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Chapter 15. Disruptive, Impulse- Control, and Conduct Disorders https://doi-org.proxy-library.ashford.edu/10.1176/ appi.books.9781585624836.jb15

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Introduction John W. Barnhill, M.D. Executive functions help control and regulate attention, memory, and behavior. They are critical to adaptation, to the initiation and completion of tasks, and to the ability to delay gratification. They inhibit inappropriate, dangerous, and hurtful behaviors. Disruptive, impulse-control, and conduct disorders compose make up a heterogeneous cluster of people who all tend to have impaired executive functioning. The DSM-5 chapter defining these conditions includes oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania, as well as categories for people who have clinically relevant symptoms but do not meet criteria for a named disorder. Other DSM-5 disorders are associated with impulsivity, poor planning, and interpersonal conflicts, and these other disorders—ranging from attention-deficit/hyperactivity disorder to substance use disorders to some of the

personality disorders—are frequently comorbid with the disorders described in this chapter. Furthermore, disruptive impulsivity is associated with substance use, HIV and hepatitis C infections, traumatic brain injury, and all manner of dangerous behavioral patterns that produce direct physiological assaults on executive functioning and can lead to intensifying cycles of dysfunctional behavior. All of these disorders tend to start early in life, which is unsurprising given the relative immaturity of executive functions during childhood and adolescence. If the clinical interview indicates that one of the disruptive, impulse- control, or conduct disorders has suddenly sprouted during the adult years, the individual most likely either has developed a serious neuropsychiatric disorder or has not provided an accurate history. On the other hand, children who present with one of these disorders do not inevitably go on to develop such pervasively damaging diagnoses as antisocial personality disorder or lifelong intermittent explosive disorder. They are at risk for ongoing problems, however, including depressive, anxiety, and substance use disorders. These children are also at risk for encountering a disproportionate amount of societal trouble, and DSM-5 provides a structure for investigating severity. In individuals with oppositional defiant disorder, for example, pervasiveness of symptoms across settings is a useful marker for severity, whereas “limited prosocial emotions” is a specifier for conduct disorder that identifies greater severity and a different treatment response. Poorly controlled behavior and emotions lie on a continuum, and most sporadically impulsive behavior and dysregulated emotions do not indicate a DSM-5 disorder

but rather immaturity intensified by such situational issues as family and interpersonal strife, intoxication, and peer pressure. As is the case throughout DSM-5, the onus is on the clinician to carefully consider when thoughts, feelings, and behaviors cross the line into a level of distress and dysfunction that warrants a diagnosis. Particularly relevant variables include frequency, setting, and duration of the troublesome episodes. An accurate history is necessary to gather this information. Such an investigation can be stymied by the fact that, as is the case with the personality disorders, people other than the identified patient may be more distressed than the patient. Furthermore, psychiatric history tends to depend on patient honesty, and many of these patients are not spontaneously and transparently forthcoming. For these reasons, evaluations are often initiated by family and institutions (school, work, the legal system) and are unlikely to be complete without collateral information. Suggested Readings

• Buitelaar JK, Smeets KC, Herpers P: Conduct disorders. Eur Child Adolesc Psychiatry 22 (suppl 1):S49–S54, 2013 PubMed ID: 23224151

• Hollander E, Stein DJ (eds): Clinical Manual of Impulse-Control Disorders. Washington, DC, American Psychiatric Publishing, 2006

• Pardini DA, Frick PJ, Moffitt TE: Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section. J Abnorm Psychol 119(4):683–688, 2010 PubMed ID: 21090874

