Conduct Disordered Youth in Group Care: An Examination of Negative Peer Influence

We examined the potential impact of negative peer influence within a treatment-focused residential care setting. Subjects were 712 youth consecutively admitted to a large residential treatment program (9–19 years of age). Based on Diagnostic Interview Schedule for Children (DISC) scores, 247 (35%) of these youth qualified for a Conduct Disorder diagnosis at admission. The dependent measures were the number of DISC Oppositional Defiant Disorder (ODD)/Conduct Disorder (CD) symptoms and the sum of Conduct Problem behaviors observed daily for each youth. Both the Conduct Problem Behaviors and the ODD/CD symptoms for both CD and non-CD groups decreased over time. Youth with a CD diagnosis or who were female improved at a faster rate than their peers. The data analyzed in this study do not support a negative peer influence effect for antisocial youth placed in a treatment-focused residential care setting.     

Positive and Negative Peer Influence in Residential Care

The potential for negative peer influence has been well established in research, and there is a growing interest in how positive peer influence also impacts youth. No research, however, has concurrently examined positive and negative peer influence in the context of residential care. Clinical records for 886 residential care youth were used in a Hierarchical Linear Model analysis to examine the impact of negative and positive peer influence on naturally occurring patterns of serious problem behavior over time. Negative peer influence, where the majority of youth in a home manifested above the average number of serious behavior problems, occurred 13.7% of the time. Positive peer influence, where the majority of youth manifested no serious problem behaviors for the month, occurred 47.7% of the time. Overall, youth problem behavior improved over time. There were significantly lower rates of serious problem behavior in target youth during positive peer influence months. Conversely, there were significantly higher rates of serious problem behaviors in target youth during negative peer influence months. Negative peer influence had a relatively greater impact on target peers’ serious behavior problems than did positive peer influence. Caregiver experience significantly reduced the impact of negative peer influence, but did not significantly augment positive peer influence. Months where negative peer influence was combined with inexperienced caregivers produced the highest rates of serious problem behavior. Our results support the view that residential programs for troubled youth need to create circumstances that promote positive and control for negative peer influence.     

Youth with Oppositional Defiant Disorder at Entry into Home-Based Treatment,Foster Care,and Residential Treatment

We explored and compared rates of youth diagnosed with oppositional defiant disorder (ODD) at entry into three broad program types, home-based care, foster care, and residential care. We also explored factors other than an ODD diagnosis that could be associated with program placement, and compared the presence of these factors in youth with and without an ODD diagnosis. Analyses were conducted using data from an ongoing, private-agency led, outcome measurement project. Programs were grouped into low (home-based), moderate (foster), or high (residential) categories, based upon levels of supervision and structure provided. A sample of 9,564 youth admitted into care between years 2005 and 2007 was used. Results suggested the following rates of ODD: 14.2 % overall; 7.9 % for low level programs; 5.3 % for moderate level programs; 21.1 % for high level programs. Rates were significantly different by program level (p ≤ 0.001). Sixty of 65 additional risk factors were also significantly associated with placement by level of program. No risk factors were unique to youth with ODD. Of the significant factors for youth with ODD, 4 were particularly strong: Classification as a child in need of services (CHINS), history of neglect, verbal aggression, and truancy. Youth classified as CHINS and with substantiated or suspected neglect were more likely placed into a moderate level program. Youth with verbal aggression or truancy were more likely placed into a high level program. Results suggested many factors are considered at program entry. Given the potential for poor prognosis and social costs of ODD, results support an individualized approach to placement determinations, with increased attention to symptoms of ODD and associated features at program entry.     

Externalizing Outcomes of Youth with and without ADHD: Time-Varying Prediction by Parental ADHD and Mediated Effects

Although parental attention-deficit/hyperactivity disorder (ADHD) is a risk factor for multiple negative youth outcomes, it is unknown how change in parental ADHD symptoms over time affects change in child ADHD symptoms; moreover, mediators of these predictions are largely unknown. Parents of 230 5–10 year-old children (68 % male) with (n = 120) and without ADHD (n = 110) were followed prospectively for 6–7 years across three separate waves. Parents self-reported their ADHD and depression symptoms and similarly rated offspring ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms; youth self-reported their substance use. Temporally-ordered mediators consisted of parental expressed emotion (EE), derived from the Five Minute Speech Sample, and self-reported positive and negative parenting behavior. Controlling for key demographics and parental depression symptoms, increasing parental ADHD symptoms were a time-varying predictor of worsening youth ADHD and ODD, although it was unrelated to change in CD and alcohol/substance use. Next, although EE facets (i.e., criticism, emotional over-involvement) did not mediate these predictions, negative parenting behavior significantly mediated predictions of youth ADHD (and marginally in predictions of ODD) from parental ADHD symptoms. These quasi-experimental findings suggest that parental ADHD symptoms are a potential unique causal risk factor for offspring ADHD and ODD; also, preventing negative parenting behavior secondary to parental ADHD symptoms is critical to improve trajectories of youth ADHD and ODD. We consider parental ADHD symptoms and family factors underlying emergent externalizing problems utilizing a developmental psychopathology framework, including implications for intervention and prevention.     

