Overview of Disruptive Behavior Disorders in Youth

Mental health challenges can pose problems for social integration (Sijbrandij et al., 2017) and the main developmental tasks of children are to properly socialize, develop networks, and cooperate in group settings (Winiarski et al., 2020). As we see with James, his early social life and developmental tasks have been largely disrupted by his problem behaviors. The most common disorders in children tend to be externalizing (Erskine et al., 2015), which can disrupt the main developmental tasks of children. Externalizing disorders are often characterized by problems with regulation of action, where there is difficulty managing impulses, self-regulation of affect, and problem-solving skills (Shader & Beauchaine, 2020). Externalizing disorders present on a spectrum that ranges from problems such as impulsivity, aggression, and substance use, or from diagnostic categories including attention deficit/hyperactive disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD; Shader & Beauchaine, 2020).

For James, these problems are extending beyond the typical age for externalizing problems, and it can be inferred that the outbursts are frequent and big enough that there is an impairment in his functioning. Without proper intervention, these problems can create disruption in the many systems of James’s future.

Prevalence of Disruptive Behavior Disorders

Externalization is typical for children ages 2 to 3, fitting the developmental appropriateness of testing limits, learning about the world, and being shaped by social and behavioral norms. Externalizing problems beyond these early years (i.e., 3 years old and beyond), becomes problematic, as they can predict negative health behaviors later in development, such as substance use and delinquent behavior (Pardini, 2016; Winiarski et al., 2020). One of the biggest predictors of delinquent behavior is the presence of problematic behaviors in childhood (Pardini, 2016).

The main diagnostic categories for problematic externalizing behaviors are ODD and CD. These diagnoses have a high global prevalence, and oftentimes, disruptive behavior is one of the main reasons for referral to services (Waddell et al., 2018). There are shared etiologies within the spectrum of externalizing disorders, warranting the attention of transdiagnostic intervention application (Shader & Beauchaine, 2020).

Recent estimates of the prevalence of ODD and CD have a range of 3 to 5%, with a combined prevalence of ODD/CD estimated to be 6.1% (Boat et al., 2015; Riley et al., 2016). Most of the studies are estimates because there is no population level prevalence data, and community samples can show upwards to 16.1% prevalence of ODD (Boat et al., 2015). Data from SSI allowances show that there was an increase of the rate of SSI recipients for both ODD and CD (Boat et al., 2015). Lifetime prevalence hovers around 10% in adult community samples, with similar rates for both males and females (Boat et al., 2015). Comorbidity is typical for children with either ODD or CD. ADHD co-occurs in 14 to 40% of children with ODD, with anxiety being present in 14% of ODD cases (CDC, 2020).

Development of Disruptive Behavior Disorders in Youth

The developmental systems perspective considers biological, familial, psychological, and environmental processes as facilitators for problem behavior. Our umbrella theory can accommodate the various explanations of problematic behavior. Social structure theories, or functional perspectives, all stress that externalizing problems result from the breakdown of society’s norms and social organization (University of Minnesota, 2016). A popular explanation is social disorganization theory, which defines social disorganization as a weakening of social institutions such as the family, school, and religion that in turn weakens the strength of social bonds and norms and the effectiveness of socialization (University of Minnesota, 2016). Social process theories all stress that crime results from the social interaction of individuals with other people, particularly their friends and family and the influence they have on us, as well as the meanings and perceptions we derive from their views and expectations (University of Minnesota, 2016). Hirschi’s social bonding theory focuses on family and school processes. When the family relationship is warm and harmonious and children respect their parents’ values and parents treat their children firmly but fairly, children are less likely to commit antisocial behavior during childhood and delinquency during adolescence (University of Minnesota, 2016). Schools also matter; students who do well in school and are very involved in extracurricular activities are less likely than other students to engage in delinquency (Bohm & Vogel, 2011). Labeling theory assumes that labeling someone as a deviant or a problem child makes the person more likely to continue to have acting out behavior (University of Minnesota, 2016). This result occurs, argues the theory, because the labeling process gives someone a negative self-image, reduces the potential for prosocial activities like employment or extracurricular interests, and makes it difficult to have friendships.

