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Chapter 23: Disruptive Behavior Disorders

Key Terms:
Callous and Unemotional Traits: personality characteristics such as lack of empathy, lack of remorse for
bad behavior, shallow or superficial emotions, and no concern of care for problematic behaviors or
issues
Conduct Disorder: characterized by persistent antisocial behavior in children and adolescents that
significantly impairs their ability to function in social, academic, or occupational areas
Disruptive Disorder: include problems with the persons ability to regulate own emptions or behaviors;
characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression toward
people and property
Externalizing Behavior: aggressive, angry, sometimes destructive behavior resulting from externalizing
and acting out ones environmental stress and adversity
Intermittent Explosive Disorder (IED): involves repeated episodes of impulsive, aggressive, violent
behavior and angry verbal outbursts, usually lasting less then 30 minutes
Internalizing Behavior: isolative and withdrawn behavior, as well as somatic illness, depression, and
anxiety resulting from internalizing ones environmental stress and anxiety
Limit Setting: an effective technique that involves three steps: stating the behavioral limit (describing
the unacceptable behaviors), identifying the consequences if the limit is exceeded, and identifying the
expected or desired behavior
Oppositional Defiant Disorder (ODD): consists of enduring pattern of uncooperative, defiant,
disobedient, and hostile behavior toward authority figures without major antisocial violations
Time-Out: retreat to a neutral place to give the opportunity to regain self-control
Objectives:
Discuss the characteristics, risk factors, and family dynamics of disruptive disorders
o Characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression
toward people and property
o Primary Disorders:
Oppositional Defiant Disorder (ODD):
Some practitioners view ODD and conduct disorder as a continuum that also
includes antisocial personality disorder, whereas others view it as a milder form
of conduct disorder
Certain level common in children and adolescents; almost expected at some
phases such as 2-3 years of age and in early adolescents
Acceptable Characteristics and Abnormal Behavior in Adolescence Table 23.1 pg
454
Diagnosed only when behaviors are more frequent and intense than in unaffected
peers and cause dysfunction in social, academic, or work situations
25% develop conduct disorder; 10% diagnosed with antisocial personality
disorder as adults; early oneset is associated with increased risk of developing
conducting disorder 30%
Disruptive defiant behaviors usually begin at home with parents to parental
figures and are more intense in this setting than settings outside the home
Occurs more often in males, with an increase in females occurrence over past
few years
Believe that gene, temperament, and adverse social conditions interact to create
ODD
Children have lower self-concept and lack competence in social situations
o Limited abilities to make associations between behavior and consequences
of behavior- both negative and positive, indicative of a reduced sensitivity
to reward and punishment
o Impaired problem-solving abilities, and deficiencies in attention,
flexibility of thinking, and decision making
Lack in confidence in social situations
Little insight into consequences
Often comorbid with other psychiatric disorders such as attention hyperactivity
disorder (ADHD) anxiety and/or mood disorders that need to be treated as well
Conduct Disorder:
Children and adolescents have significantly impaired abilities to function in
social, academic, or occupational areas
Symptoms clustered into four areas:
o Aggression to people and animals
o Destruction of property
o Deceitfulness and theft
o Serious violation of rules
Associated with early onset of sexual behavior, drinking, smoking, use of illegal
substances, and other reckless or risky behaviors
Persistent antisocial behavior; two subtypes based on age of onset:
o Childhood- Onset (Before age 10): physical aggression toward others and
disturbed peer relationships, likely to have persistent conduct disorder and
develop antisocial personality disorder as an adult
o Adolescent-Onset (After age 10): less likely to be aggressive, have more
normal peer relationships, less likely to have persistent conduct disorders
or antisocial personality disorder as adults
Classification:
o Mild: has some conduct problems that cause relatively minor harm to
others (repeated lying, truancy, minor shoplifting, staying out late without
permission)
o Moderate: number of conduct problems increases as does the amount of
harm to others (vandalism, conning others, running away from home,
verbal bullying and intimidation, drinking alcohol, sexual promiscuity)
o Severe: person has many conduct problems that cause considerable harm
to others (forced sex, cruelty to animals, physical fights, cruelty to peers,
use of a weapon, burglary, robbery, violation of previous made parole or
probation requirements)
Etiology: interaction of genetic vulnerability, environmental adversity, factors
such as poor coping
Intermittent Explosive Disorder (IED):
Can occur after age 6, can occur at any age, but is often dx from adolescent to
young adulthood
Often viewed as an impulse control disorder
More common in males
Many have a comorbid psychiatric disorder, most commonly substance use/abuse,
ADHD, ODD, conduct disorder, anxiety disorders, depression
