Nicohwilliam

Assignment 2: at least 250 words, APA format, use video, textbook, relevant sources

Read the following directions carefully and answer the questions in your initial post.  After reading the text and viewing the videos, please answer the following questions:

1.   How might a child internalize disorders? 

2.   How likely is a child to externalize disorders?

3.   Give examples of each type of disorder that might be internalized or externalized and discuss the effects on that child's life... socially, academically, psychologically.  Use the videos and your text in the discussion as well as any other peer-reviewed sources.

Please post the question single-spaced before your response. 

YouTube video:

Attachment Disorder: Diagnosis and Treatment

http://www.youtube.com/watch?v=WV6d1nAgBNI

Textbook :

Sue, D., Sue, D. W., Sue, D., & Sue, S. (2014). Essentials of understanding abnormal behavior (2nd ed.). Belmont, CA: Wadsworth Cengage Learning.

Chapter 15

15-1Internalizing Disorders Among Youth

Disorders involving emotional symptoms that are directed inward are referred to as  internalizing disorders . As with adults, children and adolescents with internalizing disorders display heightened reactions to trauma, stressors, or negative events, as well as difficulty tolerating distress and regulating their emotions. Anxiety and depressive disorders are the most common internalizing disorders. These disorders are prevalent in early life (see Table 15.1) and are of particular concern because they often lead to substance abuse and suicide (O’Neil, Conner, & Kendall, 2011). Certain behavior patterns among youth with internalizing disorders, such as abrupt changes in behavior or self-destructive or sexualized behavior, can signal the need for assessment to rule out possible sexual abuse (Floyed, Hirsh, Greenbaum, & Simon, 2011).

Did You Know?

Children who report abdominal pain in the absence of an identifiable medical cause are up to 5 times more likely than their peers to develop anxiety disorders and depression during adulthood.

Source: Shelby et al., 201315-1aAnxiety, Trauma, and Stressor-Related Disorders in Early Life

Anxiety, trauma, and stressor-related disorders in childhood or adolescence typically result from a combination of biological predisposition and exposure to environmental influences. Anxiety disorders are the most prevalent mental health disorder in childhood and adolescence (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Among the 32 percent of adolescents who have experienced an anxiety disorder, specific phobias (19 percent) and social phobia (9 percent) are most common (Merikangas, He, Burstein, Swanson, et al., 2010). Specific phobias often begin in early to middle childhood, whereas social phobias typically begin in early to middle adolescence (Rapee, Schniering, & Hudson, 2009).

Youth with anxiety disorders experience extreme feelings of worry, discomfort, or fear when facing unfamiliar or anxiety-provoking situations. Early-onset anxiety can significantly affect academic and social functioning and, if untreated, can lead to adult anxiety disorders (Ginsburg et al., 2014). Children who are inhibited and fearful are at higher risk for anxiety disorders, and overprotective or controlling parenting practices, low parental warmth, or perceived parental rejection can exacerbate the issue (Bayer et al., 2011). Anxiety disorders associated with childhood include:

· separation anxiety disorder —severe distress or worry about leaving home, being alone, or being separated from primary caregivers; and

· selective mutism —consistent failure to speak in certain social situations.

Children with these disorders display exaggerated autonomic responses and are apprehensive in new situations, preferring to stay at home or in other familiar environments (Kossowsky, Wilhelm, Roth, & Schneider, 2012). Cognitive-behavioral therapy is an effective treatment for childhood anxiety disorders; approximately half of those receiving comprehensive intervention maintain the improvement made during treatment (Compton et al., 2014).

Attachment Disorders

Infants and children raised in stressful environments that lack predictable parenting and nurturing sometimes demonstrate significant difficulties with emotional attachments and social relationships (Gleason et al., 2011). Attachment problems can manifest in the inhibited behaviors seen in reactive attachment disorder or the excessive attention seeking seen in disinhibited social engagement disorder. These childhood stressor and trauma-related disorders are diagnosed only when symptoms are apparent before age 5 and when early circumstances prevent the child from forming stable attachments. Situations that can disrupt attachment include frequent changes in primary caregiver, persistent neglect of physical or psychological safety (including physical abuse), and environments that are devoid of stimulation or affection.

Children with  reactive attachment disorder (RAD)  appear to have little trust that the adults in their lives will attend to their needs; therefore, they do not readily seek or respond to comfort, attention, or nurturing. Children with RAD often behave in a very inhibited or watchful manner, even with family and caregivers. They appear to use avoidance as a psychological defense, and subsequently experience difficulty responding to or initiating social or emotional interactions. Children with RAD rarely show positive emotions and may demonstrate irritability, sadness, or fearfulness when interacting with adults (APA, 2013).