Externalizing disorders tend to have multiple risk factors that accumulate over time. Some of the common biological factors include nicotine use by parents, prenatal nutritional deficiencies, and developmental delays (Riley et al., 2016). Psychological factors range from insecure attachment, harsh parenting practices, parental psychopathology, and inconsistent parenting (Riley et al., 2016). Social factors include poverty, community violence, peer rejection, and poor academic achievement (Riley et al., 2016).

Developmental Systems Considerations for Disruptive Behavior Disorders

Bronfenbrenner’s (1977) ecological theory finds direct application here. It highlights the transactional cycle that contributes to externalizing problems, as it explains what begins in one system (e.g., the family system can translate to the school system or neighborhood system). Deviant peer relationships and neighborhood disorganization or distress can influence children and serve as an attractive outlet for problem behaviors, as these deviant networks normalize problematic behavior (Shader & Beauchaine, 2020). Family influences and power dynamics with authority figures such as school personnel play a significant role with the development of CD, often acting as the starting points for problem behaviors that are later generalized to peers (Shader & Beauchaine, 2020).

Costello & Klein (2018) conducted a study that revealed that more than 80% of children in the United States witness intimate partner violence (IPV). Exposure to community violence is a major risk factor for externalizing disorders (Dinizulu et al., 2014). These behaviors can be precipitated by early traumatic or adverse childhood experiences, inconsistent parenting and power struggles with authority figures at school or affiliation with delinquent peers (Pardini, 2016). The risk factors for these disorders can go beyond the treatable symptoms in the therapy office (Waddell et al., 2018) and unfortunately increase the likelihood of involvement with the justice system (Becker et al., 2012).

So, what’s going on with James? We can see there’s some difficulty with school and the family system. A key component here can be time, or what Bronfenbrenner calls the chronosystem (Bronfenbrenner & Evans, 2000). Are his parents experiencing new stressors that weren’t present when raising the other children? Are the school staff judging him on the standard of the “normal” experiences they had with James’s siblings? Lastly, we should consider what is seen as developmentally appropriate in the context of culture or the family system, and as we’ve seen, James’s parents have had a prior understanding of the development of their other children. Based on this family’s experiences with their other children, James’s behavior is seen as not in line with developmental expectations.

Experiences Across Race and Ethnicity. Some literature suggests that despite similarities of prevalence of ODD across racial groups (Boat et al., 2015; CDC, 2020), the practice of diagnosis in real settings show that Black children tend to have higher diagnoses of ODD (Ballentine, 2019). There are some factors to consider with this claim. Clinician bias can confuse culturally bound behaviors with psychopathology, and often Black youth can be misdiagnosed as a result (McNeil et al., 2002). Even in the realm of disruptive disorders, racial and ethnic minority youth tend to receive a diagnosis of ODD opposed to a disruptive behavior disorder (Fadus et al., 2020). Diagnosis is complex, having to account for the various biopsychosocial factors; however, the reality is that diagnostic disparities still exist.

White clinicians may overlook the experience of preferences of black and brown parents (Ballentine, 2019), or even the experience of those in poverty who tend to use more authoritative parenting practices (Ballentine, 2019; Fadus et al., 2020). This inequity in the mental health treatment of Black and Brown children points to the larger inequities seen in the US (Okeke, 2013), and it can be historically situated within the accounts of medical experimentation on Black people and the overall lack of proper care and compassion at the hands of predominantly White medical professionals (Okeke, 2013). Because of the distrust between Black and Brown people, and White medical professionals, Black and Brown people tend to be wary of seeking mental health support which can further exacerbate mental health outcomes.

Take a pause to reflect on your own interpretation of James. Did you envision him in a particular race or ethnic group? Be aware of culture, power, and privilege, as well as your own biases and prejudices when working with communities of color. Oftentimes, when working with Black and Brown people, they feel disempowered due to experiences of perceived racism. This not only perpetuates the stigma of mental health but can exacerbate symptoms the individual is already experiencing (Bailey et al., 2017).

