UNIT 8: DISRUPTIVE BEHAVIOUR DISORDERS PART II STRUCTURE 8.0 Learning Objectives 8.1 Introduction 8.2 Assessment with Cognitive Tests 8.3 Psychological Tests 8.4 Specific Syndrome Tests 8.4 Prognosis and Treatment 8.5 Summary 8.6 Keywords 8.7 Learning Activity 8.8 Unit End Questions 8.9 References 8.0 LEARNING OBJECTIVES After studying this unit, students will be able to: • Assess disruptive behaviour disorder using Cognitive Testing • Explain Psychological Testing and Specific Syndrome Testing for disruptive behaviour disorder • Explain prognosis and treatment of disruptive behaviour disorder 8.1 INTRODUCTION Disruptive Behavior Disorders (DBD) are those most commonly referred by parents and teachers for professional help (Kazdin, Siegel, & Bass, 1990; Wells & Forehand, 1985) and also the most common mental health problems presented in paediatricians’ offices. * The assessment, differential diagnosis, and treatment of DBD thus require careful consideration. The foundation for any such assessment includes the definition of the disorder and the specific criteria to be used in its diagnosis. Any child may display DBD to some degree at specific times or in certain settings, but in order to be considered clinically significant, they 201 CU IDOL SELF LEARNING MATERIAL (SLM)
must exceed the range of normal for the child’s age group in terms of frequency, pervasiveness, severity, and interference with the child’s ability to function adaptively (see Chapter 1, this volume). At older ages, these DBD and maladaptive interactions tend to have greater chronicity and severity. We use the term disruptive behavior disorder (DBD) to include the behaviours associated with Conduct Disorder, Oppositional Defiant Disorder, and Attention-Deficit/ Hyperactivity Disorder, whether these are conceptualized categorically or dimensionally and whether or not a formal diagnosis is warranted. Other terms in the literature that are also subsumed by our term DBD are \"externalizing,\" \"acting-oue,\" and \"disruptive behaviour problems.\" 8.2 ASSESSMENT WITH COGNITIVE TESTS The way you perform daily tasks, how you retain and use information, and how your brain wholly functions can collectively be called “cognition.” Cognition is essentially your day-to- day functioning as well as how you can spatially, verbally, and logically relate and problem- solve. When one is affected by mental illness, one or more of these areas can be impaired. Cognitive testing, also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental conditions exist. If so, this testing allows one to determine if said condition is getting better or worse. Assessments of this kind can be used in mental health facilities or for employment screenings. Early versions of cognitive tests were established around 100 years ago and developed through the ages. “Pencil and pen” tests were widely used up until the advent of computerized testing in the 1970s and 1980s. These new tests offered more accurate data reporting and a better assessment on response time. Cognition tests are not necessarily considered intelligence tests, or IQ tests. As reported by Cog State, an Australian cognitive science and technology company, these assessments measure three common areas of cognition: memory, executive function, and attention. Of course, these areas have more specific facets. The questions asked during a cognitive test aim to explore basic function and these areas. Some cognitive regions that may be tested are: • Physical appearance including age, weight, height, and other vitals. This can help differentiate mental and physical conditions. This can be useful in the case of substance abuse or alcohol dependency. • Orientation of basic information such as your name, the date, the season, where you live, and names of family members. As confusion can be associated with some mental illnesses, this can help make a better and more accurate diagnosis. • Attention span, can be a determinant in the rest of the cognitive assessment. This tests your ability to complete a thought and think rationally. This portion of an assessment also looks at how easily you are distracted. 202 CU IDOL SELF LEARNING MATERIAL (SLM)
• Recent past and memory can include questions on childhood memories, family members, your current job or living situation, or current events. As memory can be impacted with certain mental illnesses or substance addictions, it’s important to understand if and how severely memory has been impaired. • Language testing involves your ability to read, write, and speak clearly. Testing may involve you writing or reading sentences or saying words out loud. • Judgment can be largely subjective but the questions generally asked during this stage of testing help a physician to understand any impairment to reasoning and problem- solving abilities. Questions might include moral decisions like what might you do if you found someone’s wallet or if you got pulled over by the police while driving. 8.3 PSYCHOLOGICAL TESTS Psychological assessment is a series of tests conducted by a psychologist, to gather information about how people think, feel, behave and react. The findings are used to develop a report of the person’s abilities and behavior—known as a psychological report—which is then used as a basis to make recommendations for the individual’s treatment. Psychological assessments and reports are used in other fields as well—like in the case of career planning for young adults or in the job application process to determine how well an applicant will fit into the open role. The procedures used to create an assessment are: • Interviews • Observation • Written assessment • Consultation with other mental health professionals • Formal psychological tests Psychological assessment is also used in other fields, like: • Education—to assess a student’s ability to learn, and progress in the classroom • Legal system—to assess the mental health status of a person What is a psychological test? A psychological test is used to measure an individual’s different abilities, such as their aptitude in a particular field, cognitive functions like memory and spatial recognition, or even traits like introverted. These tests are based on scientifically tested psychological theories. The format of a test can vary from pencil and paper tasks to computer-based ones. They include activities such as puzzle-solving, drawing, logic problem solving, and memory games. 203 CU IDOL SELF LEARNING MATERIAL (SLM)
Some tests also use techniques—known as projective techniques—which aim to access the unconscious. In these instances, the subject’s responses are analyzed through psychological interpretation and more complex algorithms than the non-projective techniques mentioned above. For example, the Rorschach test, popularly known as the ink-blot test can provide insight into the person’s personality and emotional functioning. Psychological tests may also involve observing someone’s interactions and behavior. Based on the result of the test, an inference will be drawn about the individual’s inherent abilities and potential. Psychological testing covers a number of different areas: Mental health assessment A mental health assessment includes information about a person’s medical history, their family history, and the current status of their mental health. The assessment helps identify if there are any mental health issues present, and determine a diagnosis and treatment accordingly. A psychologist or psychiatrist is likely to start an appointment with a mental health assessment, which will enable them to correctly diagnose and treat you. Adaptive behavior assessments This measures the social and practical skills of a person, to determine their ability to function on a daily basis at home, school or work; and are usually conducted along with cognitive tests. For example, it may be used to assess a child’s ability to function in social activities with other students in school. Aptitude testing An aptitude test measures a person’s ability to perform different kinds of tasks. This is done to determine the areas in which their skills are the strongest. Some people may be better with quantitative tasks that require math and logical reasoning skills, some at language, and some at creative thinking. These tests are used by vocational therapists to measure ability, and figure out the kind of professions or job roles a person may be suited for. They may also be used by career counsellors to guide people towards higher education in fields where they demonstrate high ability. Cognitive testing 204 CU IDOL SELF LEARNING MATERIAL (SLM)