Case 15.1 Doesn’t Know the Rules

Juan D. Pedraza, M.D. Jeffrey H. Newcorn, M.D. Kyle was a 12-year-old boy who reluctantly agreed to admission to a psychiatric unit after getting arrested for breaking into a grocery store. His mother said she was “exhausted,” adding that it was hard to raise a boy who “doesn’t know the rules.” Beginning as a young child, Kyle was unusually aggressive, bullying other children and taking their things. When confronted by his mother, stepfather, or a teacher, he had long tended to curse, punch, and show no concern for possible punishment. Disruptive, impulsive, and “fidgety,” Kyle was diagnosed with attention-deficit/hyperactivity disorder (ADHD) and placed in a special education program by second grade. He began to see a psychiatrist in fourth grade for weekly psychotherapy and medications (quetiapine and dexmethylphenidate). He was adherent only sporadically with both the medication and the therapy. When asked, he said his psychiatrist was “stupid.” During the year prior to the admission, he had been caught stealing from school lockers (a cell phone, a jacket, a laptop computer), disciplined after “mugging” a classmate for his wallet, and suspended after multiple physical fights with classmates. He had been arrested twice for these behaviors. His mother and teachers agreed that although he could be charming to strangers, people quickly caught on to the fact that he was a “con artist.” Kyle was consistently unremorseful, externalizing of blame, and uninterested in the feelings of others. He was disorganized, was inattentive and uninterested in instructions, and constantly lost his possessions. He generally did not do his homework, and when he did, his performance was erratic. When confronted

about his poor performance, he tended to say, “And what are you going to do, shoot me?” Kyle, his mother, and his teachers agreed that he was a loner and not well liked by his peers. Kyle lived with his mother, stepfather, and two younger half-siblings. His stepfather was unemployed, and his mother worked part-time as a cashier in a grocery store. His biological father was in prison for drug possession. Both biological grandfathers had a history of alcohol dependence. Kyle’s early history was normal. The pregnancy was uneventful, and he reached all of his milestones on time. There was no history of sexual or physical abuse. Kyle had no known medical problems, alcohol or substance abuse, or participation in gang activities. He had not been caught with weapons, had not set fires, and had not been seen as particularly cruel to other children or animals. He had been regularly truant from school but had neither run away nor stayed away from home until late at night. When interviewed on the psychiatric unit, Kyle was casually groomed and appeared his stated age of 12. He was fidgety and made sporadic eye contact with the interviewer. He said he was “mad” and insisted he would rather be in jail than on a psychiatric unit. His speech was loud but coherent, goal directed, and of normal rate. His affect was irritable and angry. He denied suicidal or homicidal ideation. He denied psychotic symptoms. He denied feeling depressed. He had no obvious cognitive deficits but declined more formal testing. His insight was limited, and his judgment was poor by history. Diagnoses

• Conduct disorder, childhood-onset type, severe, with limited prosocial emotions

• Attention-deficit/hyperactivity disorder Discussion Kyle is a 12-year-old boy who was brought to a psychiatric unit after getting caught breaking into a grocery store. He has a lengthy history of behaviors that violate the rights of others. These behaviors deviate significantly from age- appropriate societal norms and have caused social, academic, and functional impairment. He has a disorder of conduct. In DSM-5, the criteria for conduct disorder (CD) are organized into four categories of behavior: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. A CD diagnosis requires three or more specific behaviors out of the 15 that are listed within these four categories. The behaviors must have been present in the last 12 months, with at least one criterion present in the prior 6 months. Kyle has at least seven of the 15: bullying, fighting, stealing (with and without confrontation), break-ins, lying, and truancy. Kyle also has a history of comorbid DSM-5 ADHD, as evidenced by persistent symptoms of hyperactivity, restlessness, impulsivity, and inattention. ADHD is found in about 20% of youth with CD. The criteria for the two disorders are relatively distinct, although both entities present with pathological levels of impulsivity. DSM-5 includes multiple specifiers that allow CD to be further subdivided. Kyle’s behavior began before age 10, which places him in the category of childhood-onset type as opposed to adolescent-onset type. There is also an unspecified-onset designation, used when information is inadequate to clarify whether the behaviors began before age 10. When trying to identify the age at onset, the