Negative Halo Effects in Parent Ratings of ADHD,ODD, and CD

Attention-deficit/hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) are highly comorbid, with symptoms that share some similarities. The evidence-based diagnostic process for these disorders includes ratings from adults in the child’s life to assess behavior across settings, so it is important to understand how these raters think about potentially overlapping symptoms. Researchers have identified negative halo effects in ratings of ADHD and ODD symptoms, but ratings of CD have not been examined in these prior studies. Thus, the current study extended past research to examine negative halo effects in parent ratings of the predominantly hyperactive-impulsive presentation of ADHD (i.e., ADHD/HI), ODD, and CD. Parent participants read one of four vignettes that portrayed an 11-year-old boy displaying symptoms of ADHD/HI, ODD, CD, or typical development, and then completed a disruptive behavior scale. The general trend we found was that the presence of a relatively more severe disorder (i.e., CD) artificially inflated ratings of - or showed a negative halo effect for - the relatively less severe disorder (i.e., ADHD/HI), but with some nuance as discussed in the paper. These findings explain and validate how important it is that clinicians conduct evidence-based psychological assessments to decrease the chance of misdiagnosis.

     

The Early Risers Preventive Intervention: Testing for Six-year Outcomes and Mediational Processes

We examined effects of the Early Risers “Skills for Success” early-age-targeted prevention program on serious conduct problems following 5 years of continuous intervention and one year of follow-up. We also examined if intervention effects on proximally-targeted variables found after 3 years mediated intervention effects on conduct problems found after 6 years. Participants included 151 at-risk children (106 males and 45 females) followed from first through sixth-grade, from 23 semi-rural schools in Minnesota. After 6 years, program children showed fewer oppositional defiant disorder (ODD) symptoms than control children. Program children did not significantly differ from controls on number of conduct disorder (CD) symptoms, DSM-IV diagnoses of ODD and CD, or drug use involvement. Results of the mediation analysis indicated that fewer ODD symptoms among program youth after 6 years were partially mediated by social skills and effective discipline. The study provides support for the early-starter model of conduct problems development that provides the framework for the Early Risers intervention. The study’s implications for prevention and limitations are discussed.     

The role of a lifetime history of oppositional defiant and conduct disorders in adults with ADHD: implications for clinical practice

IntroductionAttention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) are frequently co-occurring disorders in children and adolescents. However, their clinical status among adults is still under discussion. This study analyzes how the current clinical presentation of adult ADHD might be influenced by a lifetime history of CD and ODD. METHODS: We compared three groups of patients: ADHD without history of CD/ODD (n = 178), ADHD + history of ODD (n = 184), and ADHD + history of CD (n = 96). RESULTS: A history of CD (and to a lower extent ODD) is associated with a more severe and externalizing profile.ConclusionPast CD and ODD entail a significant negative mental health impact on persistent ADHD, reinforcing the importance of actively assessing the developmental history of adult ADHD patients.     

Parenting Behavior and Conduct Problems in Children with and Without Attention-Deficit/Hyperactivity Disorder (ADHD): Moderation by Callous-Unemotional Traits

There is evidence that negative parenting positively predicts oppositional defiant disorder (ODD) and conduct disorder (CD) and that children’s callous-unemotional (CU) traits may moderate this association. However, it is largely unknown if CU traits show similar interactive effects with positive parenting for ODD/CD. 208 ethnically diverse (56% Caucasian) 6–9 year-old children with and without attention-deficit/hyperactivity disorder (ADHD) were ascertained using multiple methods and informants for ODD, CD, and CU traits. CU traits, corporal punishment, positive parenting, and each of their interactions with CU traits were unrelated to parent- and teacher-rated ODD. Corporal punishment and CU traits were similarly unrelated to parent- and teacher-rated CD. However, positive parenting inversely predicted parent-reported CD symptoms and it was significantly moderated by CU traits. Positive parenting was negatively associated with CD at low to moderate levels of CU traits, but it was unrelated to CD at high levels of CU traits. Children with elevated levels of CU traits exhibited significantly higher levels of CD symptoms that were largely independent of positive parenting behavior. We discuss these findings within a developmental psychopathology framework to provide further perspectives on reciprocal influences between parenting behavior and CU traits in the development of ODD and CD.     

