Oppositional defiant disorder and conduct disorder grown-up

Safety and Efficacy of Deep Transcranial Magnetic Stimulation for Management of Emotional Dysregulation in Children and Adolescents with Externalizing Behavior Disorders: Protocol of a Transdiagnostic Sham Controlled fMRI Study

Background

High-frequency deep transcranial magnetic stimulation (dTMS) on the anterior cingulate cortex (ACC) and medial prefrontal cortex (mPFC) has been known to be effective in modulating emotional experience but not studied in children and adolescents with externalizing behavior disorders (EBDs). We present a novel protocol for a study that aims to assess the safety and efficacy of adjuvant dTMS in managing emotional dysregulation in EBDs in children and adolescents.

Methods

The trial is prospectively registered in the Clinical Trial Registry of India (CTRI) at www.ctri.nic.in with registration number: CTRI/2023/03/050701. In total, 40 subjects with age less than 18 years with EBDs would be randomized into two groups (active and sham dTMS); receiving 15 sessions of high-frequency dTMS, each, over 3 weeks. The subjects and rater would remain blind to treatment allocation. Assessments would be done at baseline and immediately after completion of the treatment using the Child Behavior Checklist (CBCL), Difficulty in Emotional Regulation Scale (DERS), Modified Overt Aggression Scale (MOAS), Affective Reactivity Index (ARI), Barratt's Impulsivity Scale (BIS), Drug Abuse Screening Test (DAST), Children Global Assessment Scale (CGAS), and Clinical Global Impression (CGI). A checklist for side effects will be administered following each session in both groups.

Result

Data shall be analyzed utilizing the statistical software Statistical Package for Social Sciences for outcome variables as defined for the purpose of the study. Safety of dTMS in young subjects as assessed by TMSens_Q and reduction in scores of DERS would be primary outcome variables. Functional Magnetic Resonance Imaging (fMRI) task-based assessment of the difference in activation of mPFC and ACC at baseline and after application of dTMS and reduction in scores of BIS, ARI, MOAS, CGI, and CGAS would be measured as secondary outcome variables.

Conclusion

The study's results are going to provide insight into potential role of dTMS in addressing emotional dysregulation in EBDs in children and adolescents adding one more tool to the armamentarium.

Paternal mind-mindedness and infant-toddler social-emotional problems

A growing body of evidence suggests that paternal behaviors are influential in child development. However, few studies have focused on paternal mind-mindedness, that is, the tendency of fathers to view their child as having mental agency, which is manifested as a propensity to name the child's mental states while they are interacting with the child. The purpose of this study was to better understand the role of paternal mind-mindedness in the development of social-emotional problems during infancy. 131 families (father-mother-child) were recruited from the community and assessed when children were 6, 12, and 18 months old. Paternal and maternal mind-mindedness was assessed through observation of father-child and mother-child dyads at 6 months. Children's social-emotional problems were measured with a questionnaire completed by both parents at 12 and 18 months. Results indicate that maternal mind-mindedness at 6 months predicts fewer social-emotional problems at 12 months, while fathers' mind-mindedness at 6 months predicts fewer social-emotional problems at 18 months. This study highlights the unique contribution of paternal mind-mindedness to children's early social-emotional development.

Cognitive behavioral program on aggression and self-concept among institutionalized children with conduct disorder

PURPOSE

To explore the effect of cognitive-behavioral programs on aggression and self-concept among institutionalized children with conduct disorder. A quiz-experimental design was employed in this study.

BACKGROUND

Conduct Disorder (CD) is defined as repetitive and persistent behavior that violates the rules of society and social norms. It is also characterized by aggressive behaviors toward people or animals, dishonesty or theft, destruction of property, or serious violation of rules, and persists in children or adolescents in the past 12 months before age 18.

METHOD

This research was carried out at the Dammam Observation Center in Saudi Arabia and the Cairo Caring Center in Egypt. Approximately 100 institutionalized children with conduct disorder who had evidence of conduct disorder were included in the study as part of a purposive sampling procedure. The information was gathered through the use of three different tools: Aggressive behavior and self-concept scales, as well as a sociodemographic data sheet.

RESULTS

According to the findings, children with conduct disorder exhibited less aggression after participating in cognitive behavioral sessions (p = .011), resulting in lower mean aggression scores for the intervention group than the control group. After the training, about 64% of them had a moderate level of self-concept, whereas 44% of them had a moderate level of self-concept before the program. The study also revealed a statistically significant negative correlation between aggressive behavior and self-concept.

