CU-MA-PSY-SEM-I-Developmental Disorders Child Psychopathology- Second Draft-converted

Social problems and peer group rejection have been found to contribute to delinquency. Low socioeconomic status has been associated with conduct disorders. Children and adolescents exhibiting delinquent and aggressive behaviours have distinctive cognitive and psychological profiles when compared to children with other Mental Health Disorders problems and control groups. A decrease of activity in frontal lobe functioning has been associated with poor ability to inhabit behavioral responses. This also leads to a weakness in planning ability. Empirically supported treatments Educating the parents of children with conduct disorders (CD) and providing them with information on the disorder are well-established treatments. Also, modifying the behavior in the classroom can be an effective treatment modality in children with conduct disorder (CD). Certain cognitive-behavioral approaches have been proven to be effective when working with children that have CD. It has been documented that children with CD have problems processing social information. This may include difficulty encoding social cues, interpreting these cues, developing social goals, and developing appropriate social responses. These cognitive-behavioral techniques are designed specifically to help children overcome these deficiencies in social cognition and social problem solving. Family therapy helps families gain an understanding of the problems with conduct disorder and how they can be corrected. Therapists evaluate how different family members interact in a therapy type environment. Typically, family therapy is directed towards helping parents work together as a whole, help them cope more efficiently, and to equip parents with better disciplinary skills. 12.4 ICD 10 CRITERIA F91.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2021 edition of ICD-10-CM F91.9 became effective on October 1, 2020. This is the American ICD-10-CM version of F91.9 - other international versions of ICD-10 F91.9 may differ. Applicable to • Behavioral disorder NOS 201 CU IDOL SELF LEARNING MATERIAL (SLM)

• Conduct disorder NOS • Disruptive behavior disorder NOS • Disruptive disorder NOS The following code(s) above F91.9 contain annotation back-references that may be applicable to F91.9: F01-F99 Mental, Behavioral and Neurodevelopmental disorders F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence F91 Conduct disorders Approximate Synonyms • Abnormal behavior • Abnormal behaviour • Behavior disorder • Conduct disorder • Stroke, late effects, behavioral/cognitive disorder Clinical Information A classification of disorders in the diagnostic and statistical manual of mental disorders (dsm) that are usually diagnosed in infancy, childhood or adolescence and are characterized by an individual's inability to behave in a cooperative manner. A disorder diagnosed in childhood or adolescence age group characterized by aggressive behavior, deceitfulness, destruction of property or violation of rules that is persistent and repetitive, and within a one year period. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. These behaviours include aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive conduct that causes property loss or damage, deceitfulness or theft, and serious violations of rules. The onset is before age 18. (from dsm-iv, 1994) Any of various conditions characterized by impairment of an individual's normal behavioral functioning, and caused by social, psychological, biochemical, genetic, or other factors, such as infection or head trauma. 202 CU IDOL SELF LEARNING MATERIAL (SLM)

Disorders characterized by persistent and repetitive patterns of behavior that violate societal norms or rules or that seriously impair a person's functioning. Compare behavior problems. Mental disorder of childhood and adolescence characterized by repetitive and persistent patterns of conduct in which rights of others and age-appropriate societal rules are violated; the conduct is more serious than ordinary mischief and pranks. Repetitive and persistent aggressive or nonaggressive behavior in which basic rights of others or social norms are violated. Self-esteem is generally low, and an inability to develop social relationships and lack of concern for others may or may not be present. 12.5 INCIDENCE As is the case with other psychiatric disorders of children, prevalence estimates of ODD and CD in the general population primarily employ surveys of parents, children, or both to arrive at diagnoses within a cohort and weights that estimate to the larger population. Some of these surveys, such as the National Comorbidity Survey, gather lifetime prevalence estimates among adults, while others focus on point-in-time estimates using parent surveys with or without teacher surveys and child interviews (Kessler, 2013). The lifetime prevalence of ODD was 10.2 percent in an adult community sample, with men at 11.2 percent and women at 9.2 percent (Nock et al., 2007). Almost all respondents with ODD reported comorbid mood, anxiety, or drug disorders, but, for the most part, the ODD occurred prior to the onset of other symptoms. The median duration of symptoms was 5 to 6 years. The adolescent replication of the National Comorbidity Study provided higher estimates of lifetime prevalence, with 12.6 percent of the sample positive for ODD (6.5 percent severe) and 6.8 percent positive for CD (Merikangas et al., 2010). Point prevalence estimates of ODD in children from community samples range from 2 to 16 percent, but most estimates from stratified community samples range from 1 to 3 percent. Cross-sectional prevalence varies by study design, ascertainment, and analyses, but the Centres for Disease Control and Prevention employed the National Survey of Children’s Health (NSCH) to provide a combined prevalence estimate for ODD and CD. In 2007, parent-reported data asking about prior diagnoses and conditions identified 4.6 percent (CI of 4.3–5.0 percent) of children aged 3–17 years with ODD or conduct disorder. An estimated 3.5 percent (CI of 3.1–3.8 percent) had a current condition (Perou et al., 2013). Boys were twice as likely as girls to have these conditions. Age was associated with an increased reporting of ODD and CD. 203 CU IDOL SELF LEARNING MATERIAL (SLM)

12.6 PREVALENCE There are cross-cultural studies. In a review of 25 studies, meta-regression analyses found no remarkable differences across countries and geography. The majority of differences in prevalence estimate were due to methodological differences in disorder assessment or calculation (Canino et al., 2010). Several of these methodological differences are worth highlighting because they underscore why estimates of prevalence do vary across studies. For example, one of the largest factors influencing prevalence rates of CD across countries in the cross-cultural comparison was the intensity of impairment required. Studies of significant impairment had low prevalence rates, but studies with no impairment had much higher rates of prevalence for CD. Maughan notes that the prevalence of conduct disorder varies by the survey of parent, child, teacher, or combinations of the aforementioned (Maughan et al., 2004). Parents and teachers often provide different ratings of ODD symptoms in children (O’Laughlin et al., 2010). Similarly, the strong predilection for males means that samples with larger portions of boys have higher rates. In 2000, Loeber and others examined several studies and concluded that trend data over several decades were suspect because of an increase in prevalence over time due to rising arrest rates and the use of retrospective recall studies (Loeber et al., 2000). They noted that recall studies might favour a trend toward greater recent prevalence. Since that time, arrest rates have actually declined for many crimes. In an effort to respond to studies postulating longitudinal increases in the prevalence of these conditions and other mental disorders, de Graaf and a team in the Netherlands looked at trends over time in the Netherlands Mental Health Survey and Incidence Study (NEMESIS) I and II (de Graaf et al., 2012). In the mid-1990s and again 10 years later, two cross-sectional surveys of adults were carried out that assessed lifetime prevalence of mental disorders in the Dutch population. The Dutch team found almost no changes in prevalence of any disorders that reached statistical or clinical significance. Their 2006 estimate of CD prevalence was 5.6 percent, and their estimate for ODD was 2.9 percent, with exclusivity between the two categories. They concluded that the prevalence of mental disorder was stable in the Dutch population over time, a conclusion echoed in the American population by Glied and colleagues (2010), although they did not look specifically at ODD and CD in children 12.7 CAUSES Symptoms of conduct disorder vary depending on the age of the child and whether the disorder is mild, moderate, or severe. In general, symptoms of conduct disorder fall into four general categories: 204 CU IDOL SELF LEARNING MATERIAL (SLM)