Experiences of LGBTQ+ Youth. LGBTQ+ youth have difficulties that are particular to their own life experience. Studies have shown that these youth can frequently engage in disruptive behaviors such as fighting or problematic behaviors such as truancy (Hafeez et al., 2017). Consider the etiology of these behaviors, knowing that LGBTQ+ youth are frequently bullied in school, are victims of sexual and physical violence, and are known to experience greater severity of violence (i.e., injury aggravated by use of a weapon; Hafeez et al., 2017). Sexual minority girls are 400% more likely to engage in drug and alcohol use and report higher than average ODD and CD symptoms than heterosexual girls, as well as higher rates of suicidal ideation and self-harm behaviors (Marshal, et al., 2012). In the family system, youth may be experiencing emotional distress if they have not come out to their family, or if they have, they may be experiencing rejection (Hafeez et al., 2017). Disclosure of their sexual preferences and identities often leads to interpersonal problems (Hafeez et al., 2017).

Experiences of LGBTQ+ POC. Folx who are from minority populations are already at a disadvantage living in the United States, and furthermore, someone who identifies as a member of multiple minority populations is at an increased risk of increasing minority stress due to their intersectionality. Cyrus (2017) defines minority stress as, “Stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems” (p. 195). In this instance, the stressors of LBGTQ+ POC would be homophobia and racism.

In the previous passage, the increased drug usage amongst sexual minority youth was highlighted. Similarly, sexual minority women of color showed higher substance abuse rates in comparison to white sexual minority women (Marshal et al., 2012; Cyrus, 2017). It must be noted that although some research has found higher rates of drug use amongst folx who identify as both Black and a sexual minority, research is still conflicted on if a significant difference is truly present.
There are factors that may account for the discrepancy in the existing literature. Due to extensive history of trauma that folx from the LGBTQ+ and Black communities experience, it can be hypothesized that they have built some resilience to the racism and homophobia, making them less susceptible to negative mental health outcomes than someone who is not a part of a minority group (Meyer, 2010), which could point to fewer psychiatric diagnosis amongst LGBTQ+ POC. On the opposite side of the coin, it could be said that LGBTQ+ POC do not seek out mental health resources or do not feel comfortable turning to mental health resources. Historically, POC are underserved and underrepresented in mental health research. This leads to fewer diagnosis and misdiagnosis when POC seek out treatment (Sohail et al., 2014). When working with minority groups, resiliency must also be examined. When working with the LGBTQ+ POC population, it is important to look at their distinct experiences (e.g., their experiences as an LGBTQ+ community member and their experiences as a POC), the cumulative or synergistic effect of both of these experiences, and how their experiences shape their view of the world (Sutter & Perrin, 2016).

Assessment of Disruptive Behavior Disorders

The two primary disruptive behavior disorders are ODD and CD. The clinical features of these disorders are discussed below, along with sample screening and assessment approaches for these disorders.

Clinical Features of Oppositional Defiant Disorder

Oppositional defiant disorder is characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness lasting for at least six months (American Psychiatric Association, 2013; Riley et al., 2016). It typically manifests earlier in life (i.e. prior to age 8), and it rarely has an onset in adolescence (American Psychiatric Association, 2013; CDC, 2020; Riley et al., 2016). With children with oppositional defiant disorder, there can be a power struggle in which they may feel threatened or have a hostile appraisal of an encounter, which points to some insights offered from neurological studies (Ghosh et al., 2017). Given this potential for sensitive reward state and threat state (Ghosh et al., 2017), the non-directive approaches of parent management training explained in the intervention section can be an effective way to engage with these youth and promote positive behavioral change.

Clinical Features: Conduct Disorder

Conduct disorder goes beyond ODD and is characterized by serious violations of rules and social norms (CDC, 2020). Conduct disorder does not equate to delinquent behavior, but it is very common. Violating social norms includes prescriptive things such as school attendance, extreme disobedience of parental expectations, or destroying another’s property (e.g., vandalism or theft; CDC, 2020). ODD is known to be a significant predictor of conduct disorder (CDC, 2020).