In stark contrast, children with  disinhibited social engagement disorder (DSED)  socialize effortlessly but indiscriminately, and readily become superficially “attached” to strangers or casual acquaintances. They approach and interact with unfamiliar adults in an overly familiar manner (both verbally and physically), while moving away from caregivers. Children with DSED often have a history of harsh punishment or inconsistent parenting in addition to emotional neglect and limited attachment opportunities (APA, 2013).

Critical Thinking

Child Abuse and Neglect

Child neglect and the physical, emotional, and sexual abuse of children remain a significant national problem (X. Fang, Brown, Florence, & Mercy, 2012). In the United States, 678,810 youth were victims of child neglect or physical or sexual abuse in 2012, including 1,640 who died as a result of their injuries. These distressing statistics are likely an underestimate since many cases of abuse go unreported, particularly cases of child sexual abuse. As seen in Figure 15.1, the majority of deaths from abuse involve children age 3 or younger; in 80 percent of the cases, the perpetrator is one or both parents (U.S. Department of Health and Human Services, 2013).

Figure 15.1Fatalities from Child Abuse or Neglect by Age, 2012

The youngest are the most vulnerable.

Source: U.S. Department of Health and Human Services (2013).

Why would parents abuse or neglect their own children? We know that multiple factors, including poverty, parental immaturity, and lack of parenting skills, contribute to child maltreatment, and that many adults who abuse were themselves abused as children. Many parents involved in maltreatment are young, high school dropouts, and under severe stress. Many have personality disorders and low tolerance for frustration, or abuse alcohol and other substances (Leventhal, Martin, & Gaither, 2012). In the case of child sexual abuse, perpetrators are often friends or other family members, and the parent is unaware that the abuse occurred.

Childhood physical or sexual abuse can result in a variety of internalized or externalized symptoms during childhood or adolescence, as well as lifelong physical and psychological consequences such as depression, anxiety, eating disorders, PTSD, and suicidal ideation (Teicher & Samson, 2013). As you might expect, the more maltreatment or trauma a child encounters, the greater the risk of subsequent psychiatric illness (Benjet, Borges, & Medina-Mora, 2010).

Many communities offer parent education and support groups for high-risk families, including families who have come to the attention of child protection agencies. There is a particular need for programs to prevent the maltreatment of infants and young children. What are short-term and long-term consequences of child maltreatment? Why might those who are mistreated as children have an increased risk of becoming abusive themselves?

The course of these disorders depends on the severity of the social deprivation, abuse, neglect, or disruptions in caregiving, as well as subsequent events in the child’s life. Symptoms of RAD often disappear if children begin to receive predictable caretaking and nurturance, whereas symptoms of DSED are more persistent (Zeanah & Gleason, 2010). Issues of mistrust and difficulties with intimate relationships sometimes continue into adulthood. Children who are exposed to multiple episodes of maltreatment are particularly vulnerable to ongoing mental health issues (Kay & Green, 2013). Once RAD or DSED is identified, therapeutic support focuses on building emotional security. Effective intervention includes providing a stable, nurturing environment and opportunities to develop interpersonal trust and social-relational skills. Fortunately, many children raised under difficult circumstances do not show signs of these disorders.

Post-Traumatic Stress Disorder in Early Life

The effects of trauma and resultant post-traumatic stress disorder (PTSD) can be particularly distressing in childhood, as illustrated in the following case study.

Focus on Resilience

Enhancing Resilience in Youth

Early life experiences influence the development of mental illness. Can modifying a child’s environment increase resilience, especially in children who are genetically or environmentally at risk? In other words, are there steps that we can take to decrease the likelihood that a child will develop a mental disorder in childhood or later in life? The answer is yes. Resilience occurs when human adaptive systems are operating optimally—when brain functioning has not been compromised; when children experience social, emotional, and physical security; and when the environment supports their capacity for self-efficacy and effective problem solving (Masten, 2009).

Kevin Peterson/Photodisc/Getty Images

Some interventions increase resilience by reducing potential harm to the developing child. For example, prenatal care and the avoidance of neurotoxins help reduce the risk of conditions that interfere with optimal brain functioning, thus reducing the risk of neurodevelopmental disorders. Other interventions increase resilience by reducing environmental stress—thus providing both biological and psychological benefits to young children (S. E. Taylor, 2010). For example, intervening with parents who are experiencing mental illness or engaging in child maltreatment can improve behavioral or emotional outcomes in their children (D. G. Rosenthal et al., 2013). Similarly, early intervention when children are experiencing behavioral or emotional difficulties can prevent the downward emotional spiral seen with many disorders (Sapienza & Masten, 2011). With support, children who have been exposed to trauma can experience post-traumatic growth (e.g., increased sense of personal strength or enhanced connection with others) in response to their experiences (Meyerson, Grant, Carter, & Kilmer, 2011). Given the epidemic of mental illness, continued research regarding the best methods for promoting resilience in the face of adversity is a global priority (Masten & Narayan, 2012).

