SOWK 5430 Disruptive Impulse Control and Conduct Disorders

Hello class this is Doctor Mike Burford coming to you today to talk about psychopathology, more specifically I want to talk about disruptive impulse control and conduct disorders, I want to remind you that information from this presentation comes from the DSM-5 which is, once again I'll tell you, which is it your go to guide when you're in practice in terms of diagnostics Okay so let me give you a little overview of these types of behavioral disorders, there are problems with self control and regulation of emotions and behaviors, conflict with societal norms, rules, laws and authority

Etiology for these types of disorders, various behavioral disorders may vary and it's more commonly, they are more commonly seen in males and onset commonly occurs in childhood or adolescents and so when I think of behavioral disorders I usually think of children or adolescents and in fact I spent many years working with this particular population, in congregate care settings, group homes things of that nature, so I have lots of experience with these types of disorders The DSM-5 indicates that it is possible for adults to have some of these disorders, but again I think of children and adolescents when I think if these disorders I want to go back to the first two points when I said something about problems with self control and regulation of emotions and behaviors, I think that's probably true with the disorders that I will present today, conflict with societal norms, rules, laws and authorities, I think that will vary depending on the disorder and again like in my other presentations, I want to remind you that I'm giving you the disorders that I commonly see or have seen in a clinical setting and ones I strongly suspect that you will see too if you go into private practice or clinical practice of some kind, not necessarily private practice Alright let's talk about a behavioral disorder as a concept for a moment Behavioral disorder verses developmental angst, autonomy and boundary testing is an issue when we think of adolescents especially and kids too sometimes for that matter, but especially adolescence, we think of a developmental period and process where the kids are trying to test boundaries and see where they stand in terms of pecking order and as a adolescent it is a time of growth and it is moving from being a child towards being an adult, Bolby's attachment theory will provide lots of light on that for you, if you care to read Bowlby and his attachment theory and basically what Bolby was saying and I believe to be true, it makes good sense and of course things that make good sense are not always true, but from a a rational perspective I believe that Bolby has hit the nail on the head and and in fact Bolby and his theory, attachment theory has guided my practice on many occasions, working with these adolescence, so basically what we have with adolescents is, and according to Bolby's attachment theory, is that again adolescents are in the developmental process of moving from childhood into adulthood and so what that means is that they push boundaries, that they are attempting and practicing being an adult, at least to some degree and some of them of course do better with that than others, but almost all of them want to disengage from the way of being as a child and the relationships with their parents as a child and so they're seeking autonomy and they're trying to interact more with their social environment, they're trying to move away from the parents and more towards peers and that's why we often in adolescence have complaints, in a clinical setting, from parents that the adolescent doesn't seem interested, doesn't seem engaged in the family, is more interested in hanging out with friends, is unruly to some degree, pushes limits and boundaries and so forth