• Aggressive behavior: These are behaviours that threaten or cause physical harm and may include fighting, bullying, being cruel to others or animals, using weapons, and forcing another into sexual activity. • Destructive behavior: This involves intentional destruction of property such as arson (deliberate fire-setting) and vandalism (harming another person's property). • Deceitful behavior: This may include repeated lying, shoplifting, or breaking into homes or cars in order to steal. • Violation of rules: This involves going against accepted rules of society or engaging in behavior that is not appropriate for the person's age. These behaviours may include running away, skipping school, playing pranks, or being sexually active at a very young age. In addition, many children with conduct disorder are irritable, have low self-esteem, and tend to throw frequent temper tantrums. Some may abuse drugs and alcohol. Children with conduct disorder often are unable to appreciate how their behavior can hurt others and generally have little guilt or remorse about hurting others. The exact cause of conduct disorder is not known, but it is believed that a combination of biological, genetic, environmental, psychological, and social factors play a role. Biological: Some studies suggest that defects or injuries to certain areas of the brain can lead to behavior disorders. Conduct disorder has been linked to particular brain regions involved in regulating behavior, impulse control, and emotion. Conduct disorder symptoms may occur if nerve cell circuits along these brain regions do not work properly. Further, many children and teens with conduct disorder also have other mental illnesses, such as attention- deficit/hyperactivity disorder (ADHD), learning disorders, depression, substance abuse, or an anxiety disorder, which may contribute to the symptoms of conduct disorder. Genetics: Many children and teens with conduct disorder have close family members with mental illnesses, including mood disorders, anxiety disorders, substance use disorders and personality disorders. This suggests that a vulnerability to conduct disorder may be at least partially inherited. Environmental: Factors such as a dysfunctional family life, childhood abuse, traumatic experiences, a family history of substance abuse, and inconsistent discipline by parents may contribute to the development of conduct disorder. Psychological: Some experts believe that conduct disorders can reflect problems with moral awareness (notably, lack of guilt and remorse) and deficits in cognitive processing. 205 CU IDOL SELF LEARNING MATERIAL (SLM)

Social: Low socioeconomic status and not being accepted by their peers appear to be risk factors for the development of conduct disorder. As with adults, mental illnesses in children are diagnosed based on signs and symptoms that suggest a particular problem. If symptoms of conduct disorder are present, the doctor may begin an evaluation by performing complete medical and psychiatric histories. A physical exam and laboratory tests (for example, neuroimaging studies, blood tests) may be appropriate if there is concern that a physical illness might be causing the symptoms. The doctor will also look for signs of other disorders that often occur along with conduct disorder, such as ADHD and depression. If the doctor cannot find a physical cause for the symptoms, they will likely refer the child to a child and adolescent psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses in children and teens. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a child for a mental disorder. The doctor bases their diagnosis on reports of the child's symptoms and their observation of the child's attitudes and behavior. The doctor will often rely on reports from the child's parents, teachers, and other adults because children may withhold information or otherwise have trouble explaining their problems or understanding their symptoms. How is Conduct Disorder Diagnosed? As with adults, mental illnesses in children are diagnosed based on signs and symptoms that suggest a particular problem. If symptoms of conduct disorder are present, the doctor may begin an evaluation by performing complete medical and psychiatric histories. A physical exam and laboratory tests (for example, neuroimaging studies, blood tests) may be appropriate if there is concern that a physical illness might be causing the symptoms. The doctor will also look for signs of other disorders that often occur along with conduct disorder, such as ADHD and depression. If the doctor cannot find a physical cause for the symptoms, they will likely refer the child to a child and adolescent psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses in children and teens. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a child for a mental disorder. The doctor bases their diagnosis on reports of the child's symptoms and their observation of the child's attitudes and behavior. The doctor will often rely on reports from the child's parents, teachers, and other adults because children may withhold information or otherwise have trouble explaining their problems or understanding their symptoms. How Is Conduct Behavior Treated? • Psychotherapy: Psychotherapy (a type of counselling) is aimed at helping the child learn to express and control anger in more appropriate ways. A type of therapy called 206 CU IDOL SELF LEARNING MATERIAL (SLM)

cognitive-behavioral therapy aims to reshape the child's thinking (cognition) to improve problem solving skills, anger management, moral reasoning skills, and impulse control. Family therapy may be used to help improve family interactions and communication among family members. A specialized therapy technique called parent management training (PMT) teaches parents ways to positively alter their child's behavior in the home. • Medication: Although there is no medication formally approved to treat conduct disorder, various drugs may be used (off label) to treat some of its distressing symptoms (impulsivity, aggression, dysregulated mood), as well as any other mental illnesses that may be present, such as ADHD or major depression. Can Conduct Behavior Be Prevented? Although it may not be possible to prevent conduct disorder, recognizing and acting on symptoms when they appear can minimize distress to the child and family, and prevent many of the problems associated with the condition. In addition, providing a nurturing, supportive, and consistent home environment with a balance of love and discipline may help reduce symptoms and prevent episodes of disturbing behavior. 12.8 SUMMARY • Conduct disorder (CD) is very common among children and adolescents in our society. This disorder not only affects the individual, but his or her family and surrounding environment. Conduct disorder (CD) appears in various forms, and a combination of factors appear to contribute to its development and maintenance. • A variety of interventions have been put forward to reduce the prevalence and incidence of conduct disorder (CD). The optimum method appears to be an integrated approach that considers both the child and the family, within a variety of contexts throughout the developmental stages of the child and family’s life (Duff, 2005). • Conduct disorder is defined as a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. • Children or adolescents with conduct disorder exhibits aggressive behavior, such as bullying, threatening, initiating physical fights, cruelty towards animals, destruction of property, stealing and serious violations of rules in a variety of settings. • Conduct disorder symptoms are the most common primary presenting problems for psychiatric referral among children and adolescents in the United States, and youth diagnosed with conduct disorder have a higher degree of distress and impairment in virtually all domains of living than youth with other mental disorders. • The estimated lifetime prevalence of conduct disorder in the United States is 9.5% (12% in males and 7.1% in females) with median age of onset of 11.6 years. 207 CU IDOL SELF LEARNING MATERIAL (SLM)