CONCLUSION

The post-intervention remediation of aggressive behaviors and self-concept improvement point to the positive effect of the cognitive-behavioral program. The current study recommended that a cognitive-behavioral program is an effective, low-cost, and noninvasive intervention to improve self-concept and minimize aggressive behavior among institutionalized children with conduct disorder.

Predicting externalizing behavior in toddlerhood from early individual differences in empathy

BACKGROUND

From middle childhood onward, there is often a negative link between empathy and externalizing behavior problems. Patterns at younger ages are still unclear, with mixed findings of no association, negative associations, and positive associations. This study examines links between empathy and externalizing problems, beginning in infancy.

METHODS

A community sample of infants (N = 165) was assessed for empathy at 3, 6, 12, 18, and 36 months, using behavioral observations. Externalizing problems were reported at 18 months (by mothers) and 36 months (by mothers and daycare teachers).

RESULTS

Boys showed more externalizing problems than girls. For boys, negative associations between empathy and externalizing appeared, particularly with teacher reports. For girls, there were positive associations between empathy and externalizing, which weakened with age. For both genders, empathy at ages 3, 6, and 18 months appeared to protect against increases in externalizing from 18 to 36 months.

CONCLUSIONS

The role of empathy in the development of early externalizing depends on both gender and age; toddler boys' externalizing may more typically stem from low empathy, whereas girls' early externalizing appears to be underlain by heightened sensitivity and unregulated or assertive approach attempts.

A Longitudinal Study of Emotional and Behavioral Problems among Malaysian School Children

Background:

Emotional and behavioral problems (EBD) or mental health problems in children and adolescents are an important public health issue, but there has been no evaluation to date of the extent of such problems in near-developed countries. This study evaluated the prevalence and stability of EBD among children in Malaysia.

Methods:

This research comprises a longitudinal population-based study that measured the prevalence and 6-month stability of EBD in children aged seven to eight years and thirteen to fourteen years attending public schools in Malaysia based on parents, teachers and children’s (aged 13 to 14 years) report of the Strengths and Difficulties Questionnaire (SDQ) at baseline and 6 months later.

Findings:

The prevalence of EBD in Malaysian school children was 9.3% for teacher-report, 8.5% for parent-report and 3.9% for child-report. There was no significance difference in the prevalence of emotional and behavioral problems over six-months for all informants, except for teacher-report Emotional and Conduct problems scores which increased significantly and child-report Total Difficulties and Emotional problems scores which decreased significantly (p < 0.05).

Conclusions:

This study shows that the prevalence of EBD among Malaysian children is almost similar to the Western countries and stable over a 6-month period. These findings suggest the need for policy makers in near-developed countries to provide services aimed at preventing EBD and treating children identified as having such problems.

Risk factors for comorbid oppositional defiant disorder in attention-deficit/hyperactivity disorder

Oppositional defiant disorder (ODD) is highly prevalent in attention-deficit/hyperactivity disorder (ADHD). Individuals with both ADHD and ODD (ADHD + ODD) show a considerably worse prognosis compared with individuals with either ADHD or ODD. Therefore, identification of risk factors for ADHD + ODD is essential and may contribute to the development of (early) preventive interventions. Participants were matched for age, gender, and ADHD-subtype (diagnostic groups), and did not differ in IQ. Predictors included pre- and perinatal risk factors (pregnancy duration, birth weight, maternal smoking during pregnancy), transgenerational factors (parental ADHD; parental warmth and criticism in diagnostic groups), and postnatal risk factors (parental socioeconomic status [SES], adverse life events, deviant peer affiliation). Three models were assessed, investigating risk factors for ADHD-only versus controls (N = 86), ADHD + ODD versus controls (N = 86), and ADHD + ODD versus ADHD-only (N = 90). Adverse life events and parental ADHD were risk factors for both ADHD + ODD and ADHD-only, and more adverse life events were an even stronger risk factor for comorbid ODD compared with ADHD-only. For ADHD + ODD, but not ADHD-only, parental criticism, deviant peer affiliation, and parental SES acted as risk factors. Maternal smoking during pregnancy acted as minor risk factor for ADHD-only, while higher birth weight acted as minor risk factor for ADHD + ODD. No effects of age were present. Findings emphasise the importance of these factors in the development of comorbid ODD. The identified risk factors may prove to be essential in preventive interventions for comorbid ODD in ADHD, highlighting the need for parent-focused interventions to take these factors into account.