A cognitive test measures a person’s cognitive abilities— problem solving, reasoning, vocabulary, comprehension, and memory. They are more commonly known as intelligence or IQ tests, and are used in the field of education to identify a person’s strengths and potential. For instance, a child may be given a cognitive test to measure their ability in different subjects; allowing educators to help the child work on the subjects they’re having trouble with. Educational/achievement 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. Achievement tests are the examinations that students take in schools and colleges. Forensic psychological testing Forensic testing is used in the legal field, to determine whether a suspect is capable of committing the crime they have been accused of. It comprises cognitive, personality, and neuropsychological tests. Neuropsychological testing Neuropsychological tests analyse how an individual’s brain works, in order to identify any problems in its functioning. For instance, a person with a head injury may have to undergo neuropsychological tests to check their brain’s ability to retain information. Personality assessment A personality test focuses on the personality traits of an individual. It helps evaluate if a person is more introverted or extroverted, cautious or spontaneous, and how they may react or respond to various life situations. Interpretation of psychological tests Psychological tests are not meant to be interpreted without the context of the person being tested—their environment, socioeconomic status or physical health. While the tests do use scientifically verified scales, using its results as a stand-alone criterion can lead to misinterpretation. 205 CU IDOL SELF LEARNING MATERIAL (SLM)
For example, in the case of a blood work report—it is necessary for a doctor to read the numbers in relation to your symptoms and general physical health to arrive at an accurate diagnosis. Similarly, it’s important to note that even though many of the psychological tests mentioned above are easily available on the internet, taking them without consulting a mental health professional may not lead to getting an actual analysis of your personality, aptitude or behavior. This in turn, could mean not getting the help you need. 8.4 SPECIFIC SYNDROME TESTS Down syndrome is a disorder that causes intellectual disabilities, distinctive physical features, and various health problems. These may include heart defects, hearing loss, and thyroid disease. Down syndrome is a type of chromosome disorder. Chromosomes are the parts of your cells that contain your genes. Genes are parts of DNA passed down from your mother and father. They carry information that determines your unique traits, such as height and eye colour. • People normally have 46 chromosomes, divided into 23 pairs, in each cell. • One of each pair of chromosomes comes from your mother, and the other pair comes from your father. • In Down syndrome, there is an extra copy of chromosome 21. • The extra chromosome changes the way the body and brain develop. Down syndrome, also called trisomy 21, is the most common chromosome disorder in the United States. In two rare forms of Down syndrome, called mosaic trisomy 21 and translocation trisomy 21, the extra chromosome doesn't show up in every cell. People with these disorders usually have fewer of the characteristics and health problems associated with the common form of Down syndrome. Down syndrome screening tests show whether your unborn baby is more likely to have Down syndrome. Other types of tests confirm or rule out the diagnosis. What are the Test Used For? Down syndrome tests are used to screen for or diagnose Down syndrome. Down syndrome screening tests have little or no risk to you or your baby, but they can't tell you for sure whether your baby has Down syndrome. Diagnostic tests during pregnancy can confirm or rule out a diagnosis, but the tests have a small risk of causing a miscarriage. 206 CU IDOL SELF LEARNING MATERIAL (SLM)
Why do I need a Down syndrome Test? Many health care providers recommend Down syndrome screening and/or diagnostic tests for pregnant women who are 35 years of age or older. A mother's age is the primary risk factor for having a baby with Down syndrome. The risk increases as a woman gets older. But you may also be at higher risk if you've already had a baby with Down syndrome and/or have a family history of the disorder. In addition, you may want to get tested to help you prepare if the results show your baby may have Down syndrome. Knowing in advance can give you time to plan for health care and support services for your child and family. But testing isn't for everyone. Before you decide to get tested, think about how you'd feel and what you might do after learning the results. You should discuss your questions and concerns with your partner and your health care provider. If you didn't get tested during pregnancy or want to confirm the results of other tests, you may want to have your baby tested if he or she has symptoms of Down syndrome. These include: • Flattened face and nose • Almond-shaped eyes that slant upward • Small ears and mouth • Tiny white spots on the eye • Poor muscle tone • Developmental delays There are two basic types of Down syndrome tests: screening and diagnostic tests. Down syndrome screening includes the following tests done during pregnancy: • First trimester screening includes a blood test that checks the levels of certain proteins in the mother's blood. If levels are not normal, it means there is a higher chance of the baby having Down syndrome. The screening also includes an ultrasound, an imaging test that looks at the unborn baby for signs of Down syndrome. The test is done between the 10th and 14th week of pregnancy. • Second trimester screening. These are blood tests that also look for certain substances in the mother's blood that may be a sign of Down syndrome. A triple screen test looks for three different substances. It is done between the 16th and 18th week of pregnancy. A quadruple screen test looks for four different substances and is done between the 15th and 20th week of pregnancy. Your provider may order one or both of these tests. 207 CU IDOL SELF LEARNING MATERIAL (SLM)