Screening and Assessment Tools

There are limited formal screening instruments for disruptive behavior disorders, and the need for various data points is even more critical for these disorders. Keep in mind that the behaviors do need to go beyond behavioral norms for someone their age and that the frequency, duration, and magnitude of the behavior matters. These diagnoses require even more clinical judgment. In considering the core aspects of ODD and CD, the assessor should note and ask questions such as: Are conflicts with peers or with authority figures? With authority figures, is it just the child’s caregivers or is it all authority figures like teachers and other adults? Are there any current life stressors that can be affecting your child right now?

Disruptive behavior disorder screenings tend to come as a subset of broad focusing batteries. The Vanderbilt measure has screening questions for these disorders. The SDQ has subscales that address disruptive behaviors as well as prosocial questions. The Connors Rating Scales –Revised also have items. These scales do not assess ODD and Conduct Disorder separate from ADHD though. The Child Behavior Checklist aggressive behavior syndrome can be predictive of ODD and conduct disorder (Hudziak, 2004). Much like with ADHD, observation in the school domain as well as collateral from the home domain elucidate the level of impairment (if any).

Intervention

Both prevention and treatment interventions have shown success in addressing problems related to ODD and CD. The following sections will provide an overview of prevention services as well as treatment approaches.

Prevention

In the example of James, how could his behaviors have been prevented? It seems that his parents had effective strategies for the other siblings, so was it really an issue of parenting? There could have been many other factors at play then with James, such as new parental stressors like job transitions, the cumulative stress of already parenting other children, or changes in their neighborhood. Prevention requires targeting multiple risk factors and starting at critical transition years, before it is “too late” (Fisher & Sexton, 2017), as child conduct problems have a constellation of risk factors, and there are multiple bio-ecological factors at play with the onset of externalizing problems (Fisher & Sexton, 2017). Early intervention, particularly in the preschool years, can be effective for preventing conduct problems in adolescence (Fisher & Sexton, 2017). Prevention programs are best delivered to youth prior to their entry to high school (Modecki et al., 2017). Family influence can serve as a mediator between stressors and the development of mental health challenges, making family involvement critical in any prevention program (Dinizulu et al., 2014). By incorporating family, a child will be more apt to disclose their difficulties or their exposure to adverse events, as there can be a lack of help-seeking from children from their desire to not burden their caregiver (Dinizulu et al., 2014)

Research into delinquent populations shows that there is vast heterogeneity within the population, but there are signs that consistently show that 5-10% of youth are on a high-risk trajectory for adult justice system involvement (Pardini, 2016). When it comes to Black and Brown children, there are higher rates of recidivism in comparison to their white peers (Becker et al., 2012). Prevention of juvenile delinquency focuses on reducing the overall prevalence of risk factors and targeting children exposed to early socio contextual risk factors (Pardini, 2016), as well as indicated prevention to disrupt the onset of more offending and treatment for those with chronic offending behaviors. (Pardini, 2016). Coping Power is a prevention program with success in reduction of incidence of conduct problems (Modecki et al., 2017).

Parenting programs are effective for reducing or preventing child externalizing behavior (Modecki et al., 2017) as it is noted that improvement in parent functioning can have an effect on child outcomes (Wang et al., 2019) The most effective programs are the Incredible Years, Triple P, Family School Partnership, and Promoting Alternative Thinking Strategies. (Waddell et al., 2018) They have been delivered in community settings, and most involve parent training, as well as developing social and academic skills. (Waddell et al., 2018). Fast Track shows improvement of prosocial skills with children and with positive parenting practices (Fisher & Sexton, 2017) Fast Track and Early Alliance are seen as an integrated model of prevention and can incorporate other curriculums like PATH (Fisher & Sexton, 2017).

