Abnormal Psychology

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The Nature of Psychopathology and Abnormal Psychology
The Diagnosis of Mental Disorders

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Introduction to Child Psychopathology

1. Early Milestones in the History of Child Psychology

1892 American Psychological Association founded. G. Stanley Hall is first president.

1892 L. Witmer founds first psychology clinic, University of Pennsylvania, for children with learning disabilities and academic problems.

1897 Witmer’s clinic offers 4-week summer course in child psychology.

1905 Binet-Simon Intelligence Scale for measuring mental abilities in children published in France.

1907 Witmer establishes a residential school for retarded children and founds the first clinical journal.

1908 H. Goddard establishes first clinical internship program at Vineland Training School (New Jersey).

1909 Beers, supported by psychologist W. James and psychiatrist A. Meyer founds the National Association of Mental Health


1909 W. Healey establishes the first child guidance center, the Juvenile Psychopathic Institute (Chicago), to treat and prevent mental illness in juvenile offenders. Later named the Institute for Juvenile Research

1909 G. Stanely Hall invites Sigmund Sigmund Freud to lecture on psychoanalysis at Clark University.

1910 Goddard translates the Binet-Simon Intelligence Test for use with “feeble-minded children” at the Vineland School.

1911 A. Gesell appointed director of Yale’s Psychoeducational Clinic, renamed Clinic of Child Development.

1912 J.B. Watson publishes Psychology as a Behaviorist Views It.

1916 Terman’s Stanford-Benit Intelligence Test is published.

1917 APA section of clinical psychology is founded.

1920 Watson and Raynor demonstrated that fear can be conditioned in a child called “Albert”.

1922 NAMH funds eight pilot child guidance clinics established in various cities.

1926 Piaget publishes The Language and Thought of the Child.

1928 Anna Freud publishes Introduction to the Technique of Child Analysis.

1930 Kanner joins Johns Hopkins University and opens the first pediatric psychiatric clinic, Harriet Lane Pediatric Clinic.

1932 M. Klein authors The Psychoanalysis of Children.

1935 Kanner publishes first textbook on child psychology.

1937 Adolescent psychiatric ward opens at Bellevue Hospital.

1944 Kanner describes autistic behaviors and attributes illness to “refrigerator mother”.

1945 Studies by R. Spitsz raise concerns about negative impact of institutional life on children.

1948 American Association of Psychiatric Clinics for Children (AAPCC) is formed as 54 child guidance clinics come together.

1950’s Behavior therapy emerges as a treatment alternative for child and family problems.

1951 Bowlby publishes on attachment.

1952 American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). The DSM contained two disorders of childhood: Adjustment Reaction and Childhood Schizophrenia.

1953 The American Academy of Child Psychiatry is established.

1968 DSM-II published and adds “hyperkinetic reaction of childhood” (which is now referred to as Attention-Deficit/Hyperactivity Disorder.

1977 Thomas and Chess publish work on the nine categories of temperament.

1980 DSM-III is first version of DSM to make specific developmental recommendations regarding childhood disorders.

1984 Sroufe and Rutter introduce domain of child psychopathology as offshoot of developmental psychology; Developmental Psychopathology Journal is introduced.

1999 Clinical Child Psychology established as the 53rd division of American Psychological Association, renamed Society of Clinical Child and Adolescent Psychology (2001).

2. Distinguishing Normal From Abnormal Psychology

Developmental Psychology is devoted to studying the origins and course of individual maladaptive in the context of normal growth process. Young Children are especially vulnerable to psychological problems for a number of reasons:

- They do not have as complex and realistic a view of themselves and their world as they will have later- They have less self-understanding

- They have not yet developed a stable sense of identity

- They have not yet developed a clear understanding of what is expected of them and coping skills

The use of the four D’s can provide helpful guidelines in determining normal behavior from abnormal behavior in the following ways:

Deviance: Determining the degree that behaviors are deviant from the norm can be assisted through these of informal assessment such as interviews, observations, and symptom rating scales. More formal psychometric batteries like personality assessment. Classification systems can also provide clinicians with guidelines for evaluating the degree of deviance.

Dysfunction: Once a disorder is identified, the relative impact of the disorder on the individual’s functioning must be determined. Child clinicians may be interested in the degree of dysfunction in such areas as school performance (academic functioning) or social skills.