clinician should seek multiple sources of information and recall that estimates are often 2 years later than actual onset. People with an early age at onset—like Kyle—are more likely to be male, to be aggressive, and to have impaired peer relationships. They are also more likely to have comorbid ADHD and to go on to have adulthoods marked by criminal behavior and substance use disorders. In contrast, CD that manifests between ages 10 and 16 (onset is rare after age 16) tends to be milder, and most individuals go on to achieve adequate social and occupational adjustment as adults. Both groups have an elevated risk, however, of many psychiatric disorders. The second DSM-5 specifier for CD relates to the presence (or absence) of callous and unemotional traits. The “limited prosocial emotions” specifier requires the persistent presence of two or more of the following: lack of remorse or guilt; lack of empathy; lack of concern about performance; and shallow or deficient affect. Kyle has a history of disregard for the feelings of others, appears unconcerned about his performance (“What are you going to do, shoot me?”), and shows no remorse for his actions. This label applies to only a minority of people with CD and is associated with aggression and fearless thrill seeking. A third specifier for CD relates to the severity of symptoms. Lying and staying out past a curfew might qualify a person for mild CD. Vandalism or stealing without confrontation might lead to a diagnosis of moderate CD. Kyle’s behaviors would qualify for the severe subtype. Multiple other aspects of Kyle’s history are useful to understanding his situation. His father is in prison for substance use and/or dealing. Both of his biological grandfathers have histories of alcohol abuse. His mother

and stepfather are underemployed, although details about the stepfather are unknown. In general, CD risk has been found to be increased in families with criminal records, conduct disorder, and substance abuse, as well as mood, anxiety, and schizophrenia spectrum disorders. Environment also contributes, both in regard to chaotic early child-rearing and, later, to living in a dangerous, threatening neighborhood. Kyle’s diagnosis of conduct disorder is an example of how diagnoses can evolve over the course of a lifetime. His earlier behavior warranted a diagnosis of DSM-5 oppositional defiant disorder (ODD), which is characterized by a pattern of negative, hostile, and defiant behaviors that are usually directed at an authority figure (e.g., parent or teacher) and may cause significant distress in social or academic settings. However, ODD cannot be diagnosed if CD is present. As he enters adolescence, Kyle is at risk for many psychiatric disorders, including mood, anxiety, and substance abuse disorders. Of particular concern is the possibility that his aggression, theft, and rules violations will persist and his diagnosis of conduct disorder will shift in adulthood to antisocial personality disorder

CHAPTER 7 Testing Special

Populations TOPIC 7A Infant and Preschool Assessment 7.1 Assessment of Infant Capacities 7.2 Assessment of Preschool Intelligence 7.3 Practical Utility of Infant and Preschool Assessment 7.4 Screening for School Readiness 7.5 Dial-4

The individual and group tests reviewed in previous chapters are suitable for persons with normal or near-normal capacities in speech, hearing, vision, movement, and general intellectual ability. However, not every examinee falls within the ordinary spectrum of physical and mental abilities. By reason of immature age, physical disability, language

weakness, or diminished intellect, a large proportion of the population falls outside the reach of traditional tests and procedures. Infants and very young children certainly require exceptional approaches to assessment because of their limited capacities for communication. In Topic 7A, Infant and Preschool Assessment, we review the nature and application of infant and early childhood assessment devices and then investigate a fundamental question pertaining to these tests: What is the practical utility of testing children early in life? In particular, is there any predictive validity for test results obtained from infants or toddlers? If instruments for very young examinees do not predict important outcomes later in life, then using them would appear to be pointless and perhaps even misleading. We examine this quandary in some detail. Finally, we conclude the topic with a discussion of an important application of preschool testing—screening for school readiness. In Topic 7B, Testing Persons with Disabilities, we scrutinize a variety of tests

needed for the assessment of individuals with special needs. These special needs cover a wide spectrum, including language, hearing, and visual impairments. Of course, persons with developmental disabilities also require special approaches to assessment, and we provide coverage of this field as well. By one estimate, as many as 7.5 million U.S. citizens manifest intellectual disabilities, and 1 in 10 families are directly affected by this functional impairment (Grossman, Richards, Anglin, & Hutson, 2000). 7.1 ASSESSMENT OF INFANT

CAPACITIES The infant and preschool period extends from birth to roughly 6 years of age. The changes that occur during this period obviously are profound. The infant develops basic reflexes, masters developmental milestones (grasping, crawling, sitting, standing, and so forth), learns a language, and establishes the capacity for symbolic thought. For most children, the pattern and pace of development is visibly within normal limits.

