Assessment of Disruptive Behavior Disorders in Anxiety


DSM-IV criteria: attention deficit hyperactivity disorder

(A)A persistent pattern of inattention and/or hyperactivity–impulsivity that is more frequently displayed and is more severe than is typically observed in individuals at comparable level of development, starting before age 7. Individuals may meet criteria for (1) or (2):

1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) Often has difficulty sustaining attention in tasks or play activity

(c) Often does not seem to listen when spoken to directly

(d) Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

(e) Often has difficulty organizing tasks and activities

(f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

(g) Often looses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

(h) Is often easily distracted by extraneous stimuli

(i) Is often forgetful in daily activities

2. Six (or more) of the following symptoms of hyperactivity–impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

(a) Often fidgets with hands or feet or squirms in seat

(b) Often leaves seat in classroom or in other situations in which remaining seated are expected

(c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) Often has difficulty playing or engaging in leisure activities quietly

(e) Is often “on the go” or often acts as if “driven by a motor”

(f) Often talks excessively

(g) Often blurts out answers before questions have been completed

(h) Often has difficulty awaiting turn

DSM-IV criteria: oppositional defiant disorder

(A)A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

1. Often loses temper

2. Often argues with adults

3. Often actively defies or refuses to comply with adults’ requests or rules

4. Often deliberately annoys people

5. Often blames others for his or her mistakes or misbehavior

6. Is often touchy or easily annoyed by others

7. Is often angry and resentful

8. Is often spiteful or vindictive

DSM-IV criteria: conduct disorder

1. Often bullies, threatens, or intimidates others

2. Often initiates physical fights

3. Has used a weapon

4. Has been physically cruel to people

5. Has been physically cruel to animals

6. Has stolen while confronting a victim

7. Has forced someone into sexual activity

8. Has deliberately engaged in fire setting

9. Has deliberately destroyed others’ property

10. Has broken into someone else’s house, building, or car

11. Often lies to obtain goods or favors or to avoid obligations

12. Has stolen items of nontrivial value

13. Often stays out late without permission, starting before age 13

14. Has run away from home overnight at least twice

15. Is often truant from school, starting before age 13



Oppositional defiant disorder (ODD) refers to a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures. Behaviors associated with ODD include temper outbursts, persistent stubbornness, resistance to directions, unwillingness to compromise, give in, or negotiate with adults or peers, deliberate or persistent testing of limits, and verbal (and minor physical) aggression. These behaviors are almost always present in the home and with individuals the child knows well. In addition, they often occur simultaneously with low self-esteem, mood lability, low frustration tolerance, and swearing. Prevalence rates for ODD have ranged from 2 to 16% (APA, 2000).

Conduct disorder (CD) refers to a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. Symptoms 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/or serious violations of rules. Prevalence rates for CD range from 2 to 16% (APA, 2000). DSM-IV distinguishes between two types of CD: the childhood-onset subtype (onset prior to age 10) and the adolescent-onset type (absence of any CD symptoms prior to age 10). While the adolescent period is associated with increases in rebelliousness and status offenses, conduct problems are evident in a small subset of adolescents who show more extreme or persistent forms of behavior problems. DSM-IV notes that subtyping on the basis of age of onset captures differential information about the likely nature of the presenting problems, developmental course, and prognosis. Children showing the childhood-onset pattern display more severe behavior problems early in childhood that tend to worsen over development (Lahey & Loeber, 1994). These children are also more likely to continue to show antisocial and criminal behavior into adulthood (Frick & Loney, 1999).