Distress: An area closely related to dysfunction is the dress of distress the disorder causes. Children often have difficulty articulating feelings and may provide little information to assist the clinician in determining distress. Interviews with parents and teachers can provide additional sources of information. Some disorders may present little distress for the individual concerned but prove very distressing to others.

Danger: In order to determine whether a given behavior places an individual at risk, two broad areas are evaluated: risk for self-harm and risk of harm to others. Historically, the focus has been on victimization and maltreatment of children (abuse or neglect) or the assessment of risk for self-harm (suicide intent). However, more recent events, such as the 1999 Columbine shootings and increased awareness of bullying, have increased concerns regarding children as perpetrators of harm. Accordingly, increased emphasis has been placed on methods of identifying potentially dangerous children and conducting effective threat assessments.

3. Normal and Abnormal Behaviors: Developmental Considerations

Evaluation of child psychopathology from a developmental perspective requires the integration of information about child characteristics (biological and genetic) and environmental characteristics (family, peers, school, neighborhood). Therefore, understanding child psychopathology from a developmental perspective requires and understanding of that nature of cognitive, social, emotional, and physical competencies, limitations, and task expectations for each stage of development. This understanding is crucial to an awareness of how developmental issues impact psychopathology and treatment.

Reference for all of the information above comes from: http://media.wiley.com/product_data/excerpt/40/04716562/0471656240.pdf

What is child psychopathology?

Child psychopathology is the manifestation of psychological disorders in childhood and adolescence; examples include Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Pervasive Developmental Disorders (Mash & Barkley, 2003).

Factors complicating the study of child psychopathology

Since modern views of mental illness began to emerge in the late 18th and early 19th centuries, there has been far less attention given to the study of child psychopathology than psychopathology in adults. An example of this is in 1812, when Benjamin Rush, the first American psychiatrist, suggested that children were less likely to suffer from mental illness because the immaturity of their developing brains would prevent them from retaining the mental events that caused insanity (Mash & Barkley, 2003). Fortunately, psychiatrists do not think this way. Recently interest in child psychopathology has increased. This is due to the growing realization that many childhood problems have lifelong consequences and costs both for children and for society, that most adult disorders are rooted in early childhood conditions and/or experiences, and that a better understanding of childhood disorders offers promise for developing effective intervention and prevention programs (Mash & Barkley, 2003). Another factor is that there are issues present concerning the conceptualization and definition of psychopathology in children continue to be debated. Also, there is the fact that in studies conducted with children, much of the knowledge gained is based on findings obtained at a single point in a child's development and in a single context. A further complication is that childhood problems "do not come in neat packages" and that most forms of psychopathology in children are known to overlap and/or coexist with other disorders (Mash & Barkley, 2003, p. 4). As you come to learn about child psychopathology, you will see how much overlap really does occur and why this is such a complication. There is also a problem that distinct boundaries between many commonly occurring childhood difficulties and those problems that become labeled as disorders are not easily drawn. There is also a growing recognition that all current diagnostic categories of child psychopathology are heterogeneous with respect to etiology and outcome, and will need to be broken down into subtypes, as you will see with the disorders mentioned on this page. It has also become increasingly evident that most forms of child psychopathology cannot be attributed to a single unitary cause. Some disorders cannot be linked to a single gene or a single event in life. There is also the complication that numerous determinants of child psychopathology have been identified, including genetic influences, hypo- or hyper-reactive early infant dispositions, insecure child-parent attachments, difficult child behavior, social-cognitive deficits, deficits in social learning, emotion regulation, and/or impulse control and response inhibition (Mash & Barkley, 2003). The many causes and outcomes of child psychopathology operate in dynamic and interactive ways over time which makes it hard to disentangle them. To designate a specific favor as a cause or an outcome of child psychopathology usually reflects the point in an ongoing developmental process at which the child is observed and the perspective of the observer (Mash & Barkley, 2003).

Significance of child psychopathology

There has been and continues to be a great deal of misinformation and folklore concerning disorders of childhood (Mash & Barkley, 2003). Many of these unsubstantiated theories have existed in both the popular and scientific literature, one example is the misconception that over-stimulation in the classroom causes insanity. Many of the constructs used to describe the characteristics and conditions of psychopathology in children have been globally and/or poorly defined (Mash & Barkley, 2003).