If your Down syndrome screening shows a higher chance of Down syndrome, you may want to take a diagnostic test to confirm or rule out a diagnosis. Down syndrome diagnostic tests done during pregnancy include: • Amniocentesis, which takes a sample of amniotic fluid, the fluid that surrounds your unborn baby. It is usually done between the 15th and 20th week of pregnancy. • Chorionic villus sampling (CVS), which takes a sample from the placenta, the organ that nourishes your unborn baby in your uterus. It's usually done between the 10th and 13th week of pregnancy. • Percutaneous umbilical blood sampling (PUBS), which takes a blood sample from the umbilical cord. PUBS gives the most accurate diagnosis of Down syndrome during pregnancy, but it can't be done until late in pregnancy, between the 18th and 22nd week. Down syndrome diagnosis after birth: Your baby may get a blood test that looks at his or her chromosomes. This test will tell you for sure whether your baby has Down syndrome. What happens during Down Syndrome Testing? During a blood test, a health care professional will take a blood sample from a vein in your arm, using a small needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial. You may feel a little sting when the needle goes in or out. This usually takes less than five minutes. For the first trimester ultrasound, a health care provider will move an ultrasound device over your abdomen. The device uses sound waves to look at your unborn baby. Your provider will check for thickness at the back of your baby's neck, which is a sign of Down syndrome. For amniocentesis: • You'll lie on your back on an exam table. • Your provider will move an ultrasound device over your abdomen. Ultrasound uses sound waves to check the position of your uterus, placenta, and baby. • Your provider will insert a thin needle into your abdomen and withdraw a small amount of amniotic fluid. For chorionic villus sampling (CVS): • You'll lie on your back on an exam table. • Your provider will move an ultrasound device over your abdomen to check the position of your uterus, placenta, and baby. • Your provider will collect cells from the placenta in one of two ways: either through your cervix with a thin tube called a catheter, or with a thin needle through your abdomen. For percutaneous umbilical blood sampling (PUBS): • You'll lie on your back on an exam table. 208 CU IDOL SELF LEARNING MATERIAL (SLM)
• Your provider will move an ultrasound device over your abdomen to check the position of your uterus, placenta, baby, and umbilical cord. • Your provider will insert a thin needle into the umbilical cord and withdraw a small blood sample. There are no special preparations needed for Down syndrome testing. But you should talk to your health care provider about the risks and benefits of testing. There is very little risk to having a blood test or ultrasound. After a blood test, you may have slight pain or bruising at the spot where the needle was put in, but most symptoms go away quickly. Amniocentesis, CVS, and PUBS tests are usually very safe procedures, but they do have a slight risk of causing a miscarriage. What Do The Results Mean? Down syndrome screening results can only show if you have a higher risk of having a baby with Down syndrome, but they can't tell you for sure if your baby has Down syndrome you may have results that are not normal, but still deliver a healthy baby with no chromosomal defects or disorders. If your Down syndrome screening results were not normal, you may choose to have one or more diagnostic tests. It can help to speak to a genetic counsellor before testing and/or after you get your results. A genetic counsellor is a specially trained professional in genetics and genetic testing. He or she can help you understand what your results mean. Learn more about laboratory tests, reference ranges, and understanding results. Raising a child with Down syndrome can be challenging, but also rewarding. Getting help and treatment from specialists early in life can help your child reach his or her potential. Many children with Down syndrome grow up to lead healthy and happy lives. Talk to your health care provider and genetic counsellor about specialized care, resources, and support groups for people with Down syndrome and their families. 8.4 PROGNOSIS AND TREATMENT Prognosis The overall outlook for individuals with Down syndrome has dramatically improved. Many adult patients are healthier and better integrated into society, and life expectancy has improved from 25 years in 1983 to 60 years or higher today. 209 CU IDOL SELF LEARNING MATERIAL (SLM)
Approximately 75% of concept with trisomy 21 die in embryonic or fetal life. Approximately 25-30% of patients with Down syndrome die during the first year of life. The most frequent causes of death are respiratory infections (bronchopneumonia) and congenital heart disease. The median age at death is in the mid-50s. Congenital heart disease is the major cause of morbidity and early mortality in patients with Down syndrome. In addition, oesophageal atresia with or without transoesophageal (TE) fistula, Hirschsprung disease, duodenal atresia, and leukaemia contribute to mortality. The high mortality later in life may be the result of premature aging. In elderly persons with Down syndrome, relative preservation of cognitive and functional ability is associated with better survival. [17] Clinically, the most important disorders related to mortality in this population are dementia, mobility restrictions, visual impairment, and epilepsy (but not cardiovascular disease). In addition, the level of intellectual disability and institutionalization are associated with mortality. Individuals with Down syndrome have a greatly increased morbidity, primarily because of infections involving impaired immune response. Large tonsils and adenoids, lingual tonsils, choanal stenosis, or glossopteris can obstruct the upper airway. Airway obstruction can cause serous otitis media, alveolar hypoventilation, arterial hypoxemia, cerebral hypoxia, and pulmonary arterial hypertension with resulting core pulmonale and heart failure. Leukaemia, thyroid diseases, autoimmune disorders, epilepsy, intestinal obstruction, and increased susceptibility to infections (including recurrent respiratory infections) are commonly associated with Down syndrome. The aging process seems to be accelerated in patients with Down syndrome. Many patients develop progressive Alzheimer-like dementia by age 40 years, and 75% of patients have signs and symptoms of Alzheimer disease. A delay in recognizing atlantoaxial and atlanto-occipital instability may result in irreversible spinal-cord damage. Visual and hearing impairments in addition to intellectual disability may further limit the child’s overall function and may prevent him or her from participating in important learning processes and developing appropriate language and interpersonal skills. Unrecognized thyroid dysfunction may further compromise central nervous system (CNS) function. A questionnaire study by Matthews et al of caregivers of persons with Down syndrome aged 20 years or older reported that, while adults with Down syndrome who had a greater amount of health issues tended not to be independent and social and although current health problems impacted communication skills in these individuals, the number of congenital abnormalities in adults with Down syndrome was not significantly associated with scores for independence/life skills. Treatment 210 CU IDOL SELF LEARNING MATERIAL (SLM)