Parent Management Training and Collaborative & Proactive Solutions: A Randomized Control Trial for Oppositional Youth

This study examined the efficacy of Collaborative & Proactive Solutions (CPS) in treating oppositional defiant disorder (ODD) in youth by comparing this novel treatment to Parent Management Training (PMT), a well-established treatment, and a waitlist control (WLC) group. One hundred thirty-four youth (ages 7-14, 61.9% male, 83.6% White) who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for ODD were randomized to CPS, PMT, or WLC groups. ODD was assessed with semistructured diagnostic interviews, clinical global severity and improvement ratings, and parent report measures. Assessments were completed pretreatment, posttreatment, and at 6 months following treatment. Responder and remitter analyses were undertaken using intent-to-treat mixed-models analyses. Chronological age, gender, and socioeconomic status as well as the presence of comorbid attention deficit/hyperactivity and anxiety disorders were examined as predictors of treatment outcome. Both treatment conditions were superior to the WLC condition but did not differ from one another in either our responder or remitter analyses. Approximately 50% of youth in both active treatments were diagnosis free and were judged to be much or very much improved at posttreatment, compared to 0% in the waitlist condition. Younger age and presence of an anxiety disorder predicted better treatment outcomes for both PMT and CPS. Treatment gains were maintained at 6-month follow-up. CPS proved to be equivalent to PMT and can be considered an evidence-based, alternative treatment for youth with ODD and their families.

Perceived Parent-Child Relations, Conduct Problems, and Clinical Improvement Following the Treatment of Oppositional Defiant Disorder

Our objective in this study was to examine the moderating influence of parent-child relationship quality (as viewed by the child) on associations between conduct problems and treatment responses for children with oppositional defiant disorder (ODD). To date, few studies have considered children's perceptions of relationship quality with parents in clinical contexts even though extant studies show the importance of this factor in children's behavioral adjustment in non-clinical settings. In this study, 123 children (ages 7 - 14 years, 61.8% male, 83.7% white) who fulfilled DSM-IV criteria for ODD received one of two psychosocial treatments: Parent Management Training or Collaborative & Proactive Solutions. In an earlier study, both treatments were found to be effective and equivalent in treatment outcomes (Ollendick et al., in press). In the current study, pre-treatment maternal reports of conduct problems and pre-treatment child reports of relations with parents were used to predict outcomes in ODD symptoms and their severity following treatment. Elevated reports of children's conduct problems were associated with attenuated reductions in both ODD symptoms and their severity. Perceived relationship quality with parents moderated the ties between conduct problems and outcomes in ODD severity but not the number of symptoms. Mother reports of elevated conduct problems predicted attenuated treatment response only when children viewed relationship quality with their parents as poorer. When children viewed the relationship as higher quality, they did not show an attenuated treatment response, regardless of reported conduct problems. The current findings underscore the importance of children's perspectives in treatment response and reductions in externalizing child behaviors.

A Systematic Review and Meta-analysis of Neuroimaging in Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) Taking Attention-Deficit Hyperactivity Disorder (ADHD) Into Account

Oppositional defiant disorder (ODD) and conduct disorder (CD) are common behavioural disorders in childhood and adolescence and are associated with brain abnormalities. This systematic review and meta-analysis investigates structural (sMRI) and functional MRI (fMRI) findings in individuals with ODD/CD with and without attention-deficit hyperactivity disorder (ADHD). Online databases were searched for controlled studies, resulting in 12 sMRI and 17 fMRI studies. In line with current models on ODD/CD, studies were classified in hot and cool executive functioning (EF). Both the meta-analytic and narrative reviews showed evidence of smaller brain structures and lower brain activity in individuals with ODD/CD in mainly hot EF-related areas: bilateral amygdala, bilateral insula, right striatum, left medial/superior frontal gyrus, and left precuneus. Evidence was present in both structural and functional studies, and irrespective of the presence of ADHD comorbidity. There is strong evidence that abnormalities in the amygdala are specific for ODD/CD as compared to ADHD, and correlational studies further support the association between abnormalities in the amygdala and ODD/CD symptoms. Besides the left precuneus, there was no evidence for abnormalities in typical cool EF related structures, such as the cerebellum and dorsolateral prefrontal cortex. Resulting areas are associated with emotion-processing, error-monitoring, problem-solving and self-control; areas associated with neurocognitive and behavioural deficits implicated in ODD/CD. Our findings confirm the involvement of hot, and to a smaller extent cool, EF associated brain areas in ODD/CD, and support an integrated model for ODD/CD (e.g. Blair, Development and Psychopathology, 17(3), 865-891, 2005).