The growing attention to children's mental health problems and competencies arises from a number of sources. First, many young people experience significant mental health problems that interfere with normal development and functioning. In fact, as many as 1 in 5 children in the United States experiences some type of difficulty and 1 in 10 have a diagnosable disorder that causes some level of impairment (Mash & Barkley, 2003). Second, a significant proportion of children do not grow out of their childhood difficulties, although the ways in which these difficulties are expressed change in both form and severity over time. Third, recent social changes and conditions may place children at increasing risk for the development of disorders and also for the development of more severe problems at younger ages. Fourth, for a majority of children who experience mental health problems, these problems go unidentified. Only about 20% receive help, a statistic that has not changed for some time (Mash & Barkley, 2003). Fifth, a majority of children with mental health problems who go unidentified and unassisted often end up in the criminal justice or mental health system as young adults. They are at greater risk of dropping our of school and of not being fully functional members of society. Finally, a significant number of children in North America are being subjected to maltreatment and chronic maltreatment during childhood that is associated with psychopathology in children and later in adults. It has been estimated that each year as many as 2,000 infants and young children die from abuse or neglect at the hands of their parents or caregivers (Mash & Barkley, 2003).

Epidemiological considerations


The overall lifetime prevalence rates for childhood problems are estimated to be high and on the order of 14-22% of all children (Mash & Barkley, 2003). Rutter, Tizard and Whitmore (1970) found in the classic Isle of Wight Study that the overall rate of child psychiatric disorders to be 6-8% in 9 to 11 year old children (as cited in Mash & Barkley, 2003). Richman, Stevenson, and Graham (1975) found in the London Epidemiological Study that moderate to severe behavior problems for 7% of the population with an additional 15% of children having mild problems (as cited in Mash & Barkley, 2003). Boyle et al. (1987) and Offord et al. (1987) reported in the Ontario Child Health Study that 19% of boys and 17% of girls had one or more disorders (as cited in Mash & Barkley, 2003). Many other epidemiological studies have reported similar rates of prevalence.

Age differences

Some studies of nonclinical samples of children have found a general decline in overall problems with age, whereas similar studies of clinical samples have found an opposite trend. These and many other finding raise numerous questions concerning age differences in children's problem behaviors. Answers to even a seemingly simple question such as "Do problem behaviors decrease (or increase) with age?" are complicated by a lack of uniform measures of behavior that can be used across a wide range of ages, qualitative changes in the expression of behavior with development, the interactions between age and sex of the child, the use of different informants, the specific problem behaviors of interest, the clinical status of the children being assessed, and the use of different diagnostic criteria for children of different ages (Mash & Barkley, 2003).

Socioeconomic Status

Although most children with mental health problems are from the middle class, mental health problems are overrepresented among the very poor. It is estimated that 20% or more of children in North America are poor, and that as many as 20% of children growing up in inner-city poverty are impaired to some degree in their social, behavioral, and academic functioning (Mash & Barkley, 2003).

Sex differences

Findings relating to sex differences and child psychopathology are complex, inconsistent, and frequently difficult to interpret, the cumulative findings from research strongly indicate that the effects of gender are critical to understanding the expression and course of most forms of childhood disorder (Mash & Barkley, 2003).

Attention-Deficit/Hyperactivity Disorder (ADHD)


There has been a lot of debate over symptoms and what the name should be before it was decided to be called ADHD. William James referred to it as 'explosive will' and George Still called it 'volitional inhibition'. ADHD has also been referred to as minimal brain dysfunction and hyperactive child syndrome. The DSM-II called it 'hyper-kinetic reaction of childhood', which was the first childhood disorder in the DSM. DSM-III referred to it as Attention Deficit Disorder (ADD) and it had much more information on it. It was classified as with or without hyperactivity. The DSM-IV calls it ADHD. DSM-V will also refer to it as ADHD.