Treatment

Recommendations for treatment for externalizing disorders such as CD and ODD tend to focus on problem-solving skills with the child and parent management training (Riley et al., 2016; Waddell et al., 2007). Programs need to enhance regulation of action skills while improving the relationship of children to key adult figures (Modecki et al., 2017). The child focus tends to generate alternatives to the problematic behavior or assist with emotional dysregulation that can drive the behavior (Winiarski et al., 2020) and ensuing power struggle with the parent or other authority figure. Parent training focuses on decreasing unintentional positive reinforcement of disruptive behaviors and disrupts the power struggle that ensues from problem behaviors (Riley et al., 2016). Both of these approaches can be delivered individually or in group settings, with modalities focused on CBT approaches showing effectiveness (Riley et al., 2016). Medications, especially antipsychotic medications, are not recommended as a first-line intervention; however, given the comorbidity of other conditions, medication may be indicated for other problems (Riley et al., 2016). With James’s parents, treatment would most likely be similar to coaching around problem-solving strategies and ensuring that the parents remained in control of the executive system of the family.

Treatments for externalizing problems center on adaptations of CBT and parent management training (Winiarski et al., 2020). The most significant interventions for conduct disorder include the good behavior game, Classroom Centered Intervention, and Fast Track. Resilience focused interventions can be effective for externalizing problems, though they are more effective with internalizing problems for children and adolescents. (Dray et al., 2017). DBT has also been identified as helpful for externalizing disorders, as there are components to address emotional distress and build skills. (Winiarski et al., 2020). Mindfulness by itself and as part of a DBT program has promising results on externalizing disorders in middle childhood (Winiarski et al., 2020). For adolescents, there are programs like Chicago Becoming a Man, a CBT derivation meant to slow down thinking to allow for better problem-solving skills (Ludwig & Shah, 2014). Effectiveness studies show that it reduces recidivism and impacts other risk factors for delinquency (Ludwig & Shah, 2014).

An evidenced based treatment that has shown to be effective in reducing symptoms of ODD is family-based therapy (Christenson et al., 2016). When working with a family, each member involved with treatment should be viewed as a piece of the puzzle. To be specific, they cannot be whole until they are put together. Family therapy has been found to be effective regardless of setting, culture, and family type (Christenson et al., 2016). Family based therapy is often viewed as an alternative to hospitalizations, or in some cases a last step before hospitalization (Lear & Pepper, 2016). Individuals with ODD are more likely to experience suicidal ideation and self-injurious and suicidal behaviors, which can be caused by the lack of proper emotional regulation skills (Aebi et al., 2016). In many instances, the goals of family-based therapy are to foster attachment between the child and their caregivers, decrease/eliminate referral behavior(s), and to work with the caregivers on executive functioning. The American Psychological Association defines executive functioning as an individual’s ability to plan, make decisions, solve problems, assign and complete tasks, and resolve conflict. By caregivers developing their executive functioning skills, they will be able to model good emotional regulation techniques in order to give their child the love and support that they need.

How should we proceed with James? Could this have been prevented? We know that the family must be involved in treatment, this case will not be focused on James by himself. James could benefit from skill building to help with potential stress intolerance or with communication skills. Conversely, the parents may need these same skills. They may be experiencing the cumulative stress of raising other children, coping with new stressors, and having difficulty adjusting to having a “problem child.” The dysfunction can be unintended in the family system.

We can borrow from the active ingredients of Parent-Child Interaction Therapy, an evidence-based intervention to treat disruptive behavior problems in children between the ages of 2 and 7 years (McNeil & Hembree, 2010; Lineman et al., 2017). The PRIDE skills are taught to parents to help with their child’s disruptive behavior, and they include Praising appropriate behavior; Reflect appropriate talk; Imitate appropriate play; Describing appropriate behavior, and Enjoy and show interest in the child (McNeil & Hembree, 2010). With James’s parents, they may need some therapist modeling of these skills or basic psychoeducation about them; however, we’ve seen that they’ve had some success with managing the behavior of their other children. In this case, they may know these skills, so it is reminding them they have the skills and working to change the conditions around their use. For instance, when parents are stressed, they can resort to default skills that may not be in line with the PRIDE skills. Tabbi (2015) calls this distinction of problems of learning (not having a skill) or problems about learning (managing conditions related to the use of the skills, such as stress). The effective use of these skills can strengthen the relationship of the parent and the child.