Salivary oxytocin in adolescents with conduct problems and callous-unemotional traits

Callous-unemotional (CU) traits correlate with the severity and prognosis of conduct disorder in youth. The neuropeptide oxytocin (OT) has been linked to prosocial behaviors, including empathy and collaboration with others. This study discusses a possible role for OT in the biology of delinquent behavior. We hypothesized that in delinquent youth OT secretion will correlate with the severity of conduct problems and specifically with the level of CU traits. The study group included 67 male adolescents (mean age 16.2 years) undergoing residential treatment, previously assessed by an open clinical interview and history for the psychiatric diagnosis. Staff based Inventory of Callous-Unemotional traits for psychopathy and Strength and Difficulties Questionnaire were administered, and patients' medical and social personal files were systematically coded for previous history of antisocial acts using the Brown-Goodwin Questionnaire. Salivary OT was assayed by ELISA. Salivary OT levels were inversely correlated with conduct problems severity on Strength and Difficulties Questionnaire (r = -0.27; p ≤ 0.01). Recorded history of antisocial acts did not correlate with current OT levels. Odds ratio (OR) for significant CU traits among subjects with conduct problems was increased in low-OT (OR = 14, p ≤ 0.05) but not in high-OT subjects (OR = 6, p ≥ 0.05). Children with conduct problems and low levels of salivary OT are at risk for significant CU traits. These results suggest a possible role for salivary OT as a biomarker for CU traits and conduct problems severity.

A multiyear follow-up study examining the effectiveness of a cognitive behavioral group therapy program on the recidivism of juveniles on probation

The present study evaluated the long-term effectiveness of a cognitive behavioral group therapy program titled Community Opportunity Growth. This study monitored juvenile delinquents' recidivism across a 7-year time period, with the average length to follow-up being 39 months. It was hypothesized that program graduates (N = 178) would have a significantly lower recidivism rate than a control group (program nonstarters; N = 66) and program dropouts (whose predisposing factors may have influenced their program participation; N = 150). Analyses controlled for sex, ethnicity, age, prior petitions, highest class of prior petition, and months to follow-up. Results show a general trend indicating the long-term effectiveness of the program as graduates had a lower incidence of petitions at follow-up compared with dropouts and fewer petitions compared with the other two groups.

A Five-Factor Model framework for understanding childhood personality disorder antecedents

The present contribution reviews evidence that supports the relevance of childhood antecedents of personality disorders, and advocates that the validity of a Five-Factor Model framework for describing general trait differences in childhood can be extended towards the field of developmental personality difficulties. In addition, we suggest that several traditional childhood Axis I conditions include a substantial trait component that may be responsible for the recurring finding that childhood Axis I disorders are predictive for adult Axis II disorders. Given the valuable information provided by a trait assessment, we further propose to integrate dimensional personality and personality pathology measures as standard tools in mental health assessments at a young age.

Promoting self-regulation and cooperation in pre-kindergarten children with conduct problems: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness and mechanisms of Hitkashrut, a "common elements" co-parent training (PT) program for early intervention with preschoolers (3-5 years of age) at risk for conduct problems (CP).

METHOD

A randomized controlled trial with 140 participants in PT and 69 in a minimal intervention control group. The primary outcome (presence of CP) was assessed at pre-intervention, post-intervention, and 1-year follow-up. Callous-unemotional traits, effortful control, parental distress, negative/inconsistent parenting, and couple relationship quality were assessed at pre- and post-intervention, whereas callous-unemotional traits and effortful control were also assessed in the PT group at follow-up. Retention was 87.1% at post-intervention and 60% at follow-up. Hitkashrut incorporated evidence-based components of established PT programs into a culturally adapted protocol. The facilitators were trained and supervised psychologists working in Israel's Educational Psychology Services.

RESULTS

Intervention effect (Cohen's d) was large at post-intervention (ES = .76, p < .001), and an additional medium effect was found at follow-up (ES = 0.63, p < .001). Parallel post-intervention and follow-up intervention effects were also found in the degree of clinically significant improvements. Effects of the intervention on callous-unemotional traits (ES = 0.85, p < .001) and effortful control (ES = 0.47, p < .001) were maintained at follow-up. Follow-up improvement in CP was mediated by improvements in parental practices and distress.

CONCLUSIONS

Hitkashrut's implementation and subsequent dissemination in real-world settings demonstrates the potential effectiveness of common elements programs to promote innovations within service-delivery systems. Improvements in dispositional variables and the mediated follow-up effect support theoretical cascade models that emphasize early developmental malleability and the growing preventive effects of PT's facilitated parental changes on disruptive developmental trajectories. Clinical trial registration information - The effect of a "common elements" co-parent training program (called 'Hitkashrut') on conduct in preschoolers at risk for conduct problems; http://www.anzctr.org.au; ACTRN12612000148875.