There must be a persistent pattern of inattention and/or hyperactivity-impulsivity more severe and more frequent than in same-age peers. There has to be an onset of symptoms prior to seven years old, but diagnosis can occur much later. A child must display six or more symptoms of either inattention or hyperactivity-impulsivity for at least six months. Adults can have less. There must be some impairment from the symptoms present in two or more settings (e.g., at school/work and at home) and a clear impairment in social, school or work functioning. They symptoms cannot be accounted for by another mental disorder such as pervasive developmental disorder, schizophrenia, or any other psychotic disorder. The problems with inhibition (hyperactive-impulsive behavior) arise first, usually at ages 3-4, ahead of those related to inattention, with arise are 5-7 years old and then slow cognitive tempo arises at ages 8-10 (Mash & Barkley, 2003). Those with inattention are frequently diagnosed later in life due to the less disruptive nature of the problems. It will not go away with adulthood, but presentation does typically change.


Inattention symptoms:

-often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

-often has trouble keeping attention on tasks or play activities.

-often does not seem to listen when spoken to directly.

-often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

-often has trouble organizing activities.

-often avoids, dislikes, or does not want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

-often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools).

-often easily distracted.

-often forgetful in daily activities.

-inability to have sustained attention or persistence on tasks, remember and follow rules, and resist distractions (may be more related to working memory than true "attention" problems).

-exhibit more "off-task" time and less productivity (even occurs while watching television).

-slower and less likely to return to an activity once interrupted.

-less attentive to changes in the rules governing a task.

-less capable of shifting attention across tasks flexibly.

Hyperactivity symptoms:

-often fidgets with hangs or feet or squirms in seat.

-often gets up from seat when remaining in seat is expected (such as in school).

-often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

-often has trouble playing or enjoying leisure activities quietly.

-often "on the go" or often acts as if "driven by a motor".

-often talks excessively.

-greater touching of objects.

Impulsive symptoms:

-often blurts out answers before questions have been finished.

-often has trouble waiting one's turn.

-often interrupts or intrudes on others (e.g., butts into conversations or games).

The 3 Subtypes

1. Combined type: if both criteria for inattentive and hyper-impulsive symptoms are met for the past 6 months. There must be 6 symptoms present from each. Combined is the most common of the subtypes.

2. Predominately Inattentive type: If criteria for inattentive is met but criterion for hyper-impulsive is not met for the past 6 months.

3. Predominantly Hyperactive-Impulsive type: If criterion for hyper-impulsive is met but criterion for inattentive is not met for the past 6 months.


Some say that the child is "just being a kid". There is some level of all of the core symptoms is present in all children which is very normal. ADHD is separated from ordinary exuberance and "being a kid" by the degree of the symptoms and the impairment they cause.

Symptoms thresholds may not apply outside of 4-16 year old range. Fewer symptoms are needed to qualify for ADHD as age increases.

Appropriateness of item sets for different ages and genders. Inattention seems more geared for school-aged or adolescents. Hyper/Impulsive seems more applicable to younger children. This could influence the rates of diagnosis across age groups, resulting in more false-negatives as one gets older.

There is little if any research for the onset before age 7. No other mental disorder has this precise an age of onset. There is also no lower-age or IQ boundary in the DSM-IV-TR.

No research support for symptom duration of 6 months. There is some support for a 12 month period, though.

The requirement of impairment in 2/3 environments is situation specific and lacks parent-teacher agreement.

Some say that ADHD is not real and it is merely pathologizing normal behavior, which is not the case; research indicates that there are a large number of differences between ADHD and non-ADHD children.


The behavior of hyperactivity can be seen in 22-57% of children. Only 4.2-6.3% meet criteria for the action disorder, which is 5% nationwide. Parent-reports gives much lower figures than teacher-reports, which only seems to support the idea that environmental context is very important.

Sex differences

Males are 2.6-5.6 times more likely to be diagnosed as females within epidemiological samples; average ratio of 3:1. The clinic-referred samples have even higher ratios due to co-morbid Oppositional Defiant Disorder/Conduct Disorder seen in boys. This holds true even though research show that females have as great of functional impairments and deficits as the males.

Socioeconomic and cultural differences

There is little research on the relationship between socioeconomic status (SES) and ADHD rates. However, using the DSM criteria, there are higher rates of ADHD found outside the United States. This is most likely due to cultural differences in expectations or interpretations of symptoms. There are higher rates in the US reported for non-whites, yet they are from poorly controlled studies that had no correction for co-morbidity. It seems that ADHD occurs across all socioeconomic levels, although there are variations across all SES levels.