Effective parenting programs place an emphasis on strengthening parent-child relationships. A phrase commonly used by therapists in family-based therapy settings is, “Connect before you correct.” This means that in order for the parent to successfully correct a child’s negative behavior, they must first have a strong, positive relationship with their child. The child should feel secure enough in the parent-child relationship where if they were to make a mistake, it is not the end of the world and the relationship with their parent is not threatened.

In the case of James, it would appear as if there is a disconnect between he and his mother, to the point where she is unsure of what to do next when it comes to ensuring James’ academic and social success. It can be speculated that James feels disconnected from his mother, and she from him. In certain situations, therapists put “therapy” on the back burner, and focus on building the attachment between the child and their parent. By bringing a fun activity that the family enjoys doing together into the session, it not only promotes a positive interaction, but it could help James to put his metaphorical wall down and assist his mom in understanding the root of his distress.

Clinical Dialogues: Disruptive Behavior Disorders with Dr. John Siegler, PsyD

Sean E. Snyder, LCSW: Today, we’re going to look at disruptive behavior disorders, which covers oppositional defiant disorder, intermittent explosive disorder, and conduct disorders. Our interview today will focus on three core areas including engagement, assessment, and intervention. To start off, what’s your approach with parents of children with conduct disorder. For instance, about discussing conduct disorder as a new diagnosis and treatment option: how do you get buy-in?

John Siegler, PsyD: The place I would start with is to acknowledge that kids with conduct disorder can be considered very sick children that are born with conduct disorder. The classical conceptualization of conduct disorder is that it develops in a family context, where there are inconsistent parenting approaches that kind of oscillate between permissive to coercive or authoritarian, which can be quite punitive. In some cases, parents may not be paying close attention to the child, and when the child gets in trouble, the reaction of the parents is quite punitive. From a social learning perspective, this process is how the children learn about coercion and control, then they start to engage in what we see as a cycle of vicious efforts to coerce the parent, followed by the parent trying to coerce and control the child. This process continues and spirals up through oppositional defiant disorder; eventually, this cycle goes on long enough or severe enough, and we start to consider it conduct disorder.

Snyder: I can see this information as helpful with psychoeducation as an engagement strategy. Tell us more about conduct disorder.

Siegler: When the child’s aggressive behaviors start to occur in the community, and where they may have seen previously physically aggressive towards siblings or parents, or may have been destructive to property in the home, now this is spilling out into the community. So that’s the classical example of a child ending up with conduct disorder.

Snyder: How would you explain the “here and now” concerns of parents? Sometimes they are more receptive to hearing about the child as the identified patient.

Siegler: Right, sometimes parents like to know about the reasons for their stress. We normally think of conduct disorder as breaking up into two parts and a kind of a two-factor solution. For almost all, the children will have behaviors that we would say would fall on the delinquent lifestyle factor, which is what I described in the last response.

The second factor is what they described as the callous and emotional factor, and this is a very small subset of children who will meet criteria for conduct disorder frequently meeting criteria in childhood. These are children that are high risk to meet criteria for antisocial personality disorder as adults. The reason for this, as best as we understand, it has to do with some neurodevelopmental diversity that these kids have in terms of how they experience the aspect of other people. That neurodiversity makes it much more difficult for them to learn from interpersonal experiences and develop meaningful connections to people in the way that we understand connections. So encountering children with conduct disorder that has this factor is almost a different approach than without.