Related to childhood exposure to trauma, neglect, or maltreatment
Neurotransmitter imbalance (serotonin)
Plasma tryptophan depletion
Frontal lobe dysfunction
Correlated with adverse physical outcomes: CAD, HTN, stroke, DM, arthritis,
back/neck pain, ulcer, headache, other chronic pain
o Related Disorders:
Kleptomania: characterized by impulsive, repetitive theft of items not needed by the
person, either for personal use or monetary gain
Tension and anxiety are higher prior to theft
Sense of relief, exhilaration, or gratification while committing theft
Item stolen often discarded
More common in females
Often negative legal, career, family and social consequences
Pyromania: characterized by repeated, intentional fire-setting
Fascinated by fire, feels pleasure or relief of tension while setting fire, and
watching fires
Neither any monetary gain or revenge
Rare as a primary disorder
If caught become legal rather than in mental health system
Apply the nursing process to the care of clients with disruptive behavior disorders
o Conduct Disorder:
Assessment:
History: disturbed peer relationships, aggression toward people or animals,
destruction of property, deceitfulness, theft, truancy, running away, staying out all
night
General Appearance and Motor Behavior: typical for age group; may be extreme
Mood and Affect: quiet, reluctant to talk; openly hostile, angry; disrespectful
Thought Process and Content: usually intact
Sensorium and Intellectual Process: alert and oriented with intact memory and no
sensory-perceptual alteration
Judgment and Insight: limited; rule breaking
Self-Concept: tough appearance; low self-esteem
Roles and Relationships: disruptive, possibly violent
Physiologic and Self-Care Considerations: at risk for unplanned pregnancies and
sexually transmitted disease because of their early and frequent sexual behavior;
drug and alcohol use; more injuries and deaths due to weapon use
Data Analysis/ Nursing Diagnosis:
Risk for Other-Directed Violence
Noncompliance
Ineffective Coping
Impaired Social Interaction
Chronic Low Self-Esteem
Outcome Identification:
Client will not hurt others or damage property
Client will participate in treatment
Client will learn effective problem-solving and coping skills
Client will use age-appropriate and acceptable behaviors when interacting with
others
Client will verbalize positive, age- appropriate statements about self
Interventions:
Decrease violence and increasing compliance with treatment
o Protect others from clients aggression and manipulation
o Set limits for unacceptable behavior
o Provide consistency with the clients treatment plan
o Use behavioral contracts
o Institute time-out
o Provide a routine schedule of daily activities
Improving coping skills and self-esteem
o Show acceptance of the person, not necessarily the behavior
o Encourage client to keep a diary
o Teach and practice problem-solving skills
Promoting social interaction
Teach age appropriate social skills
Role model and practice social skills
Provide positive feedback for acceptable behavior
Providing client and family education
Evaluation: treatment is considered effective if the client stops behaving in an aggressive
or illegal way, attends school, and follows reasonable rules and expectations at home
Provide education to clients, families, teachers, caregivers, and community members for clients with
disruptive behavior disorders
o Teach parents social and problem-solving skills when needed
o Encourage parents to seek treatment for their own problems
o Help parents to identify age-appropriate activities and expectations
o Assist parents with direct, clear communication
o Help parents to avoid rescuing the client
o Teach parents effective limit-setting techniques
o Help parents identify appropriate discipline strategies
Discuss treatment for disruptive behavior disorders
o Oppositional Defiant Disorder (ODD):
Treatment is based on parent management training models of behavioral
interventions Learn to ignore maladaptive behaviors rather than giving the
behaviors a negative attention, positive behaviors are rewarded with praise and
reinforcement, and consistent consequences for childs defiant behavior are
implemented every time behavior occurs
Individual therapy with behavioral focus
Tx of any psychiatric comorbidities with medication
o Conduct Disorders:
Early intervention/ prevention
Parenting education, social skills training, family therapy, individual therapy,
medications (conjunction with treatment)
o Intermittent Explosive Disorder (IED):
Medications: fluoxetine (Prozac), lithium, anticonvulsant mood stabilizers valproic acid
(Depakote), phenytoin (Dilantin), topiramate (Topamax), oxcarbazepine (Trileptal); SSR
antidepressants particularly seen to reduce aggressive tendencies since serotonin
deficiencies are often linked to causation
Cognitive behavioral therapy
Anger management strategies
Avoidance of alcohol and other substances
Relaxation techniques
Evaluate your feelings, beliefs, attitudes about clients with disruptive disorders
o Recognize own beliefs about parenting, how they differ from others
o Focus on patients and familys strengths, not just problems/support family
o Try to have positive impact on patient even when disability is severe
o Recognize feelings associated with working with patients with anger, violence, and aggression
issues
Mental Health Promotion
o Parenting classes
o Assist parents to increase their own risky behaviors
o Child anxiety management
o Parent-child intervention emphasizing coping skills
o Early detection of potential problems (SNAP-IV Teacher and Parenting Rating Scale)