• An epidemiological meta-analysis estimated that the worldwide prevalence of conduct disorder among children and adolescents aged 6–18 years is 3.2% and the prevalence estimate does not vary significantly across countries. • Conduct disorder can have its onset before ten years of age or in adolescence, and children with early-onset conduct disorder are at greater risk for persistent difficulties. Current data indicates that the prevalence of conduct disorder is 2–5% in children between 5–12 years and 5–9% in adolescents between 13–18 years. • Most studies show that boys are more likely to present with symptoms of conduct disorder than girls. However, this gender difference may vary somewhat across development. In young children under five years age, gender differences are small. • This changes in adolescence, where both genders show an increase in the rates of conduct disorder and boys are two to three times more likely to be diagnosed than girls. • Conduct disorder prevalence may or may not vary in different races and ethnicities depending on socioeconomic status, neighbourhood, and parenting practices. According to current data, the lifetime prevalence of conduct disorder is 6.9% in Hispanics, 4.9% in Blacks and 5.0% in Whites. • Caucasian children are more likely to be diagnosed with oppositional defiant disorder, whereas African American children are more likely to be diagnosed with conduct disorder. Male teens, minorities and children from low-income families are likely to be diagnosed with severe problems linked to neurological, attention, and conduct functioning . 12.9 KEYWORDS • Conduct disorder - a persistent and repeating pattern of violating the rights of others. chronic bullying, intimidation, physical fighting, cruelty to animals and people, and stealing are characteristics seen in this disorder. • Deceitfulness: The act or practice of deceiving: cunning, deceit, deception, double- dealing, duplicity, guile, shiftiness. • Bullying: Bullying the behaviour of a person who hurts or frightens someone smaller or less powerful, often forcing that person to do something they do not want to do: Bullying is a problem in many schools. • Vindictiveness: Vindictiveness is a strong desire to get back at someone. People who hold grudges and seek revenge are full of vindictiven. • Incidence: Ratio of the number of new cases of the disease occurring in a population during a specified time to the number of persons at risk for developing the disease during that period. 208 CU IDOL SELF LEARNING MATERIAL (SLM)

• Prevalence: Ratio of the number of cases of a specific disease present in a population at a specific time to the number of persons in the population at the time specified. 12.10 LEARNING ACTIVITY 1. Different cultures have different expectations from people. Can children with conduct disorder be considered as normal in certain cultures? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. Are oppositional defiant disorder and conduct disorder related? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 12.11 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are symptoms of conduct disorder 2. Explain impact of conduct disorder on child 3. Discuss symptoms of conduct disorder in Child vs. adult 4. Explain epidemiology of conduct disorder 5. Discuss etiology of conduct disorder Long Questions 1. Explain ICD-10 criteria in conduct disorder 2. Explain Clinical Information of conduct disorder 3. Discuss causes of conduct disorder 4. what is incidence of conduct disorder 5. what is prevalence of conduct disorder B. Multiple Choice Questions 1. Children with ____________ shows act of aggression towards others and animals. Shows no compassion and concern for others or their feelings. a. ADHD 209 CU IDOL SELF LEARNING MATERIAL (SLM)

b. CD c. ODD d. Down syndrome 2. These are behaviors that threaten or cause physical harm and may include fighting, bullying, being cruel to other animals, using weapons, and forcing another into sexual activity. a. Aggressive behavior b. Destructive behavior c. Deceitful behavior d. Violation of rules 3. ___________ is aimed at helping the children learn to express and control anger in more appropriate ways. a. Medication b. Counselling c. Exercise d. Psychotherapy 4. This behavior include repeated lying, shoplifting, or breaking into homes or cars in order to steal. a. Deceitful behavior b. Violation of rules c. Destructive behavior d. None of these 5. A mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one’s daily activities. a. Learning Disorder b. Hyperactivity Disorder c. Anxiety d. Permissive Answers 1-(b), 2-(a), 3-(d), 4-(a), 5-(c) 12.12 REFERENCES Textbook 210 CU IDOL SELF LEARNING MATERIAL (SLM)

• Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Klein RG, Abikoff H, Klass E, Ganeles D, Seese LM, Pollack S (1997), Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psychiatry • Krishnakumar P, Geeta MG (2006), Clinical profile of depressive disorder in children. Indian Pediatr. • Kutcher S, Aman M, Brooks SJ, Buitelaar J, van Daalen E, Fegert J, et al. (2004), International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol • Lahey B, Hart E, Pliszka S, Applegate B, McBurnett K (1993), Neurophysiological correlates of conduct disorder: a rationale and a review of research. J Clin Child Psychol . References: • Kerr M, Tremblay RE, Pagani L, Vitaro F.(1997), Boys behavioral inhibition and the risk of later delinquency.Arch Gen Psychiatry • Kerr, M., Tremblay, R. E., Pagani, L., (1997) Boys: behavioral inhibition and the risk of later delinquency.Archives of General Psychiatry • Kilgus M, PumariegaA, Cuffe S (1995), Influence of race on diagnosis in adolescent psychiatric inpatients. JAmAcad ChildAdolesc Psychiatry • Kim-Cohen J, Arseneault L, CaspiA, TomasMP, TaylorA, Moffit TE (2005),Validity of DSM-IV conduct disorder in4½-5 year old children:Alongitudinal epidemiological study.AmJ Psychiatry 211 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT –13 CONDUCT DISORDER – ASSESSMENT, PROGNOSIS & TREATMENT Structure 13.0 LearningObjectives 13.1 Introduction 13.2 Assessment with cognitive tests 13.3 Psychological Tests 13.4 Specific Syndrome tests 13.5 Prognosis and Treatment 13.6 Summary 13.7 Keywords 13.8 Learning Activity 13.9 Unit End Questions 13.10 References 13.0 LEARNINGOBJECTIVES After, studying this unit, you will be able to • Describe the process of assessment for conduct disorder. • Explain the psychological tests used by child psychologists • Describe the test used for conduct disorder • Explain the concept of prognosis with respect to conduct disorder • Explain the treatments available for conduct disorder 212 CU IDOL SELF LEARNING MATERIAL (SLM)