With these factors in mind, to provide conceptualization, it has to start out from the standpoint that the parents are usually feeling overwhelmed and lack some of the basic skills that they need to be effective in working with their child. There may also be a number of contextual factors that contribute to their inability to keep their eye on the child and to maintain the level of supervision that the child needs. A lot of these can be financial and resource based. Parents will feel stressed because the child now needs a level of supervision that would be more typical of a child that was four or five years younger, but because of the nature of their disorder, they need to be watched and supervised much more closely, which ultimately is a challenge with parents. Then there are parental negotiations between each other or between a single-parent and their support system to come up with a strategy on how they’re going to ensure that their son or daughter has adequate supervision and that the people that are involved in supervising the child have effective strategies to maintain supervision.

Snyder:  A lot of ecological systems theory going on with this response, where it is family systems, school systems, community, intrapersonal systems with the caregiver going through their personal resources.

Siegler: You’ve got to look at it from their perspective, because the whole issue around engagement in joining is to look at it from an ecosystem perspective, which comes out of Bronfenbrenner’s work. Really, you’ve got to really consider the phenomenological experiences of each family member. In working with families in this predicament with a child with conduct disorder, they’re typically thinking in rather black and white terms, which is a function of their stress. This may not represent their true capacity for being able to tolerate any complexity or engage in any kind of more thoughtful consideration. The engagement process requires patience, and it requires the clinician to really think about how they’re picking your battles in terms of what they’re going to try to address immediately.

Snyder: This may be where parental guilt or shame could come in as well, if a clinician dives in too quickly for behavior change, and the child doesn’t change because of the clinician’s unrealistic expectations.

Siegler: Right, that’s humiliating for the parent because the clinician is not really acknowledging their situation, their predicament. We’re looking at getting the parent engaged in parent training to look at specific strategies that would work without just coaxing them to try those strategies and try to reignite some positive interaction with their child. The first step in the engagement is the parent has to experience the clinician as non-judgmental and supportive and to feel like they’re being heard in terms of the challenges that they’re facing as the leader of the family.

Snyder: It’s real empathy with the family and realizing the function of the stress and that the present is the history of reciprocal interactions between the parent-child system.

Siegler: Yes, a clinician has to be able to empathize with them without excusing the choices. They can join them around their emotional experience.

Snyder: I think this empathy-accountability dichotomy is very apparent with youth in the juvenile justice system. Not every child with conduct disorder goes on to have justice system involvement, but I am wondering: how does that system involvement affect engagement?

Siegler: There is still some of the self-blaming parent. I think the parents generally anticipate blame from the system and from the clinician. They most likely have had numerous experiences in the past where they felt blamed, and really the juvenile justice (JJ) system for the most part holds parents accountable for their kid’s behavior. Parents are the ones that have to pay the fines, the ones who get the looks from the police when they bring their kid home, or when they are humiliated because they have to call the police when they can’t control the child in their own home or don’t know where their child is. So, this is all more apparent when there is justice system involvement. On the whole, there are some universal things seen despite the unique situation of each family.

Families with and without JJ-involvement go through a second stage when the parents start to accept the clinicians being engaged in wanting to be helpful, where they may feel like they’re not up to the task, and they may blame themselves. There’s also some literature on maternal depression as being related to conduct disorder, and that usually would only come up in some cases over a longer-term treatment. Maternal depression may not be an issue with initial engagement necessarily, but it is something to consider with ongoing engagement.

Snyder: What is interesting about blame, too, is the idea of labeling and attribution theories. I wonder if this blaming is part of the sequelae to conduct disorder. Is it something that may have happened as a result of adversities or traumatic exposure?

Siegler: I like to take a resilience approach with conceptualization, and the America’s Promises Alliances (which came out of the Presidents’ Summit for America’s Future), outlines five things that have to be in place for the average kid to have resilience. One of these promises is that they have to have a healthy start, which would reflect living in a healthy home with good nutrition and their needs being met, psychologically and medically, up until school age. Another promise is the involvement of a responsible adult; a third promise is effective and accountable education; another is safe places to play; and a final promise is the opportunity to give back.