However, parents and professionals trained in the assessment of infants and preschoolers occasionally encounter children whose development seems to be slow, delayed, or even overtly impaired. These children elicit a flurry of anxious questions: How delayed is this child? What are the prospects for normal functioning in school? Will this child achieve personal independence in the adult years? Another area of concern for many parents is the emotional development of their infants and children. Even normal children display trials and challenges that would test the saints. Visit any busy shopping mall and you will encounter scenes of hysterical, screaming children with frazzled parents attempting to cope. Listen to any honest parent with a toddler and you will hear a story or two of food smeared on walls, puppies tormented, obstinate refusal to stay in bed, or similar unpleasant actions. At what point do difficult and problematic behaviors portend a life of emotional troubles, when not promptly treated?

At the opposite extreme are those precocious children who achieve developmental milestones months or years ahead of the normative schedule. In these cases, the proud parents have a different set of concerns: How advanced is my child? What are the strongest and weakest areas of intellectual functioning? Will this child be a gifted adult? Infant and preschool assessment tools can help answer questions about the intellectual and emotional development of children, whether they are developmentally delayed, intellectually gifted, at-risk for emotional disorder, or within the normal spectrum. In this topic, we review the nature and application of representative infant and preschool measures. These tools include individual tests, developmental schedules, and rating scales. We begin with a description of several prominent instruments and then investigate the fundamental question of purpose or utility. What is the use of these measures? What is the meaning of a score on a developmental schedule or preschool intelligence test? To what extent do these

procedures allow us to prognosticate adult functioning or, for that matter, help us to predict early school performance? These questions will be more meaningful if we first review the relevant instruments. We divide the review into two parts: infant measures for children from birth to age 2½, and preschool tests for children from age 2½ to age 6. The division is somewhat arbitrary, but not entirely so. Infant tests tend to be multidimensional and to load significantly on sensory and motor development. Beginning at age 2½, standardized measures such as the Stanford-Binet: Fifth Edition, Kaufman Assessment Battery for Children-2, and Differential Ability Scales-II are typically used in the assessment of preschool children. These tests load heavily on cognitive skills such as verbal comprehension and spatial thinking. Thus, infant scales and preschool tests measure somewhat different components of intellectual ability.

Neonatal Behavioral Assessment Scale (NBAS) The Neonatal Behavioral Assessment Scale (NBAS) is unique because of its theoretical basis, which emphasizes the need to document the contributions of the newborn to the parent– infant system. The pediatrician T. Berry Brazelton (Brazelton & Nugent, 1995) developed this instrument to identify and understand the “deviant” infant and to explore the baby’s reciprocal impact on parents: My goal in developing the NBAS was to assess

the baby’s contributions to the failures that resulted, when parents were presented with a difficult or deviant infant. If we could understand the reasons behind the infant’s deviant behavior, perhaps we could in turn lead parents to a better understanding of their role. This then could lead to a more optimal outcome. (Brazelton & Nugent, 1995)

The NBAS is suitable for infants up to two months of age but is most commonly

administered in the first week of life. The scale assesses the infant’s behavioral repertoire on 28 behavior items, each scored on a 9-point scale. Examples of the behavior items include the following:

• Response decrement to light • Orientation to inanimate visual stimulus • Cuddliness • Consolability

In addition, the infant’s neurological status is evaluated on 18 reflex items, each scored on a 4-point scale. Examples include the following: • Plantar grasp • Babinski reflex • Rooting reflex • Sucking reflex

Finally, seven supplementary items can be used to summarize the qualities of responsiveness of frail, high-risk infants, including these: • Quality of alertness • General irritability • Examiner’s emotional response to infant