Physicians and parents should be aware of the range of psychomotor potential so that early intervention, schooling, and community placement are provided. Despite continued work, no notable medical treatments for intellectual disability associated with Down syndrome have been forthcoming. However, the dramatic improvements in medical care described below have greatly improved the quality of life for patients and increased their life expectancy. Usual immunizations and well-childcare should be performed as the American Academy of Paediatrics recommends. Associated conditions should be monitored periodically as the child grows older. Surgical management of associated conditions should be provided as appropriate. Down syndrome alone does not adversely affect surgical outcomes in the absence of pulmonary hypertension. Because of potential atlanto-occipital instability, care should be taken when sedation and airway management are considered for procedures or for consideration of sports participation. Further outpatient care may include the following: • Audiologic evaluation for hearing loss • Apnea monitoring Regular screening is necessary for institutionalized older adults to diagnose early onset dementia, epilepsy, hypothyroidism, and early loss of visual acuity and hearing. Approach Considerations Surgical Care Timely surgical treatment of cardiac anomalies detected during the new born period or early infancy, may be necessary to prevent serious complications and is crucial for optimal survival. Prompt surgical repair is necessary for GI anomalies, most commonly duodenal atresia and Hirschsprung disease. Other GI anomalies include tracheoesophageal fistula, pyloric stenosis, annular pancreas, a ganglionic megacolon, and imperforate anus. Surgical intervention may be necessary to reduce atlantoaxial subluxation and to stabilize the upper segment of the cervical spine if neurologic deficits are clinically significant. Congenital cataracts occur in about 3% of children and must be extracted soon after birth to allow light to reach the retina. Afterward, appropriate correction with glasses or contact lenses helps to ensure adequate vision. Surgical intervention in children with Down syndrome has a high risk of complications, particularly infection and wound healing problems. [67] Careful anaesthetic airway management is needed because of the associated risk of cervical spine instability. Preoperative evaluation for aesthesia must include adequate evaluation of the airway and the patient’s neurologic status. Cervical radiography (with flexion and extension views) should be performed when any neurologic deficit suggests spinal-cord compression. 211 CU IDOL SELF LEARNING MATERIAL (SLM)
During laryngoscopy and intubation, the patient’s head should be maintained in a neutral position, and hyperextension should be avoided. Anticholinergics can be prescribed to control hypersecretion in the airways. Other airway complications include subglottic stenosis and obstructive apnea, which may result from a relatively large tongue, enlarged adenoids, and midfacial hypoplasia. Aden tonsillectomy may be performed to manage obstructive sleep apnea. Diet and Activity No special diet is required, unless celiac disease is present. A balanced diet and regular exercise are needed to maintain appropriate weight. Feeding problems and failure to thrive usually improve after cardiac surgery. No restriction of activities is necessary. Parents should be counselled about sports with increased risk of spinal injury, such as football, soccer, and gymnastics. Advise the patient to exercise to maintain an appropriate weight. Patients with symptoms of arrhythmia, episodes of fainting, abnormal findings on electrocardiography (ECG), and palpitations or chest pain should refrain from participating in sports and strenuous exercise. Children with C1-C2 instability or subluxation may require specific preclearance to compete in the Special Olympics. A study by Diaz reported that US children with Down syndrome tend to engage less in regular physical activity than do other children, including children without disabilities and those with other developmental disabilities/special health-care needs. This indicated that interventions/programs promoting physical activity in children with Down syndrome are needed. Consultations Consultations with the following may be indicated: • Clinical geneticist - Referral to a genetic counselling program is highly desirable • Developmental paediatrician • Cardiologist - Early cardiologic evaluation is crucial for diagnosing and treating congenital heart defects, which occur in up to 50% of these patients • Paediatric pulmonologist - Recurrent respiratory tract infections are common in patients with Down syndrome • Ophthalmologist • Dentist • Neurologist/neurosurgeon – As many as 10% of patients with Down syndrome have epilepsy; therefore, neurologic evaluation may be needed; patients with atlantoaxial instability may need to be evaluated by a neurosurgeon • Orthopaedic specialist 212 CU IDOL SELF LEARNING MATERIAL (SLM)
• Child psychiatrist - A child psychiatrist should lead liaison interventions, family therapies, and psychometric evaluations • Physical and occupational therapist • Speech-language pathologist • Audiologist Genetic Counselling Trisomy 21 A previous history of trisomy can increase a woman’s risk for a recurrence. If the couple has a child with trisomy 21, the risk of recurrence is about 1%. The risk does not appear to be increased in siblings of affected individuals if it is confirmed to not be a translocation but rather full trisomy 21. Translocation The recurrence risk depends on the type of translocation. In most cases, the recurrence risk for de novo translocations is similar to that of the general population but may be slightly higher in some situations; it is estimated to be 2-3%. In any trisomy 21 patient with a translocation, karyotype testing must be recommended to both parents to look for a translocation. If a translocation is found in one of the parents, the recurrence risk is significantly higher, and further genetic counselling is crucial. The theoretic recurrence risk for a Robertsonian carrier parent to have a liveborn offspring with Down syndrome is 1 in 3. However, only 10-15% of the progeny of carrier mothers and only 2-3% of the progeny of carrier fathers have Down syndrome. The reason for this difference is not clear. In a carrier parent with a 21q21q translocation or isochromosome, the recurrence risk is 100%. Mosaicism Most patients with mosaic Down syndrome were once trisomy 21 zygotes. The phenotype varies and possibly reflects the variable proportion of trisomy 21 cells in the embryo during early development. In rare instances, low-level mosaicism in the germinal tissue of a parent is postulated to be the cause of having more than one trisomic child in a family. Many geneticists believe that all full trisomy 21 patients are mosaic at some level. Reproduction Affected individuals rarely reproduce. About 15-30% of females with trisomy 21 are fertile and have up to a 50% risk of having child also affected with trisomy 21. Infertility in males has been attributed to defective spermatogenesis, but ignorance of the sexual act may be one of the contributing factors. Pharmacologic Therapy and Supportive Care The standard immunizations and well-child care should be provided. In addition, specific manifestations of the syndrome and associated conditions must be addressed, as follows: 213 CU IDOL SELF LEARNING MATERIAL (SLM)