Providing children with experiences that foster competence and healthy development also enhances resilience. Such an approach has the potential to promote positive developmental cascades; that is, increased personal competence not only provides the basis for coping with adversity but also promotes other positive outcomes (Masten, 2011). For example, stimulating home and preschool environments not only enhance cognitive development but also allow children to develop a sense of mastery and optimism. Further, positive attachment experiences, quality parenting, and ongoing supportive relationships with positive role models allow children to develop interpersonal trust and coping skills (Masten, 2009).

Knowing how to solve problems or regulate emotions allows children to reduce biological reactivity in response to stress or adversity (S. E. Taylor, 2010). Additionally, promotion of a healthy lifestyle (e.g., ensuring adequate sleep, nutrition, and exercise; monitoring television and computer use) can further support physical and psychological resilience (M. E. O’Connell, Boat, & Warner, 2009). One thing is clear—when basic physical, social, and emotional needs are met, youth can develop the strengths that allow them not only to overcome adversity but also to flourish.

Case Study

Several months after witnessing her father seriously injure her mother during a domestic dispute, Jenna remained withdrawn; she spoke little and rarely played with her toys. Although a protection order prevented her father from returning home, Jenna became startled whenever she heard the door open and frequently woke up screaming, “Stop!” She refused to enter the kitchen, the site of the violent assault.

Youth with PTSD experience recurrent, distressing memories of a shocking experience. As we saw with Jenna, they sometimes desperately want to avoid any cues associated with the event. The trauma that precipitates PTSD can include threats of or direct experience with death, serious injury, or sexual violation. Witnessing or hearing about the victimization of others can also result in PTSD, especially when a primary caregiver is involved. Memories of the event may entail (a) distressing dreams; (b) intense physiological or psychological reactions to thoughts or cues associated with the event; (c) episodes of playacting the event (sometimes without apparent distress); or (d) dissociative reactions, in which the child appears to reexperience the trauma or seems unaware of present surroundings. Children who experience trauma may appear socially withdrawn, show few positive emotions, or seem disinterested in activities they previously enjoyed.

Did You Know?

Sociocultural factors can affect how childhood disorders are defined and characterized. For example, in Thailand, where parenting techniques slow psychological maturation and prolong reliance on adults, children display problems involving dependence and immaturity that are not seen in the United States.

Source: Weisz, Weiss, Suwanlert, & Chaiyasit, 2006

According to DSM-5, behavioral evidence of PTSD in youth includes angry, aggressive behavior or temper tantrums; difficulty sleeping or concentrating; and exaggerated startle response or vigilance for possible threats (APA, 2013). Lifetime prevalence of PTSD among adolescents is 8 percent for girls and 2.3 percent for boys (Merikangas, He, Burstein, Swanson, et al., 2010). Trauma-focused cognitive-behavioral therapies have proven to be effective in treating childhood PTSD (Nixon, Sterk, & Pearce, 2012).

Nonsuicidal Self-Injury

Case Study

For the past year, Maria has been secretly cutting her forearms and thighs with a razor blade. She has tried to stop; however, when she feels anxious or depressed she thinks of the razor blade and the relief she experiences once she feels the cutting. Maria acknowledges that she has difficulty managing her emotions, particularly when she has conflicts with her parents or her friends. She does not understand why she cuts; she just knows it seems to help her cope when she is feeling upset. The more life hurts, the more she cuts.

Nonsuicidal self-injury  (NSSI) is a relatively new phenomenon that involves intentionally inflicted, superficial wounds. Those who engage in NSSI cut, burn, stab, hit, or excessively rub themselves to the point of pain and injury, but without suicidal intent. As we saw with Maria, intense negative thoughts or emotions and a preoccupation with engaging in self-harm (often accompanied by a desire to resist the impulse to self-injure) frequently precede episodes of self-injury. The DSM-5 has included NSSI as a diagnostic category undergoing further study; for a diagnosis, the individual must display these intentional behaviors at least 5 times over the course of a year.

Interpersonal difficulties, negative emotions, or a preoccupation with self-harm often occur just before a self-injury episode. Those who self-injure often expect that it will improve their mood, and many report that the pain produces relief from uncomfortable feelings or a temporary sense of calm and well-being. A secondary motivation for some who practice NSSI is that the self-injurious behavior serves as a form of self-punishment (Darosh & Lloyd-Richardson, 2013). NSSI is associated with increased risk of attempted suicide (Kerr, Muehlenkamp, & Turner, 2010). A negative cognitive style and negative self-talk are associated with increased frequency of NSSI and increased likelihood of suicidal behavior (Wolff et al., 2013).