Comorbidity of ADs and DBDs


ADs commonly co-occur with DBDs at a rate greater than would be expected by chance (Angold et al., 1999). Table 15.2 reports comorbidity prevalence rates of specific ADs for youth with ADHD, ODD/CD, and CD only, consistent with reported rates in the literature. Across all of these investigations, ADHD may be likely to co-occur with Generalized Anxiety Disorder (GAD), Social Phobia (SOP), Separation Anxiety Disorder (SAD), Obsessive Compulsive Disorder (OCD), and specific phobia (Pfiffner & McBurnett, 2006; Souza et al., 2005; Vance, Harris, Boots, Talbot, & Karamitsios, 2003). Further, there is evidence that SOP, specific phobia, PTSD, GAD, SAD, and panic disorder/agoraphobia may commonly co-occur with ODD/CD in epidemiological and clinical samples (Goodwin & Hamilton, 2003; Nock, Kazdin, Hiripi, & Kessler, 2007; Verduin & Kendall, 2003). Thus, the assessment of ADHD and ODD/CD is of particular importance in the identification of those specific ADs in youth.


Table 15.2
Prevalence of anxiety disorders in samples of youth with externalizing disorders



































































































Sample
Author
GAD
SOP
SAD
Phobia
OCD
PTSD
Agora
Panic

ADHD
Pfiffner and McBurnett (2006)
11
17
12
26
1
–
3
2

Souza et al. (2005)
13
4
4
–
–
–
–
–

Vance et al. (2003), parent
35
18
18
24
2
0.01
0
–

Vance et al. (2003), child
23
13
26
16
14
0.01
0
–

ODD/CD
Nock et al. (2007)
15.5
31.4
12.5
24.7
–
19.7
–
10.9

Verduin and Kendall (2003)
10.1
–
12
5
–
–
–
–

CD only
Goodwin and Hamilton (2003)
6.2
20.2
–
16.5
–
11.4
9.6
8.6


Note: Numbers reported are percentage of sample

ADHD attention-deficit/hyperactivity disorder, CD conduct disorder, ODD oppositional defiant disorder, GAD generalized anxiety disorder, SOP social phobia, SAD separation anxiety disorder, OCD obsessive–compulsive disorder, PTSD posttraumatic stress disorder, Agora agoraphobia


Clinical Characteristics of Children with Comorbid ADs and DBDs


The importance of a thorough assessment of DBDs in anxious youth is heightened by the myriad of effects these comorbid disorders may have on one another. Additionally, there is the potential for symptom overlap between ADs and DBDs; thus, careful assessment is vital to obtain accurate diagnoses. Assessment of family characteristics and social characteristics in youth with comorbid ADs and DBDs are also important in understanding impairment and overall functioning of these youth.


Symptom Overlap


The potential for symptom overlap between ADs and DBDs is important to consider in the assessment of these disorders. For example, some of the symptom criteria of SAD (i.e., refusal to separate from a major attachment figure, not wanting to sleep in one’s own bed) may overlap with symptoms of ODD (i.e., refusal to do as one is told, being argumentative). Similarly, symptoms of restlessness/fidgeting may be indicative of either an AD and/or of ADHD. Irritability may also be a manifestation of either anxiety or oppositionality. Moreover, these symptoms may be exacerbated or mitigated by the presence of the second disorder. A multi-method multi-informant method is critical for accurately determining clinical diagnoses. Overall, however, there is limited criterion overlap between ADs and DBDs; thus, this issue may not pose as serious a problem for the assessment of AD and DBDs in children as suggested by some.


Family Factors


Parent psychopathology, family conflict, and other parenting behaviors may be related to the expression of comorbid ADs and DBDs in youth and are therefore important to assess. Franco, Saavedra, and Silverman (2006) found parents of children with comorbid AD and externalizing disorders (e.g., ODD, ADHD) were significantly more likely to endorse psychopathology in themselves than parents of children with AD alone. Similarly, children of depressed parents or mixed anxious–depressed parents may have a much wider range of psychiatric disorders, such as ADs and DBDs (Beidel & Turner, 1997). Additionally, family conflict may also be related to the expression of co-occurring anxiety and aggressive behaviors in youth. For example, a recent investigation by Drabick, Gadow, and Loney (2008) concluded that higher levels of family conflict were present in clinic-referred boys (ages 6–10) with co-occurring anxiety symptoms and ODD symptoms as compared to groups with either condition alone. Additionally, cross-cultural research indicates the use of physical discipline has been linked to both anxious and aggressive behavior in children (Lansford et al., 2005). Thus, assessment of family environment factors such as parent psychopathology, family conflict, and use of physical discipline, through either behavior observations or more formal diagnostic techniques, may be useful in the assessment of the comorbid AD/DBD profile in youth.