• Give thyroid hormone for hypothyroidism to prevent intellectual deterioration and to improve the individual’s overall function, academic achievement, and vocational abilities • Give digitalis and diuretics as necessary for cardiac management • Provide prompt treatment of respiratory tract infections and otitis media • Consider pneumococcal and influenza vaccination for children with chronic cardiac and respiratory disease; consider prophylactic palivizumab, since infants with Down syndrome are at high risk for hospitalization with respiratory syncytial virus [104] • Administer anticonvulsants for tonic-colonic seizures or for infantile spasms (treat with steroids) • Provide pharmacologic agents, psychotherapy, or behavioral therapy for psychiatric disorders • Treat skin disorders with weight reduction, proper hygiene, frequent baths, application of antibiotic ointment, or systemic antibiotic therapy • Prevent dental caries and periodontal disease through appropriate dental hygiene, fluoride treatments, good dietary habits, and restorative care There are specific guidelines on when prophylaxis for subacute bacterial endocarditis is necessary and, unless there is a valve replacement or other clear reason, children with trisomy 21 are not routinely recommended to receive it. Early intervention programs are promising. Programs for infants aged 0-3 years are designed to monitor and enrich their development by focusing on feeding, as well as gross and fine motor, language, personal, and social development. Early intervention techniques may improve the patient’s social quotient. Overall, positive developmental changes are observed in children with Down syndrome, particularly in terms of their independence, community functioning, and quality of life. A literature review by Sugimoto et al indicated that neuromuscular training can improve strength in children and young adults with Down syndrome. The study found that such training can have a moderate to large impact on general strength, as well as a small to moderate effect on maximal strength. Only a small impact on functional mobility tasks was reported. Megadose of vitamins and minerals supplemented with zinc or selenium have not been found beneficial in a number of well-controlled scientific studies. Children with Down syndrome and leukaemia are more sensitive to some chemotherapeutic agents (e.g., methotrexate) than other children. Thus, they require careful monitoring for toxicity. Special Considerations in Adolescents In adolescents and young adults with Down syndrome, the following monitoring measures are indicated • Perform annual audiologic evaluation 214 CU IDOL SELF LEARNING MATERIAL (SLM)
• Perform ophthalmologic evaluations every 3 years for keratoconus or corneal opacities or cataracts Manifestations of the syndrome and associated conditions must be evaluated and addressed on an ongoing basis, as follows: • Treat dermatologic issues, such as folliculitis, xerosis, atopic dermatitis, seborrheic dermatitis, fungal infections of skin and nails, vitiligo, and alopecia • Prevent obesity by decreasing the patient’s caloric intake and increasing activity (social and leisure) • Screen for celiac disease (symptoms such as constipation, diarrhoea, bloating, poor growth, or weight loss), and treat the patient with a gluten-free diet • Address any swallowing difficulties that persist through the adolescent years • Provide antibiotic prophylaxis during dental and surgical procedures in the presence of mitral valve prolapse • Consider bone marrow transplantation if leukaemia occurs • Discuss sleep apnea, treat airway obstruction medically and surgically. • Pay special attention to perioperative modalities because of atlantoaxial instability and problems with the respiratory system • Screen for hypothyroidism and diabetes mellitus • Manage neurologic problems, including mental retardation, hypotonia, seizures, and strokes • Continue speech and language therapy, with a focus on expressive language and intelligibility • Evaluate and treat behavioral problems, such as disruptive behavior disorders, stereotypic behaviours, phobias, elimination difficulties, autism, eating problems, self- injurious behavior, and Tourette syndrome; evaluate and treat psychiatric disorders, such as depression and self-talk • Examine annually to check for development of acquired heart valve disease; perform an echocardiogram if a new murmur or gallop or symptoms of heart failure develop. • Continue subacute bacterial endocarditis prophylaxis in adolescents with cardiac defects; during adolescence, an additional 2% of patients die of complications of congenital heart disease, infections, leukaemia, and accidents • Counsel regarding the importance of protecting the cervical spine during anaesthetic or surgical interventions; monitor for signs and symptoms of cervical myopathy; repeat cervical spine radiography as needed for sports/Special Olympics participation. In particular, it is important to discuss issues related to the transition to adulthood: • Emphasize the importance of a well-balanced diet and routine exercise • Review plans for school placement and plans after high-school graduation and future vocational plans • Discuss plans for alternative long-term living arrangements (e.g., community living); parents should update estate planning and custody arrangements 215 CU IDOL SELF LEARNING MATERIAL (SLM)
• Encourage social and recreational programs with friends • Address concerns regarding menstrual hygiene, sexual abuse, pregnancy, and premenstrual syndrome • Discuss sexuality and socialization, as well as the need for supervision and degree of supervision required; review options for contraception if the teen is sexually active, as well as for prevention of sexually transmitted diseases; make recommendations for routine gynaecologic care • Monitor the family’s need for supportive care or counselling, respite care, and behavior management techniques; facilitate referrals for respite care and treatment of parental problems • Facilitate the patient’s transfer to adult health care 8.5 SUMMARY • Valid instruments that assess parents’ and teachers’ concerns for child behavior problems are needed to identify children who would benefit from targeted treatment interventions. Instruments in common use were developed in high-income, Western settings; current adaptation procedures are limited by the lack of input from key stakeholders in child development and may fail to address important societal norms for child behavior. • It is also important to incorporate reports from multiple informants that view the child from different perspectives and in different contexts, to be able to gain a more comprehensive picture of child behavior. For example, we found in our previous sibling design study a significant association between SDP and disruptive behavior when using a multi-rate approach that capitalizes on both parent and teacher report. 8.6 KEYWORDS • Cognitive testing, also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental conditions exist. • Psychological assessment is a series of tests conducted by a psychologist, to gather information about how people think, feel, behave and react. • Cognitive test measures a person’s cognitive abilities— problem solving, reasoning, vocabulary, comprehension, and memory. • 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 analyse how an individual’s brain works, in order to identify any problems in its functioning. 216 CU IDOL SELF LEARNING MATERIAL (SLM)