Risk Taking and Sensitivity to Punishment in Children with ADHD,ODD, ADHD+ODD,and Controls

We used the Balloon Analog Risk Task (BART) to examine risk taking and sensitivity to punishment, two relevant aspects of behavioral inhibition, in 203 school-age children with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), ADHD+ODD, and controls. Participants earned points on the BART by pumping 30 separate balloons that exploded at variable intervals. No points were earned on a trial when a balloon exploded. The number of pumps across all balloons estimated risk taking and the reduction in pumps following balloon explosions was interpreted as an indicator of sensitivity to negative punishment. We found that all groups significantly differed from one another on risk taking. The ADHD+ODD group pumped the most, followed by the ODD, ADHD, and the control group, respectively. For sensitivity to negative punishment, all groups performed differently, with the ODD group showing the least sensitivity to an exploded balloon, followed by the ADHD, control, and ADHD+ODD groups, respectively. Children with ADHD+ODD demonstrated significantly different patterns of risk taking and sensitivity to negative punishment than children with either ADHD-only or ODD-only. ADHD youth with comorbid ODD had the greatest levels of risk taking, but they were also the most sensitive to negative punishment. The relationship between ADHD and ODD, as well as the nature of comorbidity in constructs related to risk taking and related behaviors, are discussed.     

Unintentional Injury Risk in Children with Externalizing Behavior Disorders at Summer Camp

Children with externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) have greatly increased risk of unintentional injury, but it is unclear what mechanisms are responsible for that increased risk. This study followed 22 children participating in a summer camp for children with ADHD. Injury incidents were recorded daily and a set of primary symptoms of behavioral disorders were recorded at 15-min intervals over the course of the 6-week summer camp experience (roughly 300 h of observing each child). We predicted symptoms of ODD and CD would be more strongly related to injury incidence than symptoms of ADHD. Results from univariate Poisson regression models confirmed our prediction. Symptoms of ODD and CD—violations and intentional aggression in particular—were related to injury incidence but symptoms of ADHD were not. This finding is consistent with a growing body of evidence that oppositional, noncompliant, and aggressive behavior patterns might be primarily responsible for increased risk for injury among children with externalizing behavior disorders. Thanks to Sylvie Mrug, Peter Winslett, and the other staff members of the STP camp for their cooperation.     

Mother-Teacher Agreement on Preschoolers’ Symptoms of ODD and CD: Does Context matter?

The aims of this study were to examine mother-teacher agreement on oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms and diagnoses in preschool children; to determine if context is a source of disagreement; and to explore if sex, referral status, and age moderated agreement rates. Participants included 158 male and 139 female 3- to 5-year old preschool children, their mothers, and teachers. A structured interview, the Kiddie-Disruptive Behavior Disorder Schedule was used for maternal report and teachers completed the Early Childhood Inventory. Results indicated that mothers reported more symptoms and diagnoses of ODD and CD than teachers, and mother-teacher agreement on both ODD and CD symptoms and diagnoses was low. Level of mother-teacher agreement increased when reporting on behavior in the same context; however, the rates remain modest. Referral status increased the likelihood of mother and teacher agreement on several ODD and CD symptoms, as well as ODD and CD diagnosis. These data suggest that context plays a role in mother-teacher agreement in the assessment of young children's ODD and CD symptoms.     

Significance of Childhood Conduct Problems to Later Development of Conduct Disorder Among Children With ADHD: A Prospective Follow-Up Study

This study investigates whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviors contribute to the development of clinically diagnosed CD in adolescence, in children with attention deficit hyperactivity disorder (ADHD). Participants were 207 White boys (ages 6-12) with ADHD free of conduct disorder diagnoses. Parent and teacher ratings were obtained. Participants were assessed at mean age 18 by clinicians blind to childhood status. A non-ADHD group (recruited in adolescence) was also studied. ODD behavior ratings did not predict CD in adolescence, whereas CD behavior ratings did. No single ODD or CD behavior predicted adolescent outcome. ADHD probands with very low ratings (Not at all, Just a little) by parents and teachers on all CD behaviors were still at significantly increased risk for CD in adolescence, compared to non-ADHD controls. The same relationships were found between childhood ODD and CD behaviors, and antisocial personality disorder in adulthood (mean age, 25). We conclude that childhood ADHD is a developmental precursor of later antisocial disorder, even in the absence of comorbid ODD or CD in childhood. However, low levels of CD-type problems are not innocuous, because they predict later CD among children with ADHD without comorbid CD.     