13.1 INTRODUCTION Conduct disorder is a type of behavior disorder. It’s when a child has antisocial behavior. He or she may disregard basic social standards and rules. He or she may also: • Be irresponsible. • Skip school or run away (delinquent behavior). • Steal or do other things to violate the rights of others. • Physically harm animals or other people, such as committing assault or rape. These behaviours sometimes happen together. But one or more may occur without the others. Experts believe that many factors play a role in conduct disorder. These are: • Brain damage • A traumatic event • Genes • Child abuse • Past school failure • Social problems Some children with conduct disorders seem to have a problem in the frontal lobe of the brain. This interferes with a child’s ability to plan, stay away from harm, and learn from negative experiences. Some experts believe that a series of traumatic experiences occurs for a child to develop a conduct disorder. These experiences then often lead to depressed mood, behavior problems, and involvement in a deviant peer group. A conduct disorder is more common in boys than in girls. It is also more likely to develop in children or teens who come from homes that are: • Disadvantaged • Dysfunctional • Disorganized • Children with these mental health problems are also more likely to have conduct disorder: • Mood or anxiety disorders • Posttraumatic stress disorder (PTSD) • Substance abuse • Attention-deficit/hyperactivity disorder (ADHD) 213 CU IDOL SELF LEARNING MATERIAL (SLM)

Learning Problems Children or teens who are considered to have a difficult temperament are more likely to develop behavior problems. A child psychiatrist or qualified mental health expert can diagnose a conduct disorder. He or she will talk with parents and teachers about the child’s behavior and may observe the child. In some cases, your child may need mental health testing. If you notice symptoms of conduct disorder in your child or teen, you can help by seeking a diagnosis right away. Early treatment can often prevent future problems. 13.2 ASSESSMENT WITH COGNITIVE TESTS Cognitive testing checks for problems with cognition. Cognition is a combination of processes in your brain that's involved in almost every aspect of your life. It includes thinking, memory, language, judgment, and the ability to learn new things. A problem with cognition is called cognitive impairment. The condition ranges from mild to severe. There are many causes of cognitive impairment. They include side effects of medicines, blood vessel disorders, depression, and dementia. Dementia is a term used for a severe loss of mental functioning. Alzheimer's disease is the most common type of dementia. Cognitive testing can't show the specific cause of impairment. But testing can help your provider find out if you need more tests and/or take steps to address the problem. There are different types of cognitive tests. The most common tests are: Montreal Cognitive Assessment (MoCA) The Montreal Cognitive Assessment (MoCA) is a brief 30-question test that takes around 10 to 12 minutes to complete and helps assess people for dementia. It was published in 2005 by a group at McGill University working for several years at memory clinics in Montreal. Here's a look at what the MoCA includes, how it's scored and interpreted, and how it can assist in identifying dementia. The MoCA evaluates different types of cognitive abilities. These include: • Orientation: The test administrator asks you to state the date, month, year, day, place, and city. 214 CU IDOL SELF LEARNING MATERIAL (SLM)

• Short-term memory/delayed recall: Five words are read, the test-taker is asked to repeat them, and they are read again and asked to repeat again. After completing other tasks, the person is asked to repeat each of the five words again and given a cue of the category that the word belongs to if they are not able to recall them without the cue. • Executive function/visuospatial ability: These two abilities are assessed through the Trails B Test, which requires you to draw a line to correctly sequence alternating digits and numbers (1-A, 2-B, etc.) and through a task which requires you to draw a copy of a cube shape. • Language abilities: This task consists of repeating two sentences correctly and then listing all of the words that can be recalled that begin with the letter \"F\". • Abstraction: You are asked to explain how two items are alike, such as a train and a bicycle. This measures your abstract reasoning, which is often impaired in dementia. The Proverb interpretation test is another way to test abstract reasoning skills. • Animal naming: Three pictures of animals are shown and the individual is asked to name each one. This is mainly used to test fluency. • Attention: The test-taker is asked to repeat a series of numbers forward and then a different series backwards to evaluate attention. • Clock-drawing test: Unlike the Mini-mental state exam (MMSE) which does not include the clock drawing test, the MoCA asks the person being evaluated to draw a clock that reads ten past eleven. It is important that this test is done in the patient's first language to be accurate. Mini-Mental State Exam (MMSE) The mini mental state examination (MMSE) is a commonly used set of questions for screening cognitive function. This examination is not suitable for making a diagnosis but can be used to indicate the presence of cognitive impairment, such as in a person with suspected dementia or following a head injury. The MMSE is far more sensitive in detecting cognitive impairment than the use of informal questioning or overall impression of a patient's orientation. • The test takes only about 10 minutes but is limited because it will not detect subtle memory losses, particularly in well-educated patients. • In interpreting test scores, allowance may have to be made for education and ethnicity. • The MMSE provides measures of orientation, registration (immediate memory), short-term memory (but not long-term memory) as well as language functioning. • The examination has been validated in a number of populations. Scores of 25-30 out of 30 are considered normal; the National Institute for Health and Care Excellence 215 CU IDOL SELF LEARNING MATERIAL (SLM)

(NICE) classifies 21-24 as mild, 10-20 as moderate and <10 as severe impairment. The MMSE may not be an appropriate assessment if the patient has learning, linguistic/communication or other disabilities (eg, sensory impairments). Before administering the MMSE it is important to make the patient comfortable and to establish a rapport. Praising success may help to maintain the rapport and is acceptable. However, persisting on items the patient finds difficult should be avoided Mini-Cog • The Mini-Cog© is a 3-minute instrument that can increase detection of cognitive impairment in older adults. It can be used effectively after brief training in both healthcare and community settings. It consists of two components, a 3-item recall test for memory and a simply scored clock drawing test. As a screening test, however, it does not substitute for a complete diagnostic workup. • Cognitive impairment is an important determinant of clinical outcomes, but is often unrecognized until a crisis develops. Proactive management, aimed at crisis prevention, depends on timely detection of cognitive impairment and care planning. Cognitive assessment is a first step to better management. • Cognitive impairment and dementia reflect impaired brain function. The brain is the only vital organ that is not routinely assessed in clinical practice, yet good brain function is essential for clinician-patient partnership. The causes of cognitive impairment and dementia can be primary brain diseases (most commonly Alzheimer’s disease, ischemic vascular disease, and conditions related to Parkinson’s disease) or secondary effects of systemic diseases, medications, and other conditions. Many chronic medical disorders, including diabetes, kidney disease, chronic obstructive pulmonary disease, and heart disease are associated with significant cognitive deficits that affect outcomes of treatment. People with cognitive impairment or dementia are often unaware of the extent or impact of their cognitive deficits and can look and act healthy in routine clinical encounters. • The Mini-Cog© can be used to screen for cognitive impairment quickly during both routine visits and other clinical settings. It serves to identify patients who need more thorough evaluation. All three tests measure mental functions through a series of questions and/or simple tasks. 13.3 PSYCHOLOGICAL TESTS Suppose that you are a psychologist. A new client walks into your office reporting trouble concentrating, fatigue, and feelings of guilt, loss of interest in hobbies and loss of appetite. 216 CU IDOL SELF LEARNING MATERIAL (SLM)