Co-morbid psychiatric disorders

There are high rates of co-morbidity in ADHD; 44% in community samples and 87% for clinic-referred samples. The most common of those disorders are Oppositional Defiant Disorder (54%-67%), Conduct Disorder (26% by adulthood), Antisocial Personality disorder (12-21%), learning disorders (30-50%), anxiety disorders 25% in childhood), and mood disorders (20-30%). Up to 18% of children may develop a motor tic in childhood (a symptom of Tourette's), but this declines at a base rate of 2% by mid-adolescence and less than 1% by adulthood. Individuals with obsessive-compulsive disorder or Tourette's disorder have a marked elevation in risk for ADHD, averaging 48% or more (Mash & Barkley, 2003).

Developmental impairments

There are many concurrent developmental difficulties that are seen with ADHD:

-Physical problems: gross and fine motor control, motor sequencing.

-Working memory impairments

-Poor planning and anticipation

-lack of verbal fluency

-Inefficient self-monitoring

-Poor regulation of emotion

-Impaired academic functioning: the snowball effect-as you go on you get further behind. Between 19% and 26% of children with ADHD are likely to have any single type of learning disability, which, conservatively, is defined as a significant delay in reading, arithmetic, or spelling relative to intelligence and achievement in one of these three areas at or below the 7th percentile (Mash & Barkley, 2003).

-Reduced intelligence. These children often have lower scores on intelligence tests, especially in verbal intelligence, when compared to children without ADHD (Mash & Barkley, 2003).

-Poor social skills. Fellow classmates may not deem a child with ADHD as someone they would want to become friends with since they usually interrupt or join conversations without being invited into them. They are also seen as disruptive.

-Motor in-coordination: as many as 60% of children with ADHD, compared to up to 35% of normal children (Mash & Barkley, 2003).

All of the listed impairments can fall under the domain of "executive functioning" since they are process that assist with self-regulation, behaviors that modify the probability of a subsequent behavior so as to change the probability of a later consequence. They are mediated by the prefrontal cortex.

Health Outcomes

Studies have concluded that children with ADHD are more accident-prone and get injured more often than children without the disorder. About 16% of a sample of hyperactive children from a study had at least four or more serious accidental injuries (broken bones, lacerations, head injuries, severe bruising, lost teeth, etc.), compared to the 5% of children in the control group (children without ADHD) (Mash & Barkley, 2003). Teenagers with ADHD have a higher frequency of vehicular crashes and a history of citations for speeding than children without ADHD (Mash & Barkley, 2003). This may be due to the inattention and/or hyperactive-impulsive behavior of a teenager with ADHD. Children with ADHD also have more sleep problems than a child without; they experience a longer amount of time to fall asleep, instability of sleep duration, tiredness at waking, or frequent waking during the night (Mash & Barkley, 2003).


ADHD arises from a combination of environmental, genetic, and neurological factors, meaning that there is no one true developmental pathway. Whatever pathway it takes, it often ends up disrupting prefrontal cortical-striatal network, which is smaller and less active in people with ADHD. Social factors may play a role in expression, but would not be purely responsible for this disorder.

Theoretical framework

Barkley's model focuses on how behavioral disinhibition impacts four primary executive functions; poor working memory, delayed internalization of speech, immature regulation of affect/motivation/arousal, and impaired reconstruction. These impairments in executive function in turn impair social self-sufficiency. Barkley's assumptions were; 1.) behavioral inhibition develops ahead of these four executive functions, 2.) each executive function emerges at different times and has a different developmental trajectory, 3.) ADHD impair the behavioral inhibition, which in turn impairs the executive function, 4.) deficit in behavioral inhibition is due to biological factors, 5.) deficits in self-regulation are caused by the primary behavioral inhibition, but in turn feedback to cause even poorer behavioral inhibition, and 6.) model does not apply to inattentive types of ADHD (this is the model's biggest problem).