Brazelton and Nugent (1995) do not provide an integrative scoring system; that is, there are no

summary scores for the entire battery or its subcomponents. Instead, the “scoring” of the NBAS consists of a summary sheet with ratings on each specific item. In clinical work, the instrument is used to provide feedback to parents. Specifically, Brazelton recommends that health care professionals demonstrate the NBAS in order to sensitize parents to their baby’s uniqueness and to promote a positive parent–infant relationship. Hawthorne (2009) describes the clinical application of the instrument for promoting successful caregiving strategies. Regarding clinical use of the test, Fowles (1999) compared mothers who received a demonstration of the NBAS with a matched control group and showed that the intervention group subsequently rated their infants as significantly more predictable. Thus, the NBAS was found to be useful in helping mothers anticipate their infants’ responses to environmental stimuli. However, based on a comprehensive review of published studies, Britt and Myers (1994) provide a less optimistic review of the effects of the NBAS intervention,

noting inconsistent findings in areas such as parent–infant interaction, infant development, temperament, and parental attitudes and satisfaction. For research on newborn outcomes, various investigators have developed scoring systems for the NBAS, including a popular seven-cluster scoring method proposed by Lester (1984). This method provides summary scores for identified clusters (habituation, orientation, motor performance, arousal/lability, regulation, autonomic stability, and reflexes). Using a quantitative scoring approach, researchers have linked prenatal cocaine exposure to inferior performance on the NBAS (Morrow et al., 2001; Schuler, 1999). In addition, the NBAS is also sensitive to the detrimental effects of polychlorinated biphenyls (PCBs) on babies born to women who consumed contaminated Lake Ontario fish (Stewart, Reihman, Lonky, Darvill, & Pagano, 1999). The NBAS also shows sensitivity to the impact of major depression in mothers by revealing greater arousal and less attentiveness to face/voice

stimuli in their newborn babies (Hernandez- Reif, Field, Diego, & Ruddock, 2006). Further, the instrument is sensitive to changes in feeding behavior of premature infants (Medoff-Cooper & Ratcliffe, 2005). In general, these studies demonstrate the value of the NBAS in a wide variety of research endeavors with infants. In spite of the proven utility of the NBAS as a clinical and research tool, reviewers have been somewhat skeptical about the psychometric properties of the instrument. For example, Majnemer and Mazer (1998) point to very low test–retest reliability coefficients (r = −0.15 to +0.32 for the individual items) and weak interrater agreement. One likely explanation is that in newborn infants, individual traits may fluctuate rapidly over short periods of time, which would produce an underestimate of true reliability when the NBAS is given twice over a period of days or weeks. For this reason, deviant scores from a single administration of the NBAS should not be overinterpreted. Bayley-III

Originally released in 1969, the Bayley test is now in its third edition (Bayley, 2006). Suitable for children 1 month to 42 months of age, this instrument is an important mainstay for the evaluation of developmental delay in infants and toddlers. Known formally as the Bayley Scales of Infant and Toddler Development-III and informally as the Bayley-III, the most recent version represents a vast extension and revision of the earlier editions. For example, the first edition of the test evaluated only the cognitive and motor capacities of infants, whereas the latest edition provides for the assessment of five domains. The domains and representative capacities tested are listed here. • Cognitive Scale: 91 items involving sensory

acuity, perceptual skill, attention, object permanence, exploration and manipulation, puzzle solving, color matching, and counting. The Cognitive Scale does not contain separate subtests.

• Language Scale: 48 items involving receptive and expressive communication. Items involve recognition of sounds,

nonverbal expression, following simple directions, identifying action pictures, naming objects, and answering questions. The Language Scale yields separate scores for Expressive Communication and Receptive Communication as well as a composite Language Scale score.

• Motor Scale: 138 items pertaining to gross motor and fine motor skills. Items involve object manipulation, functional hand skills, postural control, dynamic movement, and motor planning. The Motor Skill yields separate scores for Gross Motor and Fine Motor as well as a composite Motor Scale score.

• Social-Emotional: 35 items involving interactive and purposeful use of emotions, ability to convey feelings, and connection of ideas and emotions. The Social-Emotional Scale does not contain separate subtests.