the interesting thing with those kids is that, adolescence, is that they tend to like to have parents there as a safety net, so even though they're moving away from parents and they're practicing being in the social world and becoming their own unique autonomous individual, they do find comfort in knowing that mom and dad are or who ever it is, care provider, that they're still there and that they serve as a safety net and also remember that kids do, even though sometimes they don't act like it, they do need to be provided with structure and need to know that someone is in control and that provides safety for them, so back to the issue at hand, sometimes it's a bit difficult to know the difference between a natural developmental process in adolescence for instance, as opposed to a disorder, a true behavioral disorder and so oftentimes the difference is clear in terms of frequency and duration of the problem and intensity as well, in the cases that I've seen in clinic, it was quite obvious that the adolescents were struggling with way more than just the normal developmental period that all adolescents tend to go through Yhe other thing I can say about it is that parents have often brought their kids into me to be fixed and they will plop junior or sissy down in front of me and they'll proclaim something along the lines of I have brought my kid to you so you can do something with them, so you can fix them and often times what I will say to the parent is that well okay I understand that your child or your adolescent has some behavioral problems, but more than likely we're also going to need to look at some parenting styles and your role in things and how you're doing or not doing things and some parents are okay with that and then some of them look at me like I've lost my mind that I would ask them to participate in therapy and that indeed they are most likely, not always, but most likely part of the problem and need to make some adjustments on their parenting style Okay so let's talk about some of the disorders now One of the most common disorders that I see in adolescence is Oppositional Defiant Disorder and it's basically how it sounds, there's a pattern of irritable angry mood that is often present, they are often argumentative and defiant and often vindictive, I'm thinking of several cases mostly cases actually that I have had without adolescents with ODD and they were markedly angry and agitated towards their caregiver, their primary caregiver, whether it be a parent or grandparent or what have you, to the point that they would intentionally start arguments and just be very nasty in general verbally to that person, the intensity over their anger and defiance far outweighs anything you would see in a normal adolescent developmental behavior, to be around these types of kids one immediately recognizes that something's very much a mess and wrong Alright so for this disorder this pattern of behavior from the adolescent or child needs to be greater than six months, so a duration greater than six months and they commonly disrespect authority across fears and oftentimes they can be nice for a while if they choose too, but it's usually a very shallow, short-lived effort at being pleasant, the minute that they feel that their toes are stepped upon then they become angry and argumentative and defiant, most often that's the case anyway and it's common to see these types of kids have problems at home and at school, in social settings sometimes police may be involved, in terms of family disputes and that kind of thing or maybe the school safety officer or something along those lines, it's certainly not uncommon for these types of students or these types of clients to be very disruptive and disrespectful at school and social settings and that kind of thing, I'll give you two really quick examples, I remember from my cases years ago, I remember one particular fellow that had Oppositional Defiant Disorder and and he was having a tantrum and there was an administrator that for the agency where I worked and she happened to be coming through a building and the windows had just been replaced in the building and she immediately got involved with the kids tantrum, which was a mistake she did not have a relationship of any kind with this particular boy, teenage boy and so naturally he didn't know or respect her at all, she had not invested time in him and so she escalated him and his behavior got worse to the point where he picked up a chair and was telling her if you don't go away and leave me to work with staff I will throw this window through the new chair or I am sorry throw this chair through this new window, well apparently she didn't believe him and so he chucked the chair through the new window and it was one of those real big windows too, so I guess he made a believer of her

I am also thinking and this was in a group home, but I am also thinking about a school environment, I had a young fellow, who had Oppositional Defiant Disorder and decided that he was unhappy in math class one day and so he was quite defiant of the teacher and wouldn't listen, would not stay in his seat, would not stop pestering other students, the teacher became more and more aggitated with him and of course his response became more and more animated and so he ended up getting under his desk, crawling up and under his desk, on all fours barking like a dog and refused to come out and stayed there for a good 30-45 minutes or so, of course we addressed that therapy, I thought it was rather humorous, it was sad in a lot of ways, he was missing out on his education, but it is one of the more colorful things that I've seen some of the students do in a classroom setting Again the last point I wanted to make, well wanted to tell you real quickly that there are three different sub-types or three different specifiers for ODD and that's mild, moderate and severe for the mild specifier the symptoms occur only in one setting, for the moderate it'll be present in about two settings and then for severe it will be present in three or more settings and these people commonly defy rules sometimes for no other reason than to be defiant, sometimes it doesn't make sense at all why their doing the things that they're doing Okay let's talk about conduct disorder for just a minute In the DSM, the old DSM there were three main types of behavioral disorders that I would see a lot and conduct disorder would be the most severe followed by ODD and then something I believe it was behavioral disorder not otherwise specified and that was for behavior that did not meet criteria for ODD or conduct disorder, but yet was still more problematic than what could normally be expected and was disruptive to the person's life Okay so conduct disorder, there's a pattern of violating rights of others with conduct disorder or violation of major societal norms, rules and laws and these people may lack remorse and empathy and not be concerned about performance in school or at the job or any other place or demands are put upon them or expectations are put upon them and they may not express sincere feelings at all and this disorder requires the presence of at least three of the 15 DSM-5 criteria for conduct disorder within the last year, with at least one criteria being met with in the last six months and common criteria include aggression to people, such as assaults, rape, well those kinds of things and then it includes destruction of property and deceitfulness and theft and serious violation of rules and when I see somebody with conduct disorder their behavior usually is the type of behavior that if they were 18 or older they would be arrested and put in jail for the behavior that they routinely engage in