A typical battery for an ADHD assessment would include; a structured or semi-structured clinical interview that should cover developmental and family history, DSM-IV ADHD symptoms, and symptoms of typical co-morbid problems, intelligence and achievement testing to rule our learning disabilities since ADHD is highly co-morbid with them, parent, teacher and self-reports of behavior, and one could also use continuous performance measures but they have less diagnostic validity than parent or teacher report measures.


Medication is very effective at treating core symptoms. Central nervous system stimulants such as amphetamine and methylphenidate help in 70-80% of children. Another treatment is behavioral therapy, which cannot reduce the core symptoms, but it can help treat co-occurring problems such as; social skills training, parent training for oppositional behavior, helping parents shape home environment, working with teachers to shape school environment, etc. Behavioral therapy has the best long-term outcomes. A combination of medication and behavioral therapy has been found as most effective for longer-term outcomes No other treatments have been found to be effective. There are many out there that say they are, but they are basically aimed at taking people's money such as changing diets, biofeedback and vitamins.

Changes proposed for DSM-5

DSM-5 changes the symptoms from inattention or hyperactivity and impulsivity to inattention and/or hyperactivity and impulsivity. There will also be more symptoms for hyperactivity and impulsivity added. Inattentive Presentation (Restrictive) will be added among the types of presentations of ADHD (American Psychiatric Association, 2010).

ADHD References

American Psychiatric Association. (2010). Proposed Draft Revisions to DSM Disorders and Criteria. Retrieved 2010, from DSM-5 Development: http://www.dsm5.org/ProposedRevisions/Pages/Default.aspx

Lack, C. W. (2010). Abnormal Psychology. Retrieved 2010, from Caleb W. Lack, Ph.D: http://www.caleblack.com/psy4753.html

Mash, E. J., & Barkley, R. A. (2003). Child Psychopathology (2 ed.). New York, NY: The Guilford Press.

Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD)

Antisocial and aggressive behavior

Antisocial behavior (ASB) in children and adolescents can fall into two primary categories in the DSM-IV-TR, which are Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). Official rates of antisocial behavior have fallen since the 1990's, but still are much higher in the United States than in any other industrialized nation.

Defining the problem

From a legal perspective, delinquency involve children, while criminal acts involve adults. It refers to one act and not a series of acts. Also, it is official if they are caught for the act and self-reported if they only admit to doing it.

From an empirical, psychological perspective, externalizing behaviors are acting out while internalizing behaviors are acting in. Antisocial behaviors would be an externalizing, disruptive, acting out behavior. This does not refer to ADHD-type behaviors though. Aggression and antisocial behaviors frequently co-occur but are very different.

From the diagnostic perspective, ODD and CD are disruptive behavior disorders in children and adolescents and antisocial personality disorder (ASPD) is a disorder found in adults. There is a backwards trend-children with ODD or CD will not necessarily have ASPD when they get older. Many children drop out of their disorders. There is not a forward trend to this though.

From the developmental perspective, they examine development of callous, unemotional traits in childhood, and how it relates to traits of psychopathy in adults. The callous/unemotional trait may be a downward extension of the affective/interpersonal factor of psychopathy (Mash & Barkley, 2003).

Subtypes of aggression and antisocial behavior

There is verbal versus physical. Physical emerges earlier with a peak during preschool years, verbal shows later onset. There are high levels of physical during middle childhood that may warrant clinical attention, as may early emergence of verbal aggression. Physical aggression may become violent in later development. There is a difference between aggression and violence. Violence has an intent to harm while aggression is used to get their way (Lack, 2010).

Another subtype of aggression and antisocial behavior, is instrumental (goal-directed) versus hostile (inflicting pain is the goal). For the latter type, the inflicting of pain is characterized as the intent of the behavior observed (Mash & Barkley, 2003). Some levels of instrumental aggression are normative for toddlers, but extreme levels of hostile aggression demand further assessment for any age group (Mash & Barkley, 2003).

The third subtype group is proactive (bullying) versus reactive (retaliatory). Both types of aggression are highly related to each other, but they use different kinds of social-cognitive information-processing deficits and distortions (Mash & Barkley, 2003).

The fourth subtype group is direct versus indirect/relational. Direct can be described as verbal and physical manifestations, while indirect or relational are described as "getting even" by having a third party retaliate which can occur through rumors (Mash & Barkley, 2003). Indirect aggression is seen more often in females (Lack, 2010).