Two thirds of those who engage in NSSI begin the behavior in early adolescence. NSSI occurs with similar frequency in both genders, although males are more likely to hit or burn themselves, whereas females more frequently cut themselves. It is estimated that approximately 14–17 percent of adolescents and young adults have engaged in self-injury at least once; only a minority engage in repeated self-injury. Although adolescent self-harming behavior usually resolves spontaneously, underlying emotional issues such as depression or anxiety often persist (Moran et al., 2012). Adolescents who self-injure often join interactive online groups composed of other teens who engage in this behavior. Although online communities may help these teens connect with others with similar issues, there is concern that these forums may trigger the urge for self-injury, normalize and reinforce self-injurious behavior, or lead them to believe that stopping the behavior is beyond their control (Mahdy & Lewis, 2013). An effective intervention for adolescents who engage in repeated NSSI is dialectical behavior therapy, which teaches distress tolerance and emotional regulation skills (Shapiro, Heath, & Roberts, 2013).

15-1bMood Disorders in Early Life

Depressive disorders in young people are most prevalent among females and older adolescents (Merikangas, He, Burstein, Swanson, et al., 2010). Environmental factors are a frequent cause of depression in childhood, whereas genetic and other biological factors exert more of an influence during adolescence. Children are especially vulnerable to environmental factors because they lack the maturity and skills to deal with stressors. Conditions such as childhood physical or sexual abuse, parental mental or physical illness, or loss of an attachment figure can increase vulnerability to depression (D. G. Rosenthal, Learned, Liu, & Weitzman, 2013). Adolescents with depression are at high risk of experiencing chronic depressive symptoms, especially if they do not receive treatment (Melvin et al., 2013).

Demi Lovato

Singer and actress Demi Lovato engaged in disordered eating and nonsuicidal self-injury during early adolescence to cope with her emotions and bullying from classmates. When receiving treatment for these conditions, it was discovered that her mood swings were also related to undiagnosed bipolar disorder.

American Idol 2012/FOX/Getty Images Entertainment/Getty Images

Evidence-based treatment for depression in youth includes individual or group cognitive-behavioral therapy, family-focused therapy, and programs focused on building resilience based on positive psychology principles (Cheung, Kozloff, & Sacks, 2013). Intervention is critical because of the strong association between depressive disorders and adolescent suicidal ideation and suicide attempts (Nock et al., 2013). Using selective serotonin reuptake inhibitors (SSRIs) to treat depressive disorders in youth, however, is an issue because SSRIs may increase suicidality in those younger than age 25. This risk led to U.S. Food and Drug Administration (FDA) warnings regarding the use of these medications for children and adolescents (Hammad, Laughren, & Racoosin, 2006). Subsequent data analysis has indicated that the benefits of using FDA-approved antidepressants may outweigh the risk of increased suicidality, especially among youth who are moderately to severely depressed (Soutullo & Figueroa-Quintana, 2013). Best practices support careful monitoring of suicidality in all children and adolescents who are depressed, with particular attention to those taking antidepressants (Miller, Swanson, Azrael, Pate, & Stürmer, 2014).

Disruptive Mood Dysregulation Disorder

Case Study

As an infant and toddler, Juan was irritable and difficult to please. Temper tantrums, often involving attempts to hit his parents, occurred multiple times daily. Juan’s parents had hoped he would outgrow this behavior; but at age 8, Juan is still frequently “grumpy” and has continued temper outbursts in many settings.

Disruptive mood dysregulation disorder  (DMDD) is characterized by chronic irritability and severe mood dysregulation, including recurrent episodes of temper triggered by common childhood stressors such as interpersonal conflict or being denied a request. As we saw with Juan, anger reactions are extreme in both intensity and duration, and may involve verbal rage or physical aggression toward people and property. According to DSM-5, DMDD is a depressive disorder; although behavioral symptoms are directed outward, they reflect an irritable, angry, or sad mood state. For a DMDD diagnosis the child’s mood between temper episodes must be irritable or angry most of the day, nearly every day. Further, the outbursts are present in at least two settings and occur at least 3 times per week for most months over the course of 1 year.

A Typical Tantrum or DMDD?

Many young children have difficulty regulating their emotions and display occasional temper tantrums. However, persistent irritable or angry behavior that continues beyond the preschool years may eventually result in a diagnosis of disruptive mood dysregulation disorder.

Ace Stock Limited/Alamy

2013).

The negative moods associated with DMDD often predict later depressive and anxiety disorders (Leibenluft, 2011). Many children diagnosed with DMDD also have comorbid disorders associated with emotional dysregulation such as depressive disorders or oppositional defiant disorder (Dougherty et al., 2014). Additionally, clinicians making a diagnosis of DMDD need to rule out pediatric bipolar disorder, due to the overlapping symptoms involving depression and mood changes (see Table 15.2); this differential diagnosis is important because interventions for these two disorders are quite different (Jairam, Prabhuswamy, & Dullur, 2012).