Peer Factors


Social impairment commonly occurs in youth with comorbid ADs and DBDs, given the diagnostic criteria of DBDs include social impairment (APA, 2000). In terms of interactions with peers, Franco et al. (2006) found children with comorbid ADs and externalizing disorders (ADHD, ODD, or CD) were less likely to be involved in extracurricular activities as compared to children with an AD alone. Further, AD/externalizing children had significantly worse peer relationships than children with a single AD. Thus, in youth with comorbid ADs and DBDs, impairment in functioning may be evidenced specifically by social impairment.

In addition, it may be important to distinguish between social anxiety and social withdrawal when assessing psychosocial characteristics of children with comorbid AD and DBDs (Loeber, Burke, Lahey, Winters, & Zera, 2000). There is some evidence to suggest social anxiety may serve as a protective factor in predicting the severity of DBDs, whereas social withdrawal may be a risk factor in predicting symptom impairment (Kerr, Tremblay, Pagani, & Vitaro, 1997; Ollendick & Hirshfeld-Becker, 2002). Social anxiety, for example, may indicate more sensitivity to social punishment and social rewards, which may reduce the severity of DBD problems. On the other hand, behaviors symptomatic of DBDs, such as ADHD (e.g., excessive talking, difficulty awaiting turn) and ODD (e.g., frequently arguing with others), may be related to peer rejection and ultimately social withdrawal. Thus, a thorough clinical assessment using a semi-structured interview, self-reports, and behavioral observations may be a useful approach to delineate anxiety in social situations from social withdrawal.

Overall, a thorough examination of overlapping symptoms, family environment, and social is important in diagnosing and treating these co-occurring disorders. Recommendations for the assessment of ADs and DBDs are presented below.


Assessment of ADs and DBDs


Multi-informant, multi-method strategies for assessing DBDs in youth with ADs is critical for accurate determination of diagnostic profiles in youth (De Los Reyes & Kazdin, 2005; Grills & Ollendick, 2002; Jensen et al., 1999). The primary areas to assess are child behavior, the context in which this behavior occurs, associated child characteristics and disorders, and familial or extra-familial (i.e., community, school) factors. Multiple informants may include the child, parent, teacher, and other relevant individuals. Multiple methods should be used including the clinical interview, behavioral observations, situational analyses, behavior rating scales, and cognitive or neuropsychological testing. Areas of focus include a history of the child’s development (including temperament), academics, medical conditions, and previous treatment. Aspects of the child’s social environment such as parenting characteristics, parental stress, marital discord, and affiliations with deviant peers should be considered.

The “gold standard” clinical interviewing is typically a semi-structured or structured diagnostic interview with multiple informants. Several tools for the assessment of DBDs in youth with ADs are reviewed below. Specifically, situational analysis, behavioral observation, diagnostic interviews, and behavioral scales which have established psychometric support are reviewed.

Although a number of behavioral rating scales are available for the assessment of ADs, ODD, CD, and ADHD, the present chapter focuses on ratings that either assess for all DBDs (e.g., ODD, CD, and ADHD) or for broadband measures of aggressive symptomatology (see Table 15.3 for additional details). Assessment strategies for youth with primary ADs are covered in more detail in other chapters (see Chaps. 2, 4–6). In this chapter, a number of tools listed below that assess for disruptive behavior symptoms also measure for internalizing symptoms (e.g., anxiety, depressive symptoms); thus, these measures may be particularly useful for tracking symptoms in youth with comorbid ADs and DBDs.
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Mar 22, 2017 | Posted by in PSYCHOLOGY | Comments Off on Assessment of Disruptive Behavior Disorders in Anxiety

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