PSYCHIATRY GRAND ROUNDS – CHILD CONDUCT: RISK & PROTECTIVE FACTORS; Broadcast date: 4 April 2013; Presentation by: Joanna Katsanis

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PSYCHIATRY GRAND ROUNDS – CHILD CONDUCT: RISK & PROTECTIVE FACTORS; Broadcast date: 4 April 2013; Presentation by: Joanna Katsanis

– ODD & CD – poor prognosis for adjustment in adulthood of any of the childhood disorders
Distinguishes between:
– CD
– ODD – diagnostic criteria are developmentally-linked
– CP – all encompassing & which includes CD & ODD (Conduct Problems: – acting out behaviours including: aggression, stealing, shouting, juvenile delinquency, property damage)

Note: kids diagnosed with ODD are 4x more likely to be diagnosed with CD later in life.

ODD: occurs in both genders; prevalence – 3.2%; age of onset – 6 years; ODD is often linked to diagnoses of DEPRESSION, ANXIETY, ADHD, CD, and ANTI-SOCIAL PERSONALITY DISORDER
CD: more common in males; prevalence – 2%; age of onset – 9 to 12 years; once given CD is a STABLE diagnosis over time

CP FACTORS
– early v’s late onset
– at least one symptom (of CD) before the age of 11 years [Note: 65-80% of children with CP symptoms abate/go into symptom remission with parental support/natural ageing]
– the role of co-morbidities
– higher rates of co-morbidities associated with CD than ODD
– co-morbidities – see above – these occur at rates greater than chance levels and which is observed in the general population – leading to poor adjustment
– development
– risk factors [events which lead to the child experiencing poorer adjustment]
– CPs more attributed to psycho-social factors than any other childhood disorder
– risk factors thought to accumulate in an additive manner, particularly across multiple domains if these occur simultaneously
– risk factors contribute to the development of CD and ODD, with stronger associations made for CD
RISK FACTORS – INDIVIDUAL
– low birth-weight
– pre-natal substance exposure
– male
– minority status
– chronic health problems (still being researched)
– temperament: hyperactive, fussy, oppositional, emotional
– personality traits: jealousy, poor social skills, parental neediness, attention-seeking, low reaction to high-emotion situations, low awareness of consequences of behaviour, & lack of guilt
– low IQ in males (not females): deficits exist particularly in verbal reasoning which influences self-control & social problem-solving skills
RISK FACTORS – SCHOOL & PEER
– academic failure
– higher rate of conflict at school
– higher rates of peer rejection (feel stressed and isolated, and often seek out similarly rejected and isolated peers)
RISK FACTORS – PARENTAL (impacts discipline strategies and climate of the home environment
– substance abuse disorders
– ASPD
– Depression
– younger maternal age
– low-level education & occupational status
– poor parental physical health
– parental history of abuse
– parental feelings of being isolated
– parental car-giving: harsh & inconsistent discipline
– poor supervision
– low levels of parental involvement, responsiveness & warmth
– poorer quality communications and poorer/fewer positive interactions
RISK FACTORS – FAMILY
– Parents marital state
– Single parent
– Separation / Divorce
– Large family size (4+ children)
– Lack of resources
– Lack of supervision
– Modelling by older siblings
– Family instability
– Residential moves
– Changes in marital / Cohabitation arrangements
– Job loss
– School changes
– Death of a family member/ birth of a sibling
– Parent immigration status
– Low SES status
– Young, Caucasian, male (Particularly vulnerable)
– Child care
– Involvement in child care (Findings are inconsistent, insufficient evidence to date)
– Issue of quality
– What strategies are in place to manage problematic behaviour?
Neighbourhoods
– Poor quality neighbourhoods leads to increased amounts of violence being witnessed
– Poor quality neighbourhoods are associated with contact disorder (CD) not oppositional defiant disorder (ODD) or attention deficit hyperactivity disorder (ADHD)
– High neighbourhood crime rates
– Greater exposure to adults who commit crime
– High rates of neighbourhood unemployment
– High density housing
– high Rates of neighbourhood mobility
– Greater availability of drugs
– Significant community disorganisation
– Lower perceived neighbourhood quality
– Less perceived neighbourhood safety
– protective factors
– Definition of protective factors has been largely debated & Is often used inconsistently in the literature
– Is a protective factor just the opposite of a risk factor Or does it involve factors that are not related to risk?
– Research examining protective factors is still developing
PROTECTIVE FACTORS – INDIVIDUAL AND SCHOOL
– Higher than average IQ
– Good coping and reasoning skills
– High levels of academic achievement
– High levels of commitment to school
– School factors (Low levels of conflict, Academically orientated, Teaching staff who are caring)
– Relationship with an adult other than parents
– Getting along well with peers
– Participation in extra-curricular activities (Another Avenue to access an opportunity to experience success)
[Note some of this can inform treatment planning for CD]
PROTECTIVE FACTORS – PARENTS
– Good mental health
– Stable employment
– High Self-esteem
– Higher Life satisfaction
– Higher amounts of perceived social support
– Positive perception of child
– Higher warmth and involvement
– Provision of adequate supervision
PROTECTIVE FACTORS – FAMILY
– Coming from a smaller family
– Coming from a family with a middle or high SES background
– Family involvement in religious activities
[effective Treatment plans need to consider a number of domains – Aim is to increase protective factors and reduce risk factors]
[Interventions should be across School, home/family & community][EBP]
[Individual and group approaches to treatment]
– Problem solving and social skills training
– CBT Techniques to address interpersonal problems:
– Problem solving skills
– Anger control skills
– Social skills
– Coping skills
– Assertiveness skills (Without being aggressive)
Bad techniques are:
– Trying to scare the kid straight (For example taking him to the local jail and telling him this is where you will end up)
– Over-correcting, Physical punishment, Verbal reprimands, Extinction [not efficacious, but often tried by parents]
Interventions with unclear results:
– Group CBT
– Room anger management training
Parent approaches are considered a first-line treatment approach:
– Coaching parents on undesirable behaviours
– Encouraging pro-social behaviours… Through the use of:
– Positive reinforcement
– Non-violent consistent punishment/Discipline
– Effective monitoring/supervision
– Family problem-solving
– Improving the relationship
Six essential elements of parent training to coach conduct problems:
– Rehearsal of new skills
– Teaching management skills
– Practice of new strategies in the home environment
– Teaching effective punishment and strategies to build relationship
– Addressing relationship difficulties
– Early intervention

Examples of efficacious programs available:
Parent management training Oregon model (PMTO)
Individual parent management training
The incredible years program
Parent-child interaction therapy
Helping the non-compliant child Program
Triple P positive parenting program (Enhance parents knowledge, skills and mental-health)

Multi-systemic therapy approach:
– CBT individual
– Parent training
– School involved
– Pharmacological interventions
[For example: RECAP – Reaching educators children and parents; First steps to success program; Social emotional learning approach – “The Ruler” – Teach students and school staff Tools to perceive emotions, Use a motion to facilitate thought, Understand emotions, & Manage emotions]

NOTE: KNOWLEDGE OF RISK AND PROTECTIVE FACTORS IS VERY USEFUL IN GUIDING EFFECTIVE TREATMENT PLANNING

– gaps in current knowledge
– treatment/planning

OTHER THINGS TO NOTE:
– deficits in attention can have a deleterious effect upon the outcome of IQ tests

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