Table 15.2

​Disruptive Mood Dysregulation Disorder and Pediatric Bipolar Disorder

Source: APA (2013); Brotman, Schmajuk, et al. (2006); Merikangas, He, Burstein, Swanson, et al. (2010); S. E. Meyer et al. (2009).

Pediatric Bipolar Disorder

Pediatric bipolar disorder  (PBD) is a serious disorder that parallels the mood variability, depressive episodes, and significant departure from the individual’s typical functioning that characterizes adult bipolar disorder (Hauser, Galling, & Correll, 2013). PBD is illustrated in the following case study.

Case Study

Anna was a fairly cooperative, engaging child throughout her early years. However, around her 10th birthday, her behavior changed significantly. At times, she experienced periods of extreme moodiness, depression, and high irritability; on other occasions, she displayed boundless energy and talked incessantly, often moving rapidly from one topic to another as she described different ideas and plans. During her energetic periods, she could go for several weeks with minimal sleep.

Youth with PBD display mood changes and distinct periods of elevated energy and activity that may involve diminished need for sleep, distractibility, talkativeness, or inflated self-esteem (see Table 15.2). In addition to experiencing hypomanic/manic episodes, those with PBD may also display recurring depressive episodes or periods of uncharacteristic irritability that alternate with these energized episodes (Hunt et al., 2013). These symptoms can develop gradually or suddenly.

As was the case with Anna, the behavior represents a change from the child’s normal mood or temperament (APA, 2013). Youth with PBD often demonstrate rapid cycling of moods combined with difficulties in regulating behavior and social-emotional functioning (Olsavsky et al., 2012). Various brain abnormalities have been found in youth with this condition (Thomas et al., 2011). PBD often occurs in families with a history of bipolar illness and is likely to evolve into adult bipolar disorder or another chronic psychiatric disorder (B. I. Goldstein, 2012).

Did You Know?

Bullying can have serious effects on children’s physical and emotional well-being. During the school years, bullying is associated with increased risk of poor health and interpersonal difficulties in adulthood.

Source: Tsitsika et al., 2014

Lifetime prevalence in adolescents is estimated to be 3 percent, with 89 percent of those with PBD reporting severe impairment; there are no significant gender differences in prevalence (Merikangas, He, Burstein, Swanson, et al., 2010). Some experts in the field of bipolar disorder believe these prevalence rates are inflated and contend that some clinicians give this diagnosis too liberally, without ensuring that the child or adolescent meets full criteria for hypomania/mania (Weintraub et al., 2014). It is hoped that the new DMDD category will allow for greater diagnostic accuracy.

Medications, therapeutic techniques, and psychosocial intervention for PBD are similar to those used with adult bipolar disorder (Parens & Johnston, 2010). Family-focused interventions are particularly effective in teaching children to regulate their mood symptoms (Miklowitz et al., 2013). The use of lithium and antipsychotic medications with children, however, concerns some mental health professionals (T. Thomas, Stansifer, & Findling, 2011). Unfortunately, emergency room visits and hospitalizations are common for youth with PBD (Berry, Heaton, & Kelton, 2011), as are suicide attempts (Hauser et al., 2013).

Checkpoint Review

1. Why is it important to intervene early with internalizing disorders?

2. Compare and contract RAD and DSED.

3. What is nonsuicidal self-injury?

15-2Externalizing Disorders Among Youth

Externalizing disorders  (sometimes called disruptive behavior disorders) include disruptive, impulse control, and conduct disorders—conditions associated with symptoms that are distressing to others. Parenting a child with externalizing behaviors can be challenging and can result in negative parent–child interactions, high family stress, and negative feelings about parenting. As you can imagine, these factors can further exacerbate behavioral difficulties. Although early intervention can help interrupt the negative course of these disorders, diagnosing disruptive behaviors is controversial because it is difficult to distinguish externalizing disorders from one another and from the defiance and noncompliance commonly observed in children and adolescents.

Diagnosis of a disruptive, impulse control, or conduct disorder requires a persistent pattern of behavior that is (a) atypical for the child’s culture, gender, age, and developmental level, and (b) severe enough to cause distress to the child or to others or negatively affect social or academic functioning. Disorders in this category include oppositional defiant disorder, intermittent explosive disorder, and conduct disorder.

15-2aOppositional Defiant Disorder

Case Study

Mark’s parents and teachers know that when they ask Mark to do something, it is likely that he will argue and refuse to comply. He has been irritable and oppositional since he was a toddler. Mark’s parents have given up trying to enlist cooperation; they vacillate between ignoring Mark’s hostile, defiant behavior and threatening punishment. However, they are well aware that when Mark is punished, he finds ways to retaliate.