You automatically think that your client may be describing symptoms of depression. However, you note that there are several other disorders that also have similar symptoms. For example, your client could be describing post-traumatic stress disorder (PTSD), insomnia or a list of other psychological disorders. There are also some physical conditions, such as diabetes or congestive heart failure, which could result in the mental symptoms that your client is reporting. So, how do you determine which diagnosis, if any, you give your client? One tool that can help you is a psychological test or psychological assessments. These are instruments used to measure how much of a specific psychological construct an individual has. Psychological tests are used to assess many areas, including: • Traits such as introversion and extroversion • Certain conditions such as depression and anxiety • Intelligence, aptitude and achievement such as verbal intelligence and reading achievement • Attitudes and feelings such as how individuals feel about the treatment that they received from their therapists • Interests such as the careers and activities that a person is interested in • Specific abilities, knowledge or skills such as cognitive ability, memory and problem- solving skills It is important to note that not everyone can administer a psychological test. Each test has its own requirements that a qualified professional must meet in order for a person to purchase and administer the test to someone else. Psychological tests provide a way to formally and accurately measure different factors that can contribute to people's problems. Before a psychological test is administered, the individual being tested is usually interviewed. In addition, it is common for more than one psychological test to be administered in certain settings. Let's look at an example involving a new client. You might decide that the best way to narrow down your client's diagnosis is to administer the Beck Depression Inventory (BDI), PTSD Symptom Scale Interview (PSSI) and an insomnia questionnaire. You may be able to rule out a diagnosis or two based on the test results. These assessments may be given to your client in one visit, since they all take less than 20 minutes on average to complete. Types of Psychological Test; 1. Individual and Group Tests 2. Instrumental and Pencil Tests 217 CU IDOL SELF LEARNING MATERIAL (SLM)

3. Intelligence Tests 4. Potential Ability Tests 5. Personality Tests 6. Interest Tests. 7. Speed and Power Tests 8. Essay and Objective Tests 9. Language and Non-Language Tests 10. Computer-Assisted Tests 11. Thomas Profiling Hiring Technique Pros and Cons of Psychological Testing: The primary advantage of psychological tests, as a selection technique, is that they can improve the selection process. Tests provide insights about the individual candidate, which may not be revealed in an interview or through the qualifications and achievements listed. A testing programme such as the one developed by sears can be of great value to any organization. Psychological testing offers objectively and standardized behaviour sample which ends itself well to statistical evaluation. Tests are less susceptible to biased interpretations on the part of the examiner. Also, it is somewhat easier to conduct evaluative research on psychological tests than on some other methods of selection. A great deal of information about a person can usually be gathered in a relatively short period of time in using tests. In terms of predictive value, it is true that tests have been more useful in predicting success in training programmes than in predicting successful job performance. 13.4 SPECIFIC SYNDROME TESTS Neuropsychological tests are specifically designed tasks that are used to measure a psychological function known to be linked to a particular brain structure or pathway.[1] Tests are used for research into brain function and in a clinical setting for the diagnosis of deficits. They usually involve the systematic administration of clearly defined procedures in a formal environment. Neuropsychological tests are typically administered to a single person working with an examiner in a quiet office environment, free from distractions. As such, it can be argued that neuropsychological tests at times offer an estimate of a person's peak level of 218 CU IDOL SELF LEARNING MATERIAL (SLM)

cognitive performance. Neuropsychological tests are a core component of the process of conducting neuropsychological assessment, along with personal, interpersonal and contextual factors. Most neuropsychological tests in current use are based on traditional psychometric theory. In this model, a person's raw score on a test is compared to a large general population normative sample that should ideally be drawn from a comparable population to the person being examined. Normative studies frequently provide data stratified by age, level of education, and/or ethnicity, where such factors have been shown by research to affect performance on a particular test. This allows for a person's performance to be compared to a suitable control group, and thus provide a fair assessment of their current cognitive function. Categories: Most forms of cognition actually involve multiple cognitive functions working in unison, however tests can be organised into broad categories based on the cognitive function which they predominantly assess. Some tests appear under multiple headings as different versions and aspects of tests can be used to assess different functions. Intelligence Intelligence testing in a research context is relatively more straightforward than in a clinical context. In research, intelligence is tested and results are generally as obtained, however in a clinical setting intelligence may be impaired so estimates are required for comparison with obtained results. Premorbid estimates can be determined through a number of methods, the most common include: comparison of test results to expected achievement levels based on prior education and occupation and the use of hold tests which are based on cognitive faculties which are generally good indicators of intelligence and thought to be more resistant to cognitive damage, e.g. language. Memory Memory is a very broad function which includes several distinct abilities, all of which can be selectively impaired and require individual testing. There is disagreement as to the number of memory systems, depending on the psychological perspective taken. From a clinical perspective, a view of five distinct types of memory, is in most cases sufficient Semantic memory and episodic memory (collectively called declarative memory or explicit memory); procedural memory and priming or perceptual learning (collectively called non- declarative memory or implicit memory) all four of which are long term memory systems; and working memory or short term memory. Semantic memory is memory for facts, episodic memory is autobiographical memory, procedural memory is memory for the performance of 219 CU IDOL SELF LEARNING MATERIAL (SLM)

skills, priming is memory facilitated by prior exposure to a stimulus and working memory is a form of short term memory for information manipulation. Language Language functions include speech, reading and writing, all of which can be selectively impaired. Executive function Executive functions is an umbrella term for a various cognitive processes and sub- processes. The executive functions include: problem solving, planning, organizational skills, selective attention, inhibitory control and some aspects of short term memory. Visuospatial Neuropsychological tests of visuospatial function should cover the areas of visual perception, visual construction and visual integration. Though not their only functions, these tasks are to a large degree carried out by areas of the parietal lobe. Dementia specific Dementia testing is often done by way of testing the cognitive functions that are most often impaired by the disease e.g. memory, orientation, language and problem solving. Tests such as these are by no means conclusive of deficits, but may give a good indication as to the presence or severity of dementia. Batteries assessing multiple neuropsychological functions There are some test batteries which combine a range of tests to provide an overview of cognitive skills. These are usually good early tests to rule out problems in certain functions and provide an indication of functions which may need to be tested more specifically. Automated computerized cognitive tests Traditional cognitive examinations are mostly paper and pen based. As such most of them are time consuming and require special training to be carried out. Today there is a rapidly growing number of automated computerized cognitive tests emerging, for example Brain on Track, Cogstate, CAMCI, CANTAB. Several of these new tests are shoving promising ability to discriminate between healthy individuals and different cognitive difficulties and/or to monitor cognitive impairment over time. Since these tests are easily administered to large groups of people this is opening up possibilities to, for example, regularly screen portions of the population at risk for cognitive decline and early on give adequate support and treatment. Benefits: 220 CU IDOL SELF LEARNING MATERIAL (SLM)