Now there are subtypes of conduct disorders, there is childhood onset type and that's for prior, onset prior to age ten years, there's also adolescent onset type and then there is unspecified onset type, now what I can tell you about childhood onset type is that kids who have conduct disorder at such a young age are more likely to carry that behavioral disorder throughout their teen years and then as an adults are much more likely to develop antisocial personality disorder Adolescents on the other hand with conduct disorder, that have recently developed the disorder, are much more likely to eventually change their behavior and improve and function a lot more appropriately and of course there's various specifiers mild, moderate and severe specifiers are there I can tell you this real quickly about a case, well over the years I've had several kids with conduct disorder, I have had kids that have committed armed robbery and who've been shot and yet turn around and do it again, one of which I recall is in state penitentiary right now and despite the conversations we had about doing the right things and making appropriate choices and all that, I mean that went in one ear and out the other apparently, but so he ended up running away and robbed another place and got caught and is in the penitentiary I have had kids that committed armed robbery at restaurants and have kids that have stolen vehicles, sometimes from the group home you know quite a feeling when you look out the window and you see the company van going down the road and you know that it's not any of the staff because their else where doing other things and you know as a therapist sometimes, well I remember once I saw somebody stealing a van and staff was not supervising the person and had been neglectful enough to leave the keys where they were able to be accessed and but anyway so, I will tell you one story that I found to be interesting, we had a boy that ran away and went down to the University of Tennessee area, went down on campus and he and another guy tried to mug a female student, well it turns out she was a soccer player and in pretty good shape, in pretty good shape as an athlete and she ended up beating him up, you know so here's this big old teenage boy, that was quite large in size and and she put the whip on him and all that, I don't condone violence, but I found that was an interesting little story there, but I've got a bunch of those I could tell you about if I ever meet with you in person and you want to know more about those kind of things, stories I could tell you about some of the interesting things that happen Now let's talk for a minute about Intermittent Explosive Disorder, in my career I've seen I don't know a handful of kids, not a whole lot, but I have seen a few with this particular disorder, this disorder entails recurrent behavioral outbursts and failure to control impulses, but they're usually verbally aggressive when they have these outbursts, physical aggression can occur, usually there is no physical damage or injury and the incident occurs at least twice weekly for a three-month period or 3 outbursts within a 12-month period, that involves physical injury or destruction of property, the magnitude of the outburst is out of proportion to the precipitator, it is not premeditated and the person is at least six years of age

I can tell you that when you have somebody with this particular disorder and their having an outburst, if you don't realize that they have this disorder it will have you sitting back scratching your head thinking whu in the world did this person get upset and what was all that about, obviously the idea is if you can identify what the problem is, perhaps it can be addressed and avoided in the future, but it can certainly leave you scratching your head wondering what it was all about I want to talk a little now about pyromania and that as you may know is a pattern of deliberate fire setting People with pyromania have a feeling of excitement prior to fire setting and satisfaction when the fire setting has been completed or when they participate in the aftermath of the fire Fire setting is not done for financial gain, to cover a crime or as an act of vengeance, in order for it to qualify as pyromania and I have had, over the years I've had I don't know, I can think of about four, 3 or 4, probably no more than five clients that had pyromania and the thing that is interesting thing about them is I can think of two of them that had been convicted of committing the crime and they tended to not be bashful at all about what they had done and actually appeared to enjoy remembering the experience and and telling me about it and they reported feeling excited and having a feeling of being empowered and having control and of having a level of defiance, that's the report that they gave me about it and of course the person that I remember that had been accused of fire setting, hadn't been convicted yet, wasn't saying a whole lot about it for obvious reasons, but I can remember two clients that I had that burned a home to the ground, in each case burned it to the ground, one of them was a foster home Okay I want to talk real briefly here about treatment for these types of disorders