Oppositional defiant disorder  (ODD) is characterized by a persistent pattern of angry, argumentative, or vindictive behavior that continues for at least 6 months. These behaviors are directed toward parents, teachers, and others in authority. At least four symptoms involving short-tempered, resentful, blaming, spiteful, or hostile behaviors must be present. Similar to the response of Mark’s parents, adults sometimes begin to do whatever they can to avoid conflict, often without success. Although youth with ODD often argue, defy adult requests, and blame others, they do not demonstrate pervasive antisocial behavior or extreme verbal or physical aggression directed toward people, animals, or property (see Table 15.3). ODD is considered mild if symptoms occur only in one setting and severe if the behaviors occur in three or more settings.

Oppositional Defiant, Intermittent Explosive, and Conduct Disorder

Disorders Chart
Disorder	DSM-5 Criteria	Prevalence	Age of Onset	Course
Oppositional defiant disorder	· Angry, irritable mood · Hostile, defiant, and vindictive behavior · Frequent loss of temper, arguing, and defiance of adult requests · Failure to take responsibility for actions; blaming others · Behaviors continue for at least 6 months	6%–13%; more common in males	Childhood	May resolve, or evolve into a conduct disorder or depressive disorder
Intermittent explosive disorder	· Recurrent outbursts of extreme verbal or physical aggression or · 3 outbursts involving physical injury or damage within 1 year · Outbursts are impulsive or anger based and not premeditated · Outbursts cause marked distress or impairment in interpersonal functioning · Behaviors continue for at least 3 months	7.8% in a community sample of adolescents	Age 12 is the average age of onset (must be age 6 for the diagnosis)	May resolve, but anger episodes often continue into adulthood
Conduct disorder	· Aggression or cruelty to people or animals · Fire-setting or destruction of property · Theft or deceit (stealing, “conning” others) · Serious rule violations (truancy, running away) · Behaviors continue for at least 12 months	2%–9%; more common in males and in urban settings	Two types: childhood onset and adolescent onset (although onset is rare after age 16)	Prognosis poor with childhood onset; often leads to the criminal behaviors, antisocial acts, and problems in adult adjustment such as antisocial personality disorder

Source: APA (2013); Froehlich, Lanphear, Epstein, et al. (2007); McLaughlin et al. (2012); Merikangas, He, Burstein, Swanson, et al. (2010); Tynan (2008, 2010).

Did You Know?

Young children with little fear had frequent arrests for criminal activity as adults, according to a longitudinal study of 3-year olds. Individuals uninhibited by fear may have difficulty learning from the negative consequences associated with inappropriate behavior.

Source: Gao, Raine, Venables, Dawson, & Mednick, 2010

Although the symptoms of ODD often resolve, especially with intervention, ODD is associated with interpersonal difficulties in early adulthood (Burke, Rowe, & Boylan, 2014). Additionally, in some cases, youth with ODD begin to demonstrate the more serious rule violations associated with conduct disorder. ODD appears to have two components, one involving negative affect and emotional dysregulation (e.g., angry, irritable mood) and the other involving defiant and oppositional behavior; negative affect predicts future depressive symptoms, whereas oppositional behaviors are more predictive of delinquency and conduct disorder (Cavanagh, Quinn, Duncan, Graham, & Balbuena, 2014).

15-2bIntermittent Explosive Disorder

Intermittent explosive disorder  (IED) is a “prevalent, persistent, and seriously impairing” disorder that is both underdiagnosed and undertreated (McLaughlin et al., 2012). A diagnosis of IED involves (a) recurrent outbursts of extreme verbal or physical aggression that occur approximately twice weekly for at least 3 months (high-frequency/lower-intensity aggressive outbursts) or (b) three outbursts occurring within a 1-year period that involve damage or injury to people, animals, or property (low-frequency/high-intensity outbursts) (Coccaro, Lee, & McCloskey, 2014). The outbursts occur suddenly in response to minor provocation and do not involve premeditation; instead, they are exaggerated angry or impulsive reactions that cause distress or impair interpersonal functioning. Unlike the negative mood associated with DMDD, the child’s mood is normal between outbursts. A child must be at least 6 years old—an age when children are presumed to have learned to control their aggressive impulses—to receive this diagnosis (APA, 2013).

Not surprisingly, IED is associated with early exposure to familial aggression, violence, and interpersonal trauma (Nickerson, Aderka, Bryant, & Hofmann, 2012). IED may be diagnosed in individuals with attention-deficit/hyperactivity disorder, conduct disorder, or ODD if periodic explosive, aggressive outbursts occur and meet the criteria for IED (Coccaro, 2012). A comprehensive study involving 6,483 adolescents found that 63.3 percent of the adolescents interviewed had experienced anger outbursts in which they destroyed property or threatened violence, or behaved violently. In fact, 7.8 percent of the group had displayed behavior that met the criteria for IED (McLaughlin et al., 2012).

Myth vs Reality

Myth

Youth who set fires or shoplift are likely to develop serious mental disorders such as pyromania or kleptomania.