The most beneficial factor of neuropsychological assessment is that it provides an accurate diagnosis of the disorder for the patient when it is unclear to the psychologist what exactly the patient has. This allows for accurate treatment later on in the process because treatment is driven by the exact symptoms of the disorder and how a specific patient may react to different treatments. The assessment allows the psychologist and patient to understand the severity of the deficit and to allow better decision-making by both parties. It is also helpful in understanding deteriorating diseases because the patient can be assessed multiple times to see how the disorder is progressing 13.5 PROGNOSIS AND TREATMENT A child psychiatrist or qualified mental health expert can diagnose a conduct disorder. He or she will talk with parents and teachers about the child’s behavior and may observe the child. In some cases, your child may need mental health testing. If you notice symptoms of conduct disorder in your child or teen, you can help by seeking a diagnosis right away. Early treatment can often prevent future problems. Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is. Treatment for conduct disorder may include: • Cognitive-behavioral therapy. A child learns how to better solve problems, communicate, and handle stress. He or she also learns how to control impulses and anger. • Family therapy. This therapy helps make changes in the family. It improves communication skills and family interactions. • Peer group therapy. A child develops better social and interpersonal skills. • Medicines. These are not often used to treat conduct disorder. But a child may need them for other symptoms or disorders, such as ADHD. Experts don’t know exactly why some children develop conduct disorder. Things such as a traumatic experience, social problems, and biological factors may be involved. To reduce the risk for this disorder, parents can learn positive parenting strategies. This can help to create a closer parent-child relationship. It can also create a safe and stable home life for the child. Early treatment for your child can often prevent future problems. Here are things you can do to help your child: • Keep all appointments with your child’s healthcare provider. 221 CU IDOL SELF LEARNING MATERIAL (SLM)

• Take part in family therapy as needed. • Talk to your child’s healthcare provider about other providers who will be involved in your child’s care. Your child may get care from a team that may include counselors, therapists, social workers, psychologists, and psychiatrists. Your child’s care team will depend on his or her needs and how serious the disorder is. • Tell others about your child’s conduct disorder. Work with your healthcare provider and schools to develop a treatment plan. • Reach out for support. Being in touch with other parents who have a child with conduct disorder may be helpful. If you feel overwhelmed or stressed out, talk with your healthcare provider about a support group for caregivers of children with conduct disorder. When shall I call my child’s healthcare provider? Call your healthcare provider right away if your child: • Feels extreme depression, fear, anxiety, or anger toward him or herself or others • Feels out of control • Hears voices that others don’t hear • Sees things that others don’t see • Can’t sleep or eat for 3 days in a row • Shows behavior that concerns friends, family, or teachers, and others express concern about this behavior and ask you to seek help Tips to help you get the most from a visit to your child’s healthcare provider: • Know the reason for the visit and what you want to happen. • Before your visit, write down questions you want answered. • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child. • Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are. • Ask if your child’s condition can be treated in other ways. • Know why a test or procedure is recommended and what the results could mean. • Know what to expect if your child does not take the medicine or have the test or procedure. • If your child has a follow-up appointment, write down the date, time, and purpose for that visit. 222 CU IDOL SELF LEARNING MATERIAL (SLM)

• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice. 13.6 SUMMARY • Conduct disorder (CD) is a behavioural problem in children and adolescents, which may involve aggression and law-breaking tendencies. • Behaviours include aggression to animals and other people, and law-breaking activities such as deliberately lighting fires, shoplifting and vandalism. • The child’s family life is a significant risk factor in the development of CD. • Treatment options include behaviour therapy, psychotherapy, parent management training and functional family therapy. • Conduct disorder (CD) refers to a set of problem behaviours exhibited by children and adolescents, which may involve the violation of a person, their rights or their property. • It is characterised by aggression and, sometimes, law-breaking activities. • CD is one of a group of behavioural disorders known collectively as disruptive behaviour disorders, which include oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). • Early intervention and treatment is important, since children with untreated CD are at increased risk of developing a range of problems during their adult years including substance use, personality disorders and mental illnesses. • A child who ultimately develops CD is usually irritable and temperamental during babyhood – although most difficult babies do not develop conduct disorder. The milder oppositional defiant disorder (ODD) usually develops before CD. Constant defiance, hostility and a hair-trigger temper are common characteristics of ODD. • Around one-third of children with CD also have attention deficit hyperactivity disorder (ADHD). One in five children with CD are depressed. CD is typically diagnosed when the child is between 10 and 16 years of age, with boys generally diagnosed at an earlier age than girls. • The causes of disruptive behaviour disorders are unknown but researchers have found that while not all children with CD have family difficulties a child’s family life is a strong risk factor for many 13.7 KEYWORDS • Cognitive testing: Cognitive testing, also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental conditions exist. 223 CU IDOL SELF LEARNING MATERIAL (SLM)

• Psychological assessment: Psychological assessment is a series of tests conducted by a psychologist, to gather information about how people think, feel, behave and react. • Cognitive test: Cognitive test measures a person’s cognitive abilities— problem solving, reasoning, vocabulary, comprehension, and memory. • Educational testing: Educational testing is conducted to test how much an individual has progressed in learning a specific subject—like mathematics, reading comprehension—to identify any difficulties they may have had in it. • Neuropsychological tests: Neuropsychological tests analyse how an individual’s brain works, in order to identify any problems in its functioning. 13.8 LEARNING ACTIVITY 1. What are the chances of therapy helping a child with conduct disorder? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. What role does the legal system have in conduct disorder management? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 13.9 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is cognitive testing in Conduct disorder? 2. What is cognitive testing used for in Conduct disorder? 3. Why do we need cognitive testing in Conduct disorder? 4. What are diagnostic tests during pregnancy in Conduct disorder 5. What are diagnostic tests for new-borns in Conduct disorder Long Questions 224 1. Write a note on Prognosis and Treatment in Conduct disorder 2. Write a note on Specific Syndrome Tests in Conduct disorder 3. Write a note on Psychological Tests in Conduct disorder 4. What is Cognitive behavioural therapy CU IDOL SELF LEARNING MATERIAL (SLM)

5. What is Family therapy and Multisystemic therapy? B. Multiple Choice Questions 1. Experts believe that many factors play a role in conduct disorder. Except: a. Genes b. Child abuse c. Traumatic event d. All of these 2. A ___________ test may be used to differentiate between dementia and depression. a. Psychological test b. Cognitive Test c. Neuropsychological Test d. Motor Test 3. ____________, according to MedlinePlus, can be a determinant in the rest of the cognitive assessment. a. Attention span b. Understanding c. Intelligence d. Ability 4. A type of disorder where a child exhibits antisocial behavior. He/she may disregard social standards and rules. a. Oppositional Defiant Disorder b. Attention deficit hyperactivity disorder c. Anxiety d. Dementia 5. A brain disorder that affects how you pay attention, sit still, and control your behavior. a. Learning disorder b. Permissive c. Hyperactivity disorder d. Attention span Answers 1-(d), 2-(c), 3-(a), 4-(a), 5-(c) 225 CU IDOL SELF LEARNING MATERIAL (SLM)