The final subtype is broadly, overt versus covert. Overt is exemplified by most of the types of physically aggressive actions noted throughout this section. Covert refers more to non-aggressive behaviors such as lying, stealing, destroying property, etc.

ASB diagnostic history

There has been research on differences in ASB children for over 60 years. The earlier research focused on "under-socialized" versus "socialized" behaviors (Lack, 2010). The DSM-III changes included operational criteria for CD, four subtypes (socialized versus under-socialized and aggressive versus non-aggressive), and introduced a mild version called "oppositional disorder". The DSM-III-R changed it significantly by increasing the number of symptoms needed, the subtypes became groups/socialized type, solitary/aggressive, and undifferentiated and "oppositional disorder" was renamed ODD. The DSM-IV-TR kept these two categories seperated and introduced several other differences (Lack, 2010).

ODD features

There is a recurrent pattern of negative, defiant, disobedient, and hostile behavior toward authority figures. It is important to remember that this is toward authority figures and not their peers. This occurs outside of normal developmental levels and leads to impairment in functioning (Lack, 2010).

DSM-IV-TR criteria

Displaying four (or more) of the following behaviors consistently over at least a six month period;

-often loses temper

-often argues with adults

-often actively defies or refuses to comply with adults' requests or rules

-often deliberately annoys people

-often blames others for his or her mistakes or misbehavior

-is often touchy or easily annoyed by others

-is often angry or resentful

-is often spiteful or vindictive

Behavior problems cause clinically significant impairment in social, academic, or occupational functioning. The behaviors are not part of a psychotic or mood disorder. Criteria not met Conduct Disorder or Antisocial Personality Disorder (Lack, 2010).

CD features

Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. There are four main categories of symptoms' aggressive conduct that threatens physical harm, non-aggressive conduct that causes property damage, deceitfulness or theft, and serious violation of rules (Lack, 2010).

DSM-IV-TR criteria

Have to have three (or more) symptoms in the past 12 months, with at least one in the last six months. The behavior problems cause clinically significant impairment in social, academic, or occupational functioning. Criteria not met for Antisocial Personality Disorder if above age 18.

Aggression to people and animals

-often bullies, threatens, or intimidates others

-often initiates physical fights

-has used a weapon that can cause serious physical harm to others (such as a bat, brick, broken bottle, knife, gun)

-has been physically cruel to people

-has been physically cruel to animals

-has stolen while confronting a victim (mugging, purse snatching, extortion, armed robbery)

-has forced someone into sexual activity

Destruction of property

-has deliberately engaged in fire setting with the intent of causing serious damage

-has deliberately destroyed others' property (by means other than fire setting)

Deceitfulness or theft

-has broken into someone else's house, building, or car

-often lies to obtain goods or favors or to avoid obligations (cons others)

-has stolen items on nontrivial value without confronting a victim (shoplifting, but without B&E, forgery)

Serious violations of rules

-often stays out at night despite parental prohibitions (beginning before the age of 13 years)

-has run away from home overnight at least twice while living in a parental home.

-is often truant from school (beginning before the age of 13 years)

CD subtypes

-Child-Onset Type: onset of at least one criteria before age 10.

-Adolescent-Onset Type: absence of any criteria before age 10.

-Unspecified Onset

-Code severity: mild, moderate, severe

Viability of CD and ODD

Both disorders are divergent from ADHD, but still distinct from ADHD. They do show significant overlap in behavioral pattern and risk factors (Lack, 2010). The difference is that those with ADHD do not mean to perform those behaviors.

There is a difference developmental course for those diagnosed with ODD only, diagnosed with ODD and then CD, and those diagnosed only with CD. There is currently no strong evidence for discontinuity of symptoms in CD predicting course. ODD is characterized by normal, developmentally appropriate behaviors and is often criticized for this fact in the popular press. Most with CD have ODD, but not all. Most with ODD do not have CD. The number of possible symptoms in CD diagnosis guarantees heterogeneity of the disorder. It can have overt, covert, or mixed presentation. The DSM-IV has included warnings not to ignore environmental context of aggressive behaviors (Lack, 2010). In some situations a behavior can be beneficial or adaptive, such as running away from an abusive home is beneficial.