Reality

Pyromania (an irresistible impulse to start fires) and kleptomania (a compulsion to steal without economic motivation) are very rare impulse-control disorders. Fire-setting during childhood or adolescence often results from stress reactions, poor impulse control, or the antisocial attitudes seen in conduct disorders. However, it is only rarely associated with the extreme fascination and arousal associated with fire that occurs in pyromania. Similarly, most youth who shoplift do so for reasons other than the extreme impulse to steal associated with kleptomania (APA, 2013).

15-2cConduct Disorder

Case Study

Ben, a high school sophomore well known for his ongoing bullying and aggressive behavior, was expelled from school after stabbing another student. Two months later, he was arrested for armed robbery and placed in juvenile detention. Peer relationships at the facility were strained because of Ben’s ongoing attempts to intimidate others.

Conduct disorder  (CD) is characterized by a persistent pattern of antisocial behavior that reflects dysfunction within the individual (rather than a pattern of behavior accepted within the person’s subculture), and includes serious violations of rules and social norms and disregard for the rights of others. Diagnosis of CD requires the presence of at least three different behaviors involving (a) deliberate aggression (bullying, physical fights, use of weapons, cruelty to people or animals, aggressive theft, forced sexual contact); (b) destruction of property, including fire-setting; (c) theft or deceit (stealing, forgery, home or car invasion, “conning others”); or (d) serious violation of rules (staying out at night, truancy, running away). In many cases, as we saw with Ben, disorderly behavior increases or becomes more serious with age.

Boys with CD are often involved in confrontational aggression (e.g., fighting, aggressive theft), whereas girls are more likely to display truancy, substance abuse, or chronic lying. Approximately 2–9 percent of youth meet diagnostic criteria for CD; it is estimated that about half of those with CD also display inattention and hyperactivity (APA, 2013).

According to DSM-5, some youth diagnosed with CD have “limited prosocial emotions”—they display minimal guilt or remorse and are consistently unconcerned about the feelings of others, their own wrongdoing, or poor performance at school or work. They are good at manipulating others and may appear superficially polite and friendly when they have something to gain (APA, 2013). Cruelty, aggression, and a pervasive lack of remorse are common characteristics of this subgroup (R. E. Kahn, Frick, Youngstrom, Findling, & Youngstrom, 2012).

Youth with these callous, unemotional traits are unconcerned about their victims’ suffering or about possible punishment for their behavior (Pardini & Byrd, 2012). In fact, they show limited neural responsiveness in brain regions associated with empathy when presented with pictures of other people in pain—a reaction that differs significantly from that displayed by children without antisocial traits (Lockwood et al., 2013). In a study using magnetic resonance imaging (MRI), adolescents with CD and callous traits demonstrated strong pleasure responses to video clips of people experiencing pain and distress (Decety, Michalska, Akitsuki, & Lahey, 2009). Not surprisingly those with these traits are at high risk for continuing criminal behavior (Kahn, Byrd, & Pardini, 2013) and receiving a diagnosis of antisocial personality disorder in adulthood (Lubit, 2012).

15-2dEtiology of Externalizing Disorders

Externalizing disorders often begin in early childhood. The etiology of these disorders involves an interaction between biological, psychological, social, and sociocultural factors. Among the externalizing disorders, biological factors appear to exert the greatest influence on the development of CD, the disorder we will focus on in this etiological discussion (Figure 15.2).

Figure 15.2Multipath Model of Conduct Disorder

The dimensions interact with one another and combine in different ways to result in a conduct disorder.

© Cengage Learning®

Biological Dimension

Antisocial behavior has been linked to brain abnormalities associated with deficits in social information processing, as well as reduced activity in the amygdala in situations associated with fear (Sterzer, 2010); these deficits appear to decrease the ability to learn from rewards and punishments (Byrd, Loeber, & Pardini, 2014). Risk of CD is increased when carriers of the genotype “low-activity MAOA” (an allele associated with fear-regulating circuitry in the amygdala) are subjected to childhood maltreatment (Fergusson, Boden, Horwood, Miller, & Kennedy, 2012). Elevated stress hormones (cortisol) have been associated with symptoms of impulsive aggression, whereas low cortisol levels occur in youth with callous and unemotional traits and predatory aggression (Barzman, Patel, Sonnier, & Strawn, 2010).

Psychological, Social, and Sociocultural Dimensions

Both family and social context play a large role in the development of externalizing disorders (Parens & Johnston, 2010). A child’s early environment appears to moderate the relationship between individual vulnerability and the age at which antisocial behavior emerges; parents and teachers are able to exert more influence on the behavior of children with antisocial tendencies during childhood compared to adolescence, a period when peer influences predominate (Fairchild, van Goozen, Calder, & Goodyer, 2013).