• Adaptive Behavior Scale: Caregivers complete items on a 4-point scale of 0 (is not able), 1 (never when needed), 2 (sometimes when needed), or 3 (always

when needed); items pertain to Communication, Community Use, Health and Safety, Leisure, Self-Care, Self- Direction, Functional Pre-Academics, Home Living, Social, and Motor. This scale yields separate scaled scores for each of the ten areas listed, as well as a General Adaptive Composite (GAC).

The five major clusters listed above each yield a composite score reported as a standard score (M = 100, SD = 15). Note that the Bayley-III does not yield an overall score akin to an IQ score on a traditional test. Such a score could be misleading in light of the broad range of diverse skills now assessed in the third edition of the test. Instead, the instrument seeks to yield a profile of scores useful in infant assessment and diagnosis. To this end, all scores on the instrument (including the many subscales listed above) can be reported as scaled scores (mean = 10, SD = 3) for purposes of intra-individual comparison. This yields a useful chart that helps pinpoint areas of needed intervention. For example, the child depicted in Table 7.1, a 37-

month-old boy referred for assessment, appears to present with mild intellectual disability characterized by problems with expressive communication, fine motor skills, communication, functional pre-academics, and self-direction. TABLE 7.1 Bayley-III Scaled Score Results for a 37-Month-Old Infant

Cog = Cognitive, RC = Receptive Communication, EC = Expressive Communication, FM = Fine Motor, GM = Gross Motor, SE = Social-Emotional, Com = Communication, CU = Community Use, FA = Functional Pre-Academics, HL = Home Living, HS = Health and Safety, LS = Leisure, SC = Self-Care, SD = Self-Direction, Soc = Social, MO = Motor. Note: An average score in the general population is 10, and scores between 8 and 12 typically are considered normal. Scores of 4 or below, indicated in bold, are areas of potential concern.

Cog Language Motor SE Cog RC E FM GM SE

6 7 4 3 8 4 Adaptive Behavior

Com CU FA HL HS LS SC SD Soc MO 4 7 4 8 7 7 5 4 6 6

The technical quality and excellent standardization of the Bayley-III mark this test as the psychometric pinnacle of its field. The normative sample of 1,700 children was stratified according to age and essential demographic variables, and the test developers also collected extensive data on children with high-incidence clinical diagnoses such as autism and intellectual disability. Internal consistency reliability of the five composite scores appears to be strong, with average reliability coefficients as high as .93 (Language) and .91 (Cognitive). Test–retest reliability over a short period (average of 6 days) is predictably lower, with coefficients ranging from .67 (Fine Motor) to .80 (Expressive Communication). Average stability coefficient across all ages for the major composites was .80, which is decent given that infants and toddlers are notoriously distractible. Validity evidence for the Bayley-III is scant at this time, but wholly supportive. For example, confirmatory factor analysis of the subtests of the Cognitive, Language, and Motor scales supported the three-factor model across all age

groups of the standardization sample, except for the youngest age group (Bayley, 2006). Concurrent validity coefficients with other instruments are strong as well. For example, The WPPSI-III Full Scale IQ scores correlated .72 to .79 with Bayley-III Cognitive composites. Correlations of the Motor and Adaptive Behavior composites with suitable instruments also were appropriately strong, on the order of .50 to .70. We agree with reviewers who assert that the Bayley-III continues to set the standard for early childhood assessment, and will maintain its status as the most frequently used measure of infant and toddler development (Albers & Grieve, 2007). Devereux Early Childhood Assessment- Clinical Form (DECA-C) The Devereux Early Childhood Assessment- Clinical Form (DECA-C) is a refreshing addition to the assessment field. The scale is designed for the assessment of preschoolers aged 2:0 through 5:11 with social and emotional troubles or significant behavioral concerns

(LeBuffe & Naglieri, 1999ab, 2003). What makes the instrument unique is the noteworthy focus on protective factors that can buffer the impact of social, emotional, or behavior difficulties. DECA-C consists of three protective factor scales (Initiative, Self-control, and Attachment), as well as four

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