Co-occurring Mental Health Problems and Peer Functioning Among Youth with Attention-Deficit/Hyperactivity Disorder: A Review and Recommendations for Future Research

It is well established that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) frequently experience co-occurring mental health problems in addition to difficulties in their peer relationships. Although substantial research has focused on the extent to which peer functioning contributes to subsequent co-occurring mental health problems, much less research has considered how co-occurring mental health problems affect peer functioning domains. Therefore, the purpose of this review is to examine the effect of co-occurring mental health problems on the peer functioning of youth with ADHD. The impact of co-occurring externalizing (i.e., oppositional defiant disorder, conduct disorder) and internalizing (i.e., anxiety, depression) symptoms are reviewed, with a focus on whether these co-occurring symptoms exacerbate, attenuate, or have no effect across peer domains of social skills/competence, peer status, and friendship among youth with ADHD. Drawing from a developmental psychopathology framework, this review then draws attention to relevant causal processes and developmental cascades (including social-cognitive, affective, and family and parenting factors) in offering promising avenues for future work.     

External Validity of Conduct and Oppositional Defiant Disorders Determined by the NIMH Diagnostic Interview Schedule for Children

We administered the Diagnostic Interview Schedule for Children (DISC) two times to a group of youth (222 boys, 147 girls) entering residential care, once at their time of entry and once 1 year later. We then compared their DISC outcomes on Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD) against changes in independent direct observations of diagnostically relevant behavior obtained over the course of that year. Results from hierarchical linear modeling analyses showed significant discriminative relationships between results from the DISC and the independent observations. Specifically, observations of symptomatic behaviors (CD or ODD) decreased for youth who met diagnostic criteria at the first administration of the DISC but not at the second, increased for youth who did not meet criteria at the first administration but did at the second, and did not change for youth who met criteria at both administrations. These results extend the data on the validity of the DISC and support continued research efforts to determine its clinical utility.     

Examining Externalizing Behavior Trajectories of Youth in Group Homes: Is there Evidence for Peer Contagion?

Although concerns about peer contagion are often cited in critiques of group treatments for troubled youths, few studies have examined the effects of exposure to deviant peers in residential group care settings. This study used administrative data of youth served at Boys Town, a nationally-known group care provider. Using latent class growth analysis, this study identified the externalizing behavior trajectories of youth in group care as well as the behavior trajectory of the peers with whom they lived, assessed the relationship between youth trajectory classes and individual and peer group characteristics as well as the relationship between an individual youth’s behavior pattern and the behavior pattern of proximal peers. Several results suggested the presence of peer contagion in group care: a trajectory class of gradually increasing externalizing behavior problems, the strength of deviant peer density in predicting an individual youth’s externalizing behavior trajectories and significant associations between behavior patterns of youth and proximal peers. While there is some evidence that suggests an increase in problem behavior during care, results from this study indicated that over 90% of the youth did not have an increase in problem behaviors and that positive peer influences may also be protective and inhibit problem behaviors.     

Impaired Neurocognitive Functions Affect Social Learning Processes in Oppositional Defiant Disorder and Conduct Disorder: Implications for Interventions

In this review, a conceptualization of oppositional defiant (ODD) and conduct disorder (CD) is presented according to which social learning processes in these disorders are affected by neurocognitive dysfunctions. Neurobiological studies in ODD and CD suggest that the ability to make associations between behaviors and negative and positive consequences is compromised in children and adolescents with these disorders due to reduced sensitivity to punishment and to reward. As a result, both learning of appropriate behavior and learning to refrain from inappropriate behavior may be affected. Likewise, problem solving is impaired due to deficiencies in inhibition, attention, cognitive flexibility, and decision making. Consequently, children and adolescents with ODD and CD may have difficulty learning to optimize their behavior in changeable environments. This conceptualization of ODD and CD is relevant for the improvement of the effect of psychological treatments. Behavioral and cognitive-behavioral interventions that have been shown to be modestly effective in ODD and CD are based on social learning. Limited effectiveness of these interventions may be caused by difficulties in social learning in children and adolescents with ODD and CD. However, although these impairments have been observed at a group level, the deficits in reward processing, punishment processing, and cognitive control mentioned above may not be present to the same extent in each individual with ODD and CD. Therefore, the neurocognitive characteristics in children and adolescents with ODD and CD should be assessed individually. Thus, instead of delivering interventions in a standardized way, these programs may benefit from an individualized approach that depends on the weaknesses and strengths of the neurocognitive characteristics of the child and the adolescent.     