In some cases, disruptive and aggressive behaviors are associated with harsh or inconsistent discipline (Pederson & Fite, 2014). Disruptive behavior may develop when parents respond to typical childhood misbehaviors in a punitive, inconsistent, or impatient manner. Parent–child conflict and power struggles can further intensify inappropriate behaviors. Patterson (1986) formulated a classic psychological-behavioral model of disruptive behavior based on the following pattern of parental reaction to misbehavior:

· The parent addresses misbehavior or makes an unpopular request.

· The child responds by arguing or counterattacking.

· The parent withdraws from the conflict or gives in to the child’s demands.

Bullying without Remorse

Children and adolescents with conduct disorder frequently engage in aggressive behavior and bully other students. Due to the pervasiveness of bullying behaviors, many schools have implemented curricula aimed at encouraging students to take a stand against bullying.

SW Productions/Stockbyte/Getty Images

If this pattern develops, the child does not learn to respect rules or authority. An alternate pattern that sometimes occurs involves a vicious cycle of harsh, punitive parental responses to misbehavior, resulting in defiance and disrespect on the part of the child and further coercive parental behaviors (Tynan, 2008). Limited parental supervision, permissive parenting and avoidance of conflict, excessive attention for negative behavior, inconsistent disciplinary practices, and failure to teach prosocial skills or use positive management techniques can further exacerbate disruptive behavior (Bernstein, 2012).

Difficult child temperament (e.g., irritable, resistant, or impulsive tendencies) contributes to behavioral conflict and increases the need for parents to learn and consistently apply appropriate behavior management skills. Similarly, these temperamental tendencies can lead to rejection by peers and a blaming, negative worldview, sometimes accompanied by aggressive behavior. Underlying emotional issues are common in CD and other disruptive behavior disorders. In fact, childhood externalizing behavior disorders are associated with the development of depressive disorders in adulthood (Loth, Drabick, Leibenluft, & Hulvershorn, 2014).

15-2eTreatment of Externalizing Disorders

Interventions that address the family and social context of behaviors, as well as deficits in psychosocial skills, can significantly improve externalizing behaviors (Parens & Johnston, 2010). A well-established intervention for externalizing disorders is cognitive-behavioral parent education; these programs teach parents to regulate their own emotions, increase positive interactions with their children, establish appropriate rules, and consistently implement consequences for inappropriate behavior. Parent-focused interventions can improve both child behavior and parent mental health (Furlong et al., 2013).

Did You Know?

Boys are more likely to show direct forms of bullying—intimidating, controlling, or assaulting other children. Girls demonstrate more relational aggression, such as threatening social exclusion.

Source: S. S. Leff & Crick, 2010

Psychosocial interventions that teach youngsters assertiveness and anger management techniques, and build skills in empathy, communication, social relationships, and problem solving, can also produce marked and durable changes in disruptive behaviors (Eyberg et al., 2008). Mobilizing adult mentors who demonstrate empathy, warmth, and acceptance is another effective intervention (Kazdin, Whitley, & Marciano, 2006). Although CD is particularly difficult to treat, success is increased when treatment begins before patterns of antisocial behavior are firmly established (Lubit, 2012).

Controversy

Are We Overmedicating Children?

Many medications are prescribed to treat childhood disorders, including antidepressants, tranquilizers, stimulants, and antipsychotics (Jonas, Gu, & Albertorio-Diaz, 2013). Medication use with children and adolescents has increased dramatically in recent years, with many prescriptions written by pediatricians and general practitioners rather than mental health specialists such as child psychiatrists (Olfson, Blanco, Wang, Laje, & Correll, 2014). However, controversy continues regarding overdiagnosis of some childhood disorders, the “quick fix” nature of medication, and the tendency to use medication without first attempting psychotherapy or other interventions (S. M. Berman, Kuczenski, McCracken, & London, 2009). For example, despite strong research supporting psychosocial interventions with ADHD, more than half of all children with ADHD have had no contact with a mental health professional in the previous year (Visser et al., 2014).

Another concern is that many medications prescribed for youth have only been tested on adults; thus, there is insufficient information regarding how these medications might affect the extensive brain development that occurs throughout childhood and adolescence. Many agree that we may not understand all adverse effects of these medications. For example, some antipsychotic medications can triple a child’s risk of developing diabetes even in the first year of use (Bobo et al., 2013). Additionally, there is limited evidence supporting the effectiveness of medications for many of the disorders for which they are prescribed (Jacobson, 2014). On the other hand, some contend that medication use with children can ameliorate the symptoms of mental disorders by normalizing brain functioning (Singh & Chang, 2012).

Many believe that medication should be considered only after comprehensive diagnostic evaluation and implementation of alternative interventions. Additionally, medication use is most successful when parents are aware of the specific symptoms being treated, possible side effects, and the prescriber’s plan for monitoring progress. How can we determine if medications are prescribed too freely and if their use with children is safe? What can parents do to ensure that adequate assessment and consideration of nonpharmaceutical interventions occur before medication is prescribed?