Prevalence rates

With shifting diagnostic criteria over the past 20 years it was hard to get good long-term data. The median estimates of 3% for ODD. There are higher rates of self-report and about 1-3% from parent-report. CD estimates from 1-10%, depending on criteria (Lack, 2010).

Sex differences

There are initially no sex differences in activity level, noncompliance and other types of difficult temperament traits. By elementary school, evident sex differences occur, with males showing more of every type of aggression. This ma be that females' developmental course steers them more toward internalizing problems and may also be the differences in externalizing symptoms in females (such as sexual promiscuity, substance use, and somatization). ODD rates are equal in early childhood, but males predominate by early elementary years. CD rates in childhood and preadolescence show a 4:1 male-female ratio. Sex differences seem to disappear by adolescence. The differences are notable in indirect/relational aggression, where females show much higher rates (Lack, 2010).


Large amounts of co-morbid problems appear in both ODD and CD. There is a co-morbidity with ADHD that is associated with worse outcomes, such as ASPD and higher levels of aggression. Also, there is a co-morbidity with academic problems. They are mediated by presence of ADHD in middle childhood. The snowball effect can be seen in this situation. It is also co-morbid with internalizing problems. Social withdrawal forms of anxiety appear to be predictive of more aggression, while fear and inhibition are related to less aggression. There is a high co-morbidity with depression, but the relationship between them is uncertain.

Risk factors

Child factors:

-difficult temperament from birth

-hyperactivity (if co-occurs with CD)


-substance use


-early-onset of disruptive behaviors


-low intelligence/executive function/information processing problems

Family factors:

-parental substance abuse

-modeling of antisocial/delinquent behavior by parents

-parental history of mental problems, particularly father's ASB and mother's depression.

Peer factors:

-Rejection by peers

-association with delinquent peers/siblings

Parenting practices:

-poor parent-child relations

-poor supervision/communication

-physical punishment

-parental neglect/abuse

-maternal nicotine use during pregnancy

-teenage/single parenthood

-disagreemenbt on discipline among parents

-high turnover of caretakers

-carelessness in allowing access to weapons

School factors:

-poor academic performance

-being older than classmates

-weak bonding to school

-low educational aspirations

-low school motivation

-poor school system

Neighborhood factors:

-neighborhood disadvantage or poverty

-disorganized neighborhood

-availability of weapons

-media portrayal of violence

Assessment and diagnosis

Structured or semi-structured clinical interview that should cover developmental and family history, DSM-IV ODD/CD symptoms, and symptoms of typical co-morbid problems (such as ADHD, LDs, anxiety/mood disorders, etc.). There should also be parent, teacher and self-reports of behaviors. Some good scales to use include BASC and CBCL for overall screeners. This is due to a high co-morbidity with ADHD, that some may want to use specific measures.


Treatment outcomes are much better for ODD than for CD. Effective treatments are based on operant conditioning and social-cognitive learning principles.

There are four empirically supported treatments:

1.) Contingency management programs: they establish clear behavioral goals to shape towards appropriate behavior, monitor the child's progress toward goals, reinforce appropriate steps toward these goals, and provide consequences for inappropriate behavior.

2.) Parent Management training (PMT): the goal is to teach the parents how to develop and implement structured contingency management programs at home. It also focuses on improving parent-child interactions, changing antecedents to problem behaviors, improving parent's monitoring of child's behavior and using more effective discipline strategies. It is a very Skinnerian technique.

3.) CBT approach: the goal is to overcome deficits in social cognition and problem solving. Also includes role-playing and modeling. Also there is stimulant medication which is useful in children with ADHD who have co-occurring behavior problems.

4.) Multisystemic therapy (MST): it grows out of a family systems approach. Intensive treatments that see problems in children's behavior as stemming from a larger family context. It focuses on the role of the misbehavior in the family, then adjusting how the family responds and reacts to both the child and each other.

References for ODD & CD

Lack, C. W. (2010). Abnormal Psychology. Retrieved 2010, from Caleb W. Lack, Ph.D: http://www.caleblack.com/psy4753.html

Mash, E. J., & Barkley, R. A. (2003). Child Psychopathology (2 ed.). New York, NY: The Guilford Press.

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