8.7 LEARNING ACTIVITY 1. Study different physical exam and laboratory tests for disruptive behaviour disorder ………………………………………………………………………………………………...... ………………………………………………………………………………………………….. 2. Discuss the statement “Conduct disorder typically emerges in children under the age of 16” ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 8.8 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is cognitive testing disruptive behaviour disorder? 2. What is cognitive testing used for in disruptive behaviour disorder? 3. Why do I need cognitive testing in disruptive behaviour disorder? 4. What are diagnostic tests during pregnancy in disruptive behaviour disorder 5. What are diagnostic tests for new-borns in disruptive behaviour disorder Long Questions 1. Write a note on : Surgical Care in approach considerations 2. Write a note on : Diet and Activity 3. Write a note on : Genetic Counselling 4. What are the steps in Pharmacologic Therapy and Supportive Care? 5. What are special considerations in adolescents B. Multiple Choice Questions 1. Early versions of cognitive test were established around 100 years ago and developed through the ages. ________________test were widely used up until the advent of computerized testing in 1970s and 1980s. a. Online Test b. Pencil and Pen Test c. Oral Test d. Physical 217 CU IDOL SELF LEARNING MATERIAL (SLM)
2. This can help differentiate mental and physical conditions. This can be useful in the case of substance abuse or alcohol dependency. a. Orientation of basic information b. Recent past and memory c. Physical appearance d. Attention span 3. A ______________ test used to measure an individual’s different abilities, such as their aptitude in a particular field, cognitive functions like memory and spatial recognition, or even traits like introversions. a. Psychological Test b. Behavioral Test c. Genetic Test d. Neuro Test 4. This measures the social and practical skills of a person, to determine their ability to function on daily basis at home, school or work: and are usually conducted along with cognitive test. a. Mental Health Assessment b. Aptitude Testing c. Cognitive Testing d. Adaptive Behaviour Assessment 5. People normally have _______ chromosomes, divided into _____ pairs, in each cell. a. 54; 27 b. 60;30 c. 46;23 d. 42;21 Answers 1-(b), 2-(c), 3-(a, 4-(d), 5-(d) 8.9 REFERENCES Textbook • Banerjee T (1997), Psychiatric morbidity among rural primary school children in West Bengal Indian J Psychiat 218 CU IDOL SELF LEARNING MATERIAL (SLM)
• Barkley RA(1987). Defiant children: a clinician’s manual for parent training. New York: Guilford. • Frick, P. J. (1991). The Alabama parenting questionnaire. Unpublished rating scale, University of Alabama. • Horton, J. J., & Chilton, L. B. (2010, June). The labour economics of paid crowdsourcing. In Proceedings of the 11th ACM conference on Electronic commerce ACM. References: • Chandler, J., & Shapiro, D. (2016). Conducting clinical research using crowdsourced convenience samples. Annual Review of Clinical Psychology. • Chorpita, B. F., Reise, S., Weisz, J. R., Grubbs, K., Becker, K. D., & Krull, J. L. (2010). Evaluation of the brief problem checklist: Child and caregiver interviews to measure clinical progress. Journal of Consulting and Clinical Psychology. • Cantwell DP, Swanson J, Connor DF (1997), Case study: adverse response to clonidine. J Am Acad Child Adolesc Psychiatry • Carey G, DiLalla D (1994), Personality and psychopathology: genetic perspectives. J Abnormal Psychol. 219 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 9: CONDUCT DISORDER PART I STRUCTURE 9.0 Learning Objectives 9.1 Introduction 9.2 DSM Criteria 9.3 ICD 10 Criteria 9.4 Incidence 9.5 Prevalence 9.4 Causes 9.5 Summary 9.6 Keywords 9.7 Learning Activity 9.8 Unit End Questions 9.9 References 9.0 LEARNING OBJECTIVES After studying this unit, students will be able to: • Explain Conduct disorder behaviour • State the DSM criteria for Conduct disorder • Study prevalence of Conduct disorder 9.1 INTRODUCTION Conduct disorder is an ongoing pattern of behavior marked by emotional and behavioral problems. Children with conduct disorder behave in angry, aggressive, argumentative, and disruptive ways. Conduct disorder in children goes beyond bad behavior. It is a diagnosable mental health condition that is characterized by patterns of violating societal norms and the rights of others. It's estimated that around 3% of school-aged children have conduct disorder. It is more common in boys than in girls 220 CU IDOL SELF LEARNING MATERIAL (SLM)
Conduct disorder extends beyond normal teenage rebellion. It involves serious behavior problems that are likely to raise alarm among teachers, parents, peers, and other adults. In order to qualify for a diagnosis of conduct disorder, children must exhibit at least three of these symptoms in the past year and at least one in the past six months: • Aggression Toward People and Animals • Bullying, threatening, or intimidating others • Initiating physical fights • Using a weapon that could cause serious harm • Physical cruelty to people • Physical cruelty to animals • Stealing while confronting a victim • Forced sexual activity • Property Destruction • Deliberate fire setting • Other destruction of property • Deceptiveness or Theft • Breaking or entering a house, car, or building • Lying for personal gain • Stealing without confronting the victim (such as shoplifting) • Serious Rule Violation • Staying out at night before the age of 13 years • Running away from home overnight at least twice • Truancy beginning before the age of 13 Impact Conduct disorder isn't just a challenge for caregivers—it actually impairs a child's ability to function. Some areas where the condition may affect a child's life include: Education: Children with conduct disorder misbehave so much that their education is affected. They usually receive frequent disciplinary action from teachers and may skip school. Children with conduct disorder may be at a higher risk of failure or dropping out of school. Legal issues: Adolescents with conduct disorder are also more likely to have legal problems. Substance abuse, violent behavior, and a disregard for the law may lead to incarceration. Relationships: Children with conduct disorder also have poor relationships. They struggle to develop and maintain friendships. Their relationships with family members usually suffer due to the severity of their behavior. 221 CU IDOL SELF LEARNING MATERIAL (SLM)
Sex: They may also engage in risky sexual behavior. Studies show that teens with conduct disorder are more likely to have multiple sexual partners and are less likely to use protection. 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. 9.2 DSM CRITERIA Conduct disorder is a more extreme form of ODD and involves more serious incidents of aggression and defiance. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules that are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months. • Aggressive conduct that threatens physical harm. • Nonaggressive conduct that causes property damage. • Deceitfulness or theft. • Serious violations of rules. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. Coding note: Onset of at least one criterion characteristic of Conduct Disorder (CD) prior to age 10 years. Aggression to People and Animals: • Often bullies, threatens, or intimidates others. 222 • Often initiates physical fights. • Has used a weapon that can cause serious physical harm to others. • A bat, brick, broken bottle, knife, gun • Has been physically cruel to people. • Has been physically cruel to animals. • Has stolen wile confronting a victim. • Mugging, purse snatching, extortion, armed robbery • Has forced someone into sexual activity. • CD Subtypes CU IDOL SELF LEARNING MATERIAL (SLM)
