Assessment of Behaviour Disorders in
Adolescents/3

• Parent conflicts
• OLeary-Porter Scale (1980)
• Conflict Tactics Scale (Partner-Strauss, 1979,
  1990)
• Parenting Alliance Inventory (Abidin, 1988)
• Child Rearing Disagreements (Jouriles et al.,
  1991)
• Parents Problems Checklist (Dadds Powell, 1991)
• Parental satisfaction with treatment procedures
• Parents Consumer Satifaction Questionaire
  (Forehandy McMahon, 1981 mcMahon, 1984)

44
Diagnostic Formulation of the Adolescents with
Behaviour Disorders/1

• Identify ICD-10/DSM-IV target symptoms
• When suggests BD consider the following
• Biopsychosocial stressors (sexual and physical
  abuse, divorse or death or key attachment
  figures)
• Educational potential, disabilities, achievement
• Peer, sibling and family problems and strengths
• Enviromental factors (disorganized home, lack of
  psychiatric illness or drug or alcohol abuse in
  parents, enviromental neurotoxins e.g. Lead)
• Adolescent or Child ego development, especially
  ability to form and maintain relationships
• AACAP (1997)

45
Diagnostic Formulation of the Adolescents with
Behaviour Disorders/2

• The subtype of the disorder
• Childhood onset vs. Adolescent onset
• Overt vs. Covert versus authority
• Under-restrained vs. Over-restrained
• Socialized vs. Undersocialized
• AACAP (1997)

46
Diagnostic Formulation of the Adolescents with
Behaviour Disorders/3

• The syndromes may be confused or cuncurrent with
• ADHD Organic Brain and seizure disorder
• ODD Specific developmental disorder
• Intermittent explosive disorder Schizophrenia
• Substance use disorder Paraphilias
• Mood disorder (bipolar and depressive)
• PTSD and Disociative disorder Mental retardation
• Borderline personality disorder
• Somatization disorder Narcisistic personality
  disorder
• Adjustment disorder
• AACAP (1997)

47
Dimensional Assessment of Behaviour Disorders in
Adolescents/1

• Individual dimensions
• Developmental preocess and moral development
• Aggressiveness subtypes
• Self-esteem and self-likeness
• Empathy and impulse control
• Comorbility
• Poor interpersonal relations
• Cognitive and atttributional processes Deficits
  and disttorsions in cognitive problem-solving
  skills, atributions or hostile intant to others,
  resentment and suspiciousness illustrate
• Risk factor and vulnerability
• Temperament
• Clinical features (specially with sign of
  antisocial behaviour)
• AACAP (1997)

48
Dimensional Assessment of Behaviour Disorders in
Adolescents/2

• Family dimensions
• Parenting and attachment styles
• Psychopathology (including drug and alcohol
  abuses)
• Untoward parent-child interactions (physical and
  sexual abuses)
• Poor or inconsistent supervision
• Marital conflicts
• Other family members with antisocial behaviour
• Family risk factors
• Genetic factors
• AACAP (1997)

49
Disruptors of effective parenting
Family Demographics Income Parent
education Neighborhood Ethnic group
Grandparental Traits Antisocial behaviour Poor
family management
Parental Traits Antisocial behaviour Susceptible
to stressors
Disrupted family-management practices
Child antisocial behaviour
Family Stressors Unemployement Marital
conflict Divorce
B. Lahey R. Loeber (1994)
50
Dimensional Assessment of Behaviour Disorders in
Adolescents/3

• School dimensions
• Acedemic deficiencies
• Neuropsychological deficits (in verbal and
  executive functions)
• Behaviour disorder in preschoolers level
• Peers relationship and perception of behaviour
• Teachers supervision and authority
• AACAP (1997)

51
Dimensional Assessment of Behaviour Disorders in
Adolescents/4

• Social and contextual dimensions
• Identification with a subculture or group
• Alienation of the individual from the wider
  social group
• Delinquency areas
• Poverty and marginalization behaviour
• Legal problems
• Social support
• AACAP (1997)

52
Cross-Sectional model
Neighborhood Disorder Criminal Subculture

School
Neighborhood organization

Severe Delinquent Behaviour
-
-a
Neighborhood Stability

-a
Delinquent Peers
-
Family Stability
-

Simcha-Fagan Schwartz (1986) (condensed and
adapted)
Age
a These parameters are counterintuitive and
probably sampling and measurement limitations
53
Potential sources of data
Parents scales
Yourself scales
Clinical interview
Peers and Social scales
Teacher scales
Initial screem
1
Any scales in Clinical range?
yes
no
Conclusion No evidence of clinical
deviance. check key items, e.g. Suicidal behaviour
Is deviance confined to the same syndrome in all
sources?
3
2
yes
no
4
no
Conclusion Childs problems correspond to
a single Syndrome e.g. aggresive
Are the same syndrome deviant in all sources?
5
Differential diagnosis
Does childs behaviour actually differ much
among contexts?
7
yes
Conclusion Childs problems comprise
multiple syndrome or profile pattern
yes
no
6
Taxonomic decision tree for using quantitative
multi-informant data to make categorical decisions
Conclusion Different behaviours may have to
be targeted for changes in different contexts
Conclusion Some informants Perceptions may Have
to be Targeted for change
8
9
Achanbach (1993) (modified)
54
Treatment of Behaviour Disorders in Adolescents/1