13.10 REFERENCES Textbook • Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Maguin E, Loeber R, LeMahieu P (1993), Does the relationship between poor reading and delinquency hold for different age and ethnic groups? J Emotional Behav Disorders • Malhotra AK, Virkkunen M, Rooney W, Eggert M, Linnoila M, Goldman D (1996), The association between the dopamine D4 receptor (DRD4) 16 amino acid repeat polymorphism and novelty seeking. Mol Psychiatry • Malhotra S, Varma VK, Verma SK, Malhotra A (1988), Childhood psychopathology measurement schedule: development and standardization. Indian J Psychiatry 30:325- 31 • Malhotra S, Aga VM, Balraj, Gupta N (1999), Comparison of conduct disorder and Hyperkinetic conduct disorder:Aretrospective clinical study from North India. Ind J Psychiatry • Malhotra S, Kohli A, Arun P (2002), Prevalence of psychiatric disorders in school children in Chandigarh, India. Indian JMedRes References: • Lewis M, MichalsonL(1983), Children’s emotions and moods.NewYork: Plenum. • Liu J (2004), Childhood Externalizing Behavior: Theory and Implications. J Child Adolesc Psychiatr Nurs • Lochman JE (1992), Cognitive-behavior intervention with aggressive boys: three-year follow-up and preventive effects. J Consult Clin Psychol 1992 • 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. JAmAcad ChildAdolesc Psychiatry 226 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT –14 CASE STUDIES Structure 14.0 LearningObjectives 14.1 Introduction 14.2 Case of Emily 14.3 Case of Bili 14.4 Summary 14.5 Keywords 14.5 Learning Activity 14.6 Unit End Questions 14.7 References 14.0LEARNINGOBJECTIVES After studying this unit, you will be able to: • Explain the prevalence for oppositional Defiant disorder and Conduct Disorder through different case studies • Explain the symptoms for oppositional Defiant disorder and Conduct Disorder through different case studies • Explain the treatment for oppositional Defiant disorder and Conduct Disorder through different case studies 14.1 INTRODUCTION A group of disorders involves a child’s or an adolescent’s relationship to social norms and rules of conduct. In both oppositional defiant disorder and conduct disorder, aggressive or antisocial behavior is the focus. As we will see, oppositional defiant disorder is usually apparent by about age 8, and conduct disorder tends to be seen by age 9. These disorders are closely linked (Thomas, 2010). However, it is important to distinguish between persistent 227 CU IDOL SELF LEARNING MATERIAL (SLM)

antisocial acts—such as setting fires, where the rights of others are violated—and the less serious pranks often carried out by normal children and adolescents. Also, oppositional defiant disorder and conduct disorder involve misdeeds that may or may not be against the law; juvenile delinquency is the legal term used to refer to violations of the law committed by minors. Commonly comorbid with ODD are ADHD, learning disorders,and communication disorders, but ODD is different from ADHD inthat the defiant behavior is not thought to arise from attentional deficitsor sheer impulsiveness. One manifestation of difference is that childrenwith ODD are more deliberate in their unruly behavior than childrenwith ADHD. Although conduct disorder is three to four times morecommon among boys than among girls, research suggests that boysare only slightly more likely to have ODD, and some studies find nodifference in prevalence rates for ODD between boys and girls In this unit, we will see six different case of oppositional defiant disorder and conducr disorder. 14.2 CASE OF EMILY Emily is 15-year-old girl from a middleclassCaucasian background who had a history of depressionduring her childhood. She had periods of low mood, poor selfesteem,and social withdrawal. She also had symptoms of anxietyand was very reluctant to leave her home. During her year inthe seventh grade, she became so fearful of going to schoolthat she missed so many days she had to repeat the grade. Shecurrently is in the eighth grade and has, to this point, missed agreat deal of school. Her family became very concerned overEmily’s low mood and isolation, so they enrolled her in an outpatienttreatment program for depression, anxiety episodes,and eating disorders. Her depression continued, and shebecame more isolated, lonely, and depressed and would notleave her room even for meals. One day her grandmother foundher in their car in the garage with the engine running in aneffort to end her life. Emily was admitted into an inpatient treatmentprogram following her serious suicide attempt. There is a history of psychiatric problems, particularly mooddisorders, in her family. Her mother has been hospitalized on threeoccasions for depression. Her maternal grandfather, now deceased,was hospitalized at one time following a manic depressive episode.In the early phases of her hospitalization, Emily underwentan extensive psychological and psychiatric evaluation. Shewas administered a battery of tests, including the MinnesotaMultiphasic Personality Inventory for Adolescents (MMPI-A). Shewas cooperative with the evaluation 228 CU IDOL SELF LEARNING MATERIAL (SLM)

and provided the assessmentstaff with sufficient information regarding her mood andattitudes to assist in developing a treatment program. Emily showed many symptoms of a mood disorder in whichboth depression and anxiety were prominent features. The psychologicalevaluation indicated that she was depressed, anxious,and felt unable to deal with the school stress that her conditionprompted. Moreover, her physical appearance and eating behaviorsuggested the strong likelihood of anorexia nervosa. Emily showedan extreme degree of social introversion on several measures andacknowledged her reticence at engaging in social interactions. Theassessment psychologist concluded that her personality characteristicsof social withdrawal, isolation, and difficult interpersonal relationshipswould likely result in her having problems in establishing atherapeutic relationship. Her treatment program involved supportivecognitive therapy along with antidepressant medication. Although she endorsed a broad range of anxiety symptoms,in her testing and in the intake interview she endorsed few itemsregarding suicidal ideation. This was not sufficient evidence tosupport a conclusion that she was at less risk for suicide; however,it could simply reflect her unwillingness to openly discussher recent attempt. Her past behavior and low mood indicateda need to consider the possibility of further suicide attempts. She remained in inpatient treatment for 3 weeks and wasdischarged with the summary that she had shown substantialimprovement. She was, however, referred for further psychologicaltreatment on an outpatient basis. 14.3 CASE OF BILL Bill, aged 11, was referred by his social worker for treatment following an incident in which he had assaulted neighbours by climbing up onto the roof of his house and throwing rocks and stones at them. He also had a number of other problems according to the school headmaster, including academic underachievement, difficulty in maintaining friendships at school, and repeated school absence. He smoked, occasionally drank alcohol, and stole money and goods from neighbours. His problems were long-standing but had intensified in the six months preceding the referral. At that time his father, Paul, was imprisoned for raping a young girl in the small rural village where the family lived. From the genogram it may be seen that Bill was one of five boys who lived with his mother at the time of the referral. The family lived in relatively chaotic circumstances. Prior to Paul’s imprisonment, the children’s defiance and rule breaking, particularly Bill’s, were kept in check by their fear of physical punishment from their father. Since his incarceration, there were few house rules and these were implemented inconsistently, so all of the children 229 CU IDOL SELF LEARNING MATERIAL (SLM)