Child-Onset Type: • Onset of at least one criteria before age 10. Adolescent-Onset Type: • Absence of any criteria before age 10. • Unspecified Onset Code Severity: • Mild, Moderate, and Sever. • Associated features Children with Conduct Disorder (CD) show acts of aggression towards others and animals. Children with conduct disorder (CD) usually show little to no compassion or concern for others or their feelings. Also, concern for the well-being of others is at a minimum. Children also perceive the actions and intentions of others as harmful and threatening than they actually are and respond with what they feel is reasonable and justified aggression. They may lack feelings of guilt or remorse. Since these individuals learn that expressing guilt or remorse may help in avoiding or lessening punishment, it may be difficult to evaluate when their guilt or remorse is genuine. Individuals will also try and place blame on others for the wrong doings that they had committed. Children with conduct disorders (CD) tend to have lower levels of self-esteem. Children diagnosed with conduct disorders (CD) are typically characterized as being easily irritable and often reckless, as well as having many temper tantrums. These children may force sexual activity and theft while confrontation (e.g. mugging). Individuals may have low self-esteem despite their projected “tough” image portrayed to society. Conduct Disorder (CD) often accompanies early onset of sexual behavior, drinking, smoking, use of illegal drugs, and reckless acts. Illegal drug use may increase the risk of the disorder persisting. The disorder may lead to school suspension or expulsion, problems at work, legal difficulties, STD’s, unplanned pregnancy, and injury from fights or accidents. Suicidal ideation and attempts occur at a higher rate than expected. They show aggressive conduct that threatens physical harm, and non-aggressive conduct that causes property damage. They display deceitfulness or theft, and serious rule violations. Rule violations sometimes include staying out all night, running away, and frequently playing truant. There are behavior problems that cause significant impairment in social, academic, or occupational functioning. There is a deliberate engagement in fire setting, with the intention of causing serious damage. They have deliberately destroyed others’ property by means other than fire setting. Often children with this disorder will lose their temper easily, argue with adults, and deliberately annoy others. 223 CU IDOL SELF LEARNING MATERIAL (SLM)
Conduct Disorder (CD) may be accompanied by a lower-than-average intelligence, particularly regarding verbal IQ. Attention-Deficit/Hyperactivity Disorder (ADHD) is common in individuals with this disorder, and the disorder may be comorbid with Learning Disorders (LD), Anxiety Disorders, Mood Disorders, and Substance-Related Disorders. Research has suggested that parents of children with conduct disorder (CD) frequently lack several important parenting skills. Parents have been reported to be more violent and critical in their use of discipline, more inconsistent, erratic, permissive, less likely to monitor their children, as well as more likely to punish pro-social behaviours, and to reinforce negative behaviours. A coercive process is set in motion during which a child escapes or avoids being criticised by his or her parents through producing an increased number of negative behaviours. These behaviours lead to increasingly aversive parental reactions which serve to reinforce the negative behaviours (Duff, 2005). Differences in affect have also been noted in conduct disordered (CD) in children. In general their affect is less positive, they appear to be depressed, and are less reinforcing to their parents. These attributes can set the scene for the cycle of aversive interactions between parents and children (Duff, 2005). Child vs. adult presentation The presentation of symptoms differs among age. As the individual matures, behaviours intensify and become more physical. Less severe behaviours tend to appear first while others emerge later. The most severe appear last. In comparison, childhood-onset presentation involves more behavioral problems. Lying, shoplifting, and burglary are just a few examples of symptoms present among adults. Gender and cultural differences in presentation Boys tend to display behavioral problems that are associated with conduct disorders than girls. Studies show findings that there is a 4:1 prevalence ratio of CD in boys to girls. However, this ratio may fluctuate throughout the child’s development. For example, the difference in prevalence among boys and girls may be small to non-existent in preschool children, but the difference usually becomes more dramatic throughout childhood. The ration then seems to drops to 2:1 (males to females) during adolescence. There is a bit of controversy about the difference in prevalence rates among boys and girls. Some argue that girls are less likely to be diagnosed with CD because they may exhibit more indirect or relational aggression. Others argue that girls showing possible symptoms of CD should be diagnosed using more lenient criteria that compares a girl to other girls, instead of a sample of both girls and boys. There is some research that has indicated that certain social factors can influence the development of this disorder. For example, the high rate of violence in the United States 224 CU IDOL SELF LEARNING MATERIAL (SLM)
(compared to other industrialized nations), and the marginalization of ethnic minorities have been noted to increase the risk of delinquent and antisocial behavior among those without the means to obtain goods through socially accepted methods. However, the findings of these studies are not conclusive. Boys diagnosed with CD tend to display more serious acts such as vandalism and theft. Whereas girls tend to display acts such as running away, truancy, and prostitution. Epidemiology The diagnosis range of individuals with conduct disorder are anywhere from 1% to no more than 10%. Also, conduct disorder (CD) ranges in 9 to 17 year old kids at about 1% to 4%.The prevalence rate of males is higher than that of females. Research has showed that the prevalence of CD has increased. Onset may occur as early as preschool, but the most significant symptoms usually appear from middle childhood through middle adolescence. Oppositional Defiant Disorder (ODD) is a common precursor to Conduct Disorder (CD). Onset after 16 years of age is rare. The course varies; in the majority of individuals, it remits by adulthood. A large portion continues to show that meet criteria for Antisocial Personality Disorder. Many achieve adequate social and occupational adjustment as adults. Early onset predicts a worse prognosis and an increased risk for Antisocial Personality Disorder and Substance-Related Disorders. Those with Conduct Disorder (CD) are at risk for Somatoform Disorders, Mood Disorders, and Anxiety Disorders as well. Etiology The etiology of conduct disorders (CD) is thought to be mostly family influenced and morally developed. Studies have shown that there is a high incidence rate of deviant behavior among families of children with conduct disorder. Also, moral development relates to the violating of rules and norms that is portrayed among conduct disorder. These behavioral characteristics pertain to moral development. 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 225 CU IDOL SELF LEARNING MATERIAL (SLM)
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. 9.3 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 • 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 226 CU IDOL SELF LEARNING MATERIAL (SLM)