• General aims
• Treatment shold be provided in a continuum of
  care that allows flexible application of
  modelities by a cohesive treatment team
• Outpatients treatment includes intervention in
  family, school and peer group
• The predominance of externalizing symptoms in
  multiple domains of functioning call for
  interpersonal psychoeducational modalities
• As a chronic condition requires extensive
  treatment and long-term follow-up
• Patients with severe BD are likely to have
  comorbidities that requiare treatment
• AACAP (1997)

55
Treatment of Behaviour Disorders in Adolescents/2

• Treat comorbid disorders
• Family interventions include parent guidance,
  training and family therapy
• Identify and work with parental strengths
• Train parents to stablish consistent positive and
  negative consequences and well-defined
• Arrange for treatment of parental psychopathology
• AACAP (1997)

56
Treatment of Behaviour Disorders in Adolescents/3

• Individual and group psychotherapy with
  adolescent
• Technique of intervention (supportive vs.
  behavioural) depends on patients age, processing
  style and ability to engage in treatment
• A combination of behavioural and explorative
  approaches is indicated, especially when there
  are internalizing and externalizing comorbidities
• Psychosocial skill-building training should
  supplement therapy
• AACAP (1997)

57
Conclussions/1

• Behaviour disorder refers to instances when
  children or adolescent evince a pattern of
  antisocial behaviour, when there is significant
  impairment in everyday functioning at home or
  school, or when the behaviours are regarded as
  unmanageable by significant others
• BUT
• When are the behaviour problems a normal
  developmental variations? Or
• Are the behaviour disorders an clinical syndrome
  with different clinical features and
  developmental expressions? And
• When are the behaviour problems, the clinical
  symptom of disocial behaviour or antisocial
  personality disorder?

58
Conclussions/2

• Behaviour disorder is multifaceted and
  symptomatic complex in so far as it includes many
  symptoms and effects many domains of functioning
• Although the disorder is discussed as a
  constellation of symptoms within the child, there
  are parent and family features often associated
  with the disorder
• The nature of the disfunction has important
  implications for assessment and intervention both
  in the context of clinical work and research

59
Conclussions/3

• Behaviour disorder represents a special challenge
  given the multiple domains of functioning that
  are affected
• It is meaningful to consider alternative
  constellation of symptoms, various subtypes and
  developmental paths and trajectories
• Research identified differences among subtypes
  Aggressive and delinquent types and childhood
  onset vs. Adolescent onset receiving major
  attention

60
Conclussions/4

• We need longitudinal follow-up research based on
  developmental psychopathology methodology, in
  order to clarify the continuity vs. Discontinuity
  of the behaviour disorders
• Understanding the confluence of multiple factors
  (childrens characteristics, features of
  behaviour disorder, parent and family functioning
  and contextual influences)
• Peer influences have been implicated in the onset
  and maintenance of antisocial behaviours
  including substance use and abuse and deliquency
• Poor bonding to home and school were related to
  subsequent bonding to deviant peers

61
Conclussions/5

• Assessment issues
• Assessment involves different sources of
  information, the challenges for research and
  clinical work consist to integrate
  multi-informant data
• Although parents are in an excellent position to
  report on their childrens behaviour, the
  evaluation cannot be assumed to be free from
  systematic influences or basis
• It is useful to mention the specificity of
  performance because in many cases symptoms are
  restricted to once or a few situations

62
Conclussions/6

• Assessment issues/2
• The BDs are the open door in order to develop
  other psychopathological disorder
• Evaluation of a symptom and set of symptoms needs
  to be developmentally based
• In our opinion the assessment process includes an
  hollistic and comprehensive procedures
  Vulnerability and risk factors, symptoms and
  clinical features and pronogsis in order to
  develop the treatment (therapeutic and preventive
  interventions)

63
Conclussions/7

• The assessment of risk and protective factors has
  been relied upon to develop both therapeutic and
  preventive interventions
• Advances in understanding behaviour disorders
  have derived from trying to move to understanding
  the interrelation of factors and how they operate
  on a day-to-day basis in producing antisocial
  behaviour and its legal and/or ideological
  implications