Now a therapeutic relationship with these adolescents and kids helps a lot, if you can develop a therapeutic relationship, if you listen and allow clients to feel heard, it's very important, even if you disagree with them, for instance I would have a kid come into me with one of these disorders and they would be in a funk, they would be, that's not clinical term by the way, a funk, but you know what I mean, but they would come and say things like I am frustrated and about to explode or tear this place up or whatever they would say and I would say well why is that, come in in and have a seat and I would make time to see them when they knocked on my office, which was in the facility and I would listen to them for I don't know, about 10 or 15 minutes and they would blow out all these frustrations and threats and all these other kind of things and oftentimes they would be yelling and I was able to you know, hey I'm not yelling and I don't understand why you're yelling and if you'd like to continue to talk with me, you need to lower your voice, I am glad to hear what you have to say, but I can't do that when you're yelling and so I get them to lower their voice and after about 15 minutes they would be fairly calm and we would be able to problem-solve and I would be able to gently challenge and help them reconstruct or reframe their point of view, but in the beginning if I were to say oh no, no you're wrong and that would just escalate the situation further, first I'll let them know that I was willing to listen, so especially when I was working in a group home there was a little saying that I had and some of the other staff members had and it went along the lines of pay me now or pay me later and that's what we knew that we would have to do for the kids, that either way they were going to get our attention, the question is how's that going to play out, now I had staff members that would come in and they would be fairly new or they would be pulled from one of the other group homes and they would come in and they would try to bark orders to the kids and be pretty stern and come down on them pretty hard and of course the kids would have none of it or very little of it a lot of them anyway and would end up in my office and that kind of thing, but the problem there is that, that person didn't have a relationship with that kid and they had not invested time with that kid and that kid didn't know them and didn't trust them, didn't think that they we're on his or her side or at least willing to hear his or her side and so the idea was and what I tried to teach staff is that you will pay attention to these kids sooner or later, so the best way to do it is do it correctly and so for example when I would go into work, as I made my way to my office, I would usually have two or three kids that would stop me along the way and they would want to ask me how my day was or tell me something they had done, engage with me in some way, so I would stop and I would talk with one of them for about five minutes or are them how they're doing and was really concerned, was really wanting to know and all that and so I built a relationship with these kids and in the group home they were usually kids that were bigger, as big or bigger than I am, I'm six feet tall, some of them were taller than me, weighed more than me and had a criminal record of aggression and violence and all that and so some of these kids were were fairly, scary kids in some ways, but even with that because I had invested in those kids and because they liked me for that reason, I could ask just about of them to stand on their head and bark like a dog if I wanted too and they would probably do it, that is the example I used for staff, these kids if you develop a relationship with them, a therapeutic relationship, will work with you, are a lot less likely to hit you, are a lot less likely to stop fighting if you jump in the middle of a fight and which if you work in a group home, sooner or later you have to do, if you want them to stop by fighting that is, so anyways it's a real simple concept you know you'll either spend time with that, investing in that kid before there's a problem, so that when there is a problem you can handle it much more smoothly and efficiently or you have the option of waiting until there's a problem and then good luck to you, it could get pretty ugly When you're working with these types of kids you want to identify common goals I remember many a time I would have a kid that would be going on and very angry and upset and sometimes rightfully so about something staff had done and I will try to address that with staff as necessary, but in private of course, but sometimes the kid would be almost inconsolable and so what I do at that point is I say well what do you want? You know and I knew that the answer was usually going to be well I want to go home or I want to go to be with Aunt Judy or I want to go be with somebody that you know and get out of congregate care, try to resume life and I'll remind them of their goal, your goal is to get out of here, your goal is not to make friends with some staff members that you don't like, your goal is not to have your nose in other peoples business or that kind of thing, remember your major goal and work towards that, even if you have to take a few things that you don't like in the meantime, don't let those little things get in the way of your common goal and so I would help them with that and when the client was cognitively able, I would help them reframe and adjust erroneous beliefs, that is borrowed from Cognitive Behavioral Therapy, as you probably know or will find out soon if you don't know and for some of them that weren't very cognitively able, we would engage in basic behavior modification techniques, for instance we would provide consistent rewards and or consequences for certain behaviors, notice I said the word consistent their and that's also incidently something that parents would have a big struggle with, was being consistent in their responses to their child's behavior, whether it was good or bad I remember one case in private practice right before I stopped private practice to come to work here, I had a parent come in with a kid and I said well you know how's the intervention going we had worked out an intervention that the parent was to do in and she said well it just doesn't work and I said well that's interesting tell me more about the whole thing and you know how it's going and why it is going that way, what you're doing and all that and it turns out she applied the intervention infrequently and certainly did not have any consistency and so what does that do, that sends a mixed message to the kid and so then when she does try to provide the intervention the behavior would be even worse from the child or from the kid so it's all about consistency folks I have already talked a little about kids needing structure again remember oftentimes good effective treatment with adolescents is every bit as much working with the parents, to help tweak what they're doing

Okay so there is some information about disruptive impulse control and conduct disorders, it can be very challenging, but yet also quite rewarding to work with these disorders and for those of you who already work in group home settings you know what I mean Incidentally, I want to recommend a book to you, that I may have recommended before, but it's by Doctor Stanton Samenow, who wrote inside the criminal mind, Doctor Samenow has influenced me greatly and my thinking in terms of psychology and all that, but he's written several books and one of the books that he has written is called Before it's too Late and it's an excellent book on working with, understanding and working with behaviorally disordered kids and their parents, again it's Doctor Stanton Samenow, he is a clinical psychologist and the book is called Before it's too Late and you can google him, he has a website, probably the cheapest way to get one of those books, will be to just order it directly from the website, he will even autograph it for you, I don't know about you, but I like for my books to be signed by the people that wrote them, if it's a book that I like and enjoy Alright thanks for your time and attention bye!

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