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. 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. 9.4 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 227 CU IDOL SELF LEARNING MATERIAL (SLM)
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. 9.5 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 228 CU IDOL SELF LEARNING MATERIAL (SLM)
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 9.4 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: • 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. 229 CU IDOL SELF LEARNING MATERIAL (SLM)
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. 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 230 CU IDOL SELF LEARNING MATERIAL (SLM)
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 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. 9.5 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. 231 CU IDOL SELF LEARNING MATERIAL (SLM)
• 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. • 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 . 232 CU IDOL SELF LEARNING MATERIAL (SLM)
9.6 KEYWORDS • Anxiety Disorders: A mental health disorder characterised by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities. • Learning Disorders: It is an information-processing problem that prevents a person from learning a skill and using it effectively. Learning disorders generally affect people of average or above average intelligence. • Hyperactivity Disorder: It is a brain disorder that affects how you pay attention, sit still, and control your behavior. It happens in children and teens and can continue into adulthood. ADHD is the most commonly diagnosed mental disorder in children. Boys are more likely to have it than girls • Permissive: allowing or characterized by great or excessive freedom of behaviour. • Erratic: not even or regular in pattern or movement; unpredictable. 9.7 LEARNING ACTIVITY 1. Study psychiatric disorders of children in India ………………………………………………………………………………………………...... ………………………………………………………………………………………………..… 2. Visit a nearby school and study on Conduct disorder ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 9.8 UNIT END QUESTIONS A. Descriptive Questions 233 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 CU IDOL SELF LEARNING MATERIAL (SLM)
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 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 234 CU IDOL SELF LEARNING MATERIAL (SLM)
Answers 1-(b), 2-(a), 3-(d), 4-(a), 5-(c) 9.9 REFERENCES Textbook • 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 Neuropsychopharmacology • 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 behavioural 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, Pumariega A, Cuffe S (1995), Influence of race on diagnosis in adolescent psychiatric inpatients. Jam Acad Child Adolesc Psychiatry • Kim-Cohen J, Arseneault L, CaspiA, TomasMP, TaylorA, Moffit TE (2005), Validity of DSM-IV conduct disorder in4½-5-year-old children: Longitudinal epidemiological study. AmJ Psychiatry 235 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 10: CONDUCT DISORDER PART II STRUCTURE 10.0 Learning Objectives 10.1 Introduction 10.2 Assessment with Cognitive Tests 10.3 Psychological Tests 10.4 Specific Syndrome Tests 10.5 Prognosis and Treatment 10.6 Summary 10.7 Keywords 10.8 Learning Activity 10.9 Unit End Questions 10.10 References 10.0 LEARNING OBJECTIVES After studying this unit, students will be able to: • Assess Conduct disorder using Cognitive Testing • Explain Psychological Testing and Specific Syndrome Testing for conduct disorder • Explain prognosis and treatment of Conduct disorder 10.1 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: 236 CU IDOL SELF LEARNING MATERIAL (SLM)
• 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) 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. 10.2 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 237 CU IDOL SELF LEARNING MATERIAL (SLM)
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. • 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. 238 CU IDOL SELF LEARNING MATERIAL (SLM)
• 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 (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 (e.g., 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 239 CU IDOL SELF LEARNING MATERIAL (SLM)
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. 10.3 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. 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 240 CU IDOL SELF LEARNING MATERIAL (SLM)
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 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. 241 CU IDOL SELF LEARNING MATERIAL (SLM)
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. 10.4 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 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 242 CU IDOL SELF LEARNING MATERIAL (SLM)
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 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 243 CU IDOL SELF LEARNING MATERIAL (SLM)
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, Cog state, 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: 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 10.5 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. 244 CU IDOL SELF LEARNING MATERIAL (SLM)
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. • 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 counsellors, 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. 245 CU IDOL SELF LEARNING MATERIAL (SLM)
• 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. • 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. 10.6 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. 246 CU IDOL SELF LEARNING MATERIAL (SLM)
• 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 10.7 KEYWORDS • Attention span, according to MedlinePlus, can be a determinant in the rest of the cognitive assessment. • Language testing involves your ability to read, write, and speak clearly. Testing may involve you writing or reading sentences or saying words out loud. • Clinical Dementia Rating (CDR), a 5-point scale that helps determine the severity of dementia by checking for symptoms that might suggest dementia or cognitive decline • Conduct disorder is a type of behavior disorder. It’s when a child has antisocial behavior. • Neuropsychological test may be used to differentiate between dementia and depression 10.8 LEARNING ACTIVITY 1. Study different physical exam and laboratory tests for conduct disorder. ………………………………………………………………………………………………...... ………………………………………………………………………………………………….. 2. Discuss the statement “Conduct disorder typically emerges in children under the age of 16. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 10.9 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 I 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 247 CU IDOL SELF LEARNING MATERIAL (SLM)
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 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 248 behavior. a. Learning disorder b. Permissive c. Hyperactivity disorder d. Attention span CU IDOL SELF LEARNING MATERIAL (SLM)
Answers 1-(d), 2-(c), 3-(a), 4-(a), 5-(c) 10.10 REFERENCES Textbook • 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: A retrospective 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. New York: Plenum. • Liu J (2004), Childhood Externalizing Behavior: Theory and Implications. J Child Adolesc Psychiatry Nurs • Lochman JE (1992), Cognitive-behaviour 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 249 CU IDOL SELF LEARNING MATERIAL (SLM)
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