showed conduct problems, but Bill’s were by far the worst Rita had developed intense coercive patterns of interaction with Bill and John (the second eldest). In addition to the parenting difficulties, there were also no routines to ensure bills were paid, food was bought, washing was done, homework was completed, or regular meal and sleeping times were observed. Rita supported the family with welfare payments and money earned illegally from farm work. Despite the family chaos, shewas very attached to her children and would sometimes take them to work with her rather thansend them to school because she liked their company. At the preliminary interview, Rita said that ‘her nerves were in tatters’. She was attending apsychiatrist intermittently for pharmacological treatment of depression. She had a long- standinghistory of conduct and mood-regulation problems, beginning early in adolescence. In particularshe had conflictual relationships with her mother and father, which were characterised bycoercive cycles of interaction. In school she had academic difficulties and peer-relationshipproblems. Paul, the father, also had long-standing difficulties. His conduct problems began in middlechildhood. He was the eldest of four brothers, all of whom developed conduct problems, but hiswere by far the most severe. He had a history of becoming involved in aggressive exchanges thatoften escalated to violence. He and his mother had become involved in coercive patterns ofinteraction from his earliest years. He developed similar coercive patterns of interaction atschool with his teachers, at work with various gangers, and also in his relationship with Rita. Hehad a distant and detached relationship with his father. Rita had been ostracised by her own family when she married Paul, whom they saw as anunsuitable partner for her, since he had a number of previous convictions for theft and assault.Paul’s family never accepted Rita, because they thought she had ‘ideas above her station’. Rita’sand Paul’s parents were in regular conflict, and each family blamed the other for the chaoticsituation in which Paul and Rita had found themselves. Rita was also ostracised by the villagecommunity in which she lived. The community blamed her for driving her husband to commitrape. On child behaviour checklists all four of the boys obtained externalising behaviour problem scores in the clinical range, but Bill’s were by far the most extreme. On teacher report forms, of the five boys, only Bill obtained an externalising behaviour problem score in the clinical range. A psychometric evaluation of Bill’s abilities with the WISC-III and the WRAT-3 showed that he was of normal intelligence, but his attainments in reading, spelling and arithmetic fell below the 10th percentile. From his WISC-III subtest profile, which included particularly low scores on Digits Span and Coding subtests, it was concluded that the 230 CU IDOL SELF LEARNING MATERIAL (SLM)

discrepancy between attainment and abilities was accounted for by a specific learning disability. The headmaster at the school which Bill and his brothers attended confirmed that Bill had academic, conduct and attainment problems, but the headmaster, Mr Dempsey, was committed to educating the boys and managing their conduct and attendance problems in a constructive way. Mr Dempsey had a reputation (of which he was very proud) for being particularly skilled in managing children with problems. Bill was an 11-year-old boy with a persistent and broad pattern of conduct problems both within and outside the home. He also had a specific learning disability and peer-relationships problems. Factors which predisposed Bill to the development of these problems include a difficult temperament, a developmental language delay, exposure to paternal criminality, maternal depression, and a chaotic family environment. The father’s incarceration six months prior to the referral led to an intensification of Bill’s conduct problems. These were maintained at the time of the referral by engagement in coercive patterns of interaction with his mother and teachers; rejection of Bill by peers at school; and isolation of his family by the extended family and the community. Protective factors in the case included the mother’s wish to retain custody of the children rather than have them taken into foster care; the children’s sense of family loyalty; and the school’s commitment to retaining and dealing with the boys rather than excluding them for truancy and misconduct. The treatment plan in this case involved a multisystemic intervention programme. The mother was trained in behavioural parenting skills. A series of meetings between the teacher, the mother and the social worker was convened to develop and implement a plan that ensured regular school attendance. Occasional relief foster care was arranged for Bill and John (the second eldest) to reduce the stress on Rita. Social skills training was provided for Bill to help him deal with peer-relationship problems. 14.4SUMMARY • Conduct problems are the most common type of referral to child and family out- patient clinics. Children with conduct problems are a treatment priority because the outcome for more than half of these youngsters is very poor in terms of criminality and psychological adjustment. In the long term the cost to society for unsuccessfully treated conduct problems is enormous. • Co-morbidity for conduct disorders and both ADHD and emotional problems such as anxiety and depression is very high, particularly in clinic populations. The central clinical features are defiance, aggression and destructiveness; anger and irritability; 231 CU IDOL SELF LEARNING MATERIAL (SLM)

pervasive relationship difficulties within the family, school and peer group; and difficulties with social cognition. Specifically, there is a failure to internalise social norms and a negative bias in interpreting ambiguous social situations. • Treatment of conduct problems must be based on a comprehensive formulation of the child’s and family’s difficulties which takes account of predisposing, precipitating and maintaining factors within the child, the family and the wider social system. Such formulations should be based on thorough multisystemic assessment. 14.5KEYWORDS • oppositional defiant disorder. An externalizing disorder of children marked by high levels of disobedience to authority but lacking the extremes of conduct disorder. 14.5 LEARNING ACTIVITY 1. Explain how the cases progressed over time? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. What is the prognosis in the cases discussed in the chapter? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 14.6 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Exaplin the comorbity of Emily? 2. What was the background of Emily? 3. Why was bill refered by a social worker? 4. What was bili provided training for? 5. Why did emily miss her school? Long Questions 1. Explain the difficulties faced by Emily and how she was helped to overcome them? 2. What were the challenges faced by Emily in school? 232 CU IDOL SELF LEARNING MATERIAL (SLM)

3. What is similarity between Bili nad John? 4. What was the plan of intervention planed for Bili? 5. Explain the imoact of family on Rita. B. Multiple Choice Questions 1. Emily’s symtoms included: a. low mood b. poor selfesteem c. withdrawal d. All of these 2. Emily had a history of . a. ADHD b. Mental retardation c. depression d. Down syndrome 3. Also known as behavior modification. a. Behavioral therapy b. Cognitive Behavioral therapy c. Cognitive Therapy d. Medication Therapy 4. Bill was suffering from. a. Learning disorderr b. Conduct Disorder c. Social Communication Disorder d. Child Mental Disorder 5. What was provided for Bill to help him deal with peer-relationship problems? a. Personal therapy b. Behavioural therapy c. Social skill training d. None of the above Answers 1-(d), 2-(c), 3-(a), 4-(b), 5-(c) 233 CU IDOL SELF LEARNING MATERIAL (SLM)

14.7 REFERENCES Textbooks • Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. 234 CU IDOL SELF LEARNING MATERIAL (SLM)