Effects of Intensive Behavioral Treatment for Children With Varying Levels of Conduct Problems and Callous-Unemotional Traits

The purpose of this study was to examine whether callous–unemotional (CU) traits moderated the effects of intensive behavior therapy in elementary school-age children with varying levels of conduct problems (CP). Both treatment response (magnitude of change between pre- and posttreatment) and treatment outcomes (likelihood of normalization from treatment) were examined. Participants were 67 children (n = 49 boys, M_age = 9.6 years) with varying levels of CP and CU who participated in an intensive 8-week summer treatment program (STP) in which behavior therapy was delivered to children in recreational and classroom settings and to parents via weekly parent training sessions. Effects of treatment were measured using parent and teacher ratings of oppositional defiant disorder (ODD), conduct disorder (CD), callous behavior, and impairment. Results showed that CU moderated treatment effects for CD and callous behavior but not ODD or impairment. The moderating effects showed some evidence that participants with high CP and high CU before treatment had better treatment responses (larger change between pre- and posttreatment) but worse treatment outcomes (lower likelihood of normalization after treatment). These results suggest that intensive treatment, such as the STP, may be necessary but not sufficient for children with CP and CU traits.     

ODD dimensions, ADHD, and callous-unemotional traits as predictors of treatment response in children with disruptive behavior disorders

To answer several questions pertinent to DSM-V, the authors examined the predictive validity of pretreatment oppositional defiant disorder (ODD) dimensions, attention-deficit/hyperactivity disorder (ADHD), and callous-unemotional (CU) traits in relation to several treatment outcomes in 177 children diagnosed with ODD or conduct disorder (CD). Multiple informants completed diagnostic interviews and rating scales at 6 assessment points (pretreatment to 3-year follow-up) to document emotional and behavioral outcomes. After controlling for pretreatment CD, the ODD dimension of hurtfulness was related to treatment-resistant CD, delinquent behaviors, and externalizing problems. In contrast, the ODD dimension tapping irritability was associated with treatment-resistant ODD, internalizing problems, and global functional impairment following treatment. Whereas pretreatment ADHD was associated with posttreatment ODD and social problems, it was unrelated to posttreatment CD symptoms and diagnosis. Contrary to predictions, CU traits were unrelated to any posttreatment outcomes after controlling for other covariates. These findings remained after controlling for measures of pretreatment global functional impairment.     

Predicting Treatment Response for Oppositional Defiant and Conduct Disorder Using Pre-Treatment Adrenal and Gonadal Hormones

Variations in adrenal and gonadal hormone profiles have been linked to increased rates of oppositional defiant disorder (ODD) and conduct disorder (CD). These relationships suggest that certain hormone profiles may be related to how well children respond to psychological treatments for ODD and CD. The current study assessed whether pre-treatment profiles of adrenal and gonadal hormones predicted response to psychological treatment of ODD and CD. One hundred five children, 6–11?years old, participating in a randomized, clinical trial provided samples for cortisol, testosterone, dehydroepiandrosterone, and androstenedione. Diagnostic interviews of ODD and CD were administered up to 3?years post-treatment to track treatment response. Group-based trajectory modeling identified two trajectories of treatment response: (1) a High-response trajectory where children demonstrated lower rates of an ODD or CD diagnosis throughout follow-up, and (2) a Low-response trajectory where children demonstrated higher rates of an ODD or CD diagnosis throughout follow-up. Hierarchical logistic regression predicting treatment response demonstrated that children with higher pre-treatment concentrations of testosterone were four times more likely to be in the Low-response trajectory. No other significant relationship existed between pre-treatment hormone profiles and treatment response. These results suggest that higher concentrations of testosterone are related to how well children diagnosed with ODD or CD respond to psychological treatment over the course of 3?years.     

Predictors of peer helpfulness: Implications for youth in residential treatment

Sociometric measures were used to predict peer helpfulness of youth in a residential treatment center. Seventeen female adolescents with conduct disorders were asked to choose three peers in their group who were most popular, similar, well-liked, and competent. These sociometric measures were correlated with the frequency in which each peer was nominated as most and least helpful in several problem scenarios representing actual situations encountered in residential settings. A multiple linear regression analysis indicated that “popularity” was the best predictor of peer helpfulness across the problem scenarios. Discussion focused on the impact of popularity on treatment strategies for youth in residential placement.