When looking at kids involved in the juvenile justice system, I look at it in terms of what pieces are missing for them in that conceptualization. And a lot of times, all of them are missing. I tend to assume that these kids are where they are because of what’s happened or hasn’t happened to them as much as it is who they are. Within that assumption is that some degree of adverse experience has been at play, and the extent to which it’s traumatic is largely a function of the kid’s individual resilience and their capacity for resilience. When working with JJS-involved youth, the needs tend to be more complex, and it becomes easy for the families to become what Minuchin calls “entangled.” The systems themselves may even begin to describe themselves as feeling like they’re entangled with the family. They’re trying to offer services, and they feel like their family’s partner expression, and it becomes like Chinese finger trap that they can’t get it off. They try, and that makes them more stuck.

Healthy boundaries are needed for family and systems in order to self-regulate themselves. Not having boundaries leads to entanglements and limits the successful discharge. It’s like having an exit strategy from the start.

Snyder: Right, systems don’t want to institutionalize kids, but at the same rate, systems also can create dependence when there isn’t an exit plan.

Siegler: And there are a lot of systems underestimating the parents’ capacity for competence. The parents get kind of infantilized, and the system takes over and loco parentis. Unless systems establish a goal to increase the parents’ confidence and competence as the primary person in authority and the primary person in charge of regulating their family system, it is easy to fixate on the kids behaviors, which leads to a continued behavioral cycle. There’s no end to it.

Snyder: I’m thinking about general child interventions. It really is about family work and establishing the executive system in the family. So, engagement is engaging the family system as well as other systems.

Siegler: Working with families is 95% parent consultation and 5% working with a kid. I think that’s true even when most of your work is with the child individually. The change that you can create is to influence the family as the context for change (unless you’re talking about transitional-age kids where the goal is really to like getting them standing on their own two feet).

Snyder: You’re probably thinking about all of that when you are doing assessments. Tell us about your process.

Siegler: In assessment, I bring the resilience conceptualization I mentioned. To start, it’s worth mentioning the impact of trauma influencing what is being assessed. There are a number of measures that can be used to screen for adverse experiences from the child and from the caregiver. There may be some things that the child doesn’t want to share or may not even recognize as being as impactful on them. Then screen for symptoms, and I tend to find that youth will have a lot of the criteria but not intrusive symptoms. Keep in mind the full-blown PTSD requires the presence of the intrusive symptoms, so there are youth that have trauma symptoms but not meet full criteria for PTSD. Now, that doesn’t mean that those other kids aren’t affected by their adverse experiences. It’s important to understand how the child would describe his current context, the current challenges, and the extent to which the description reflects an accurate or unhelpful view of themselves in the world.

Snyder: We know a lot of the times with these youth that previous trauma symptomatology can be a risk factor for delinquent behavior; for instance, hyperarousal could lead to severe aggression, or intrusive thoughts could prompt maladaptive coping like extreme risk-taking behaviors.

Siegler: That’s exactly right. Sadly, a very common thing that I encounter with the kids that are cross adjudicated or those served by both child welfare and delinquent courts. These youth clearly had issues with receiving appropriate care and ended up on their own, engaging in survival behavior that leads to arrest. A lot of these kids are runaways and come into the delinquent system for shoplifting or being involved in a group of people where there’s a robbery. It’s driven by the need to get money to live. So, is that really conduct disorder or a trauma reaction or an adaptation?

Snyder: Yes, there’s a sense of resiliency there that can be seen as resourceful albeit something that may “violate” social or legal norms. But what happened to them is a violation of social norms in and of itself!

Siegler: Exactly so. In those cases, we really try to work with the court system to get them to recognize that the child clearly needs help with their problem solving, but that they also need to live in a place where they will consistently have these needs met so that they can be comfortable enough to stay there.

Snyder: It’s Maslow’s hierarchy, right?

Siegler: Yes, and this is probably as old as written history, the notion of looking at the poor in a way that’s negative because of their proclivity to engage in criminal behavior like when they’re starving.

Snyder: We are looking at assessment through a trauma lens with this. To broaden the conversation, what other types of comorbid conditions do you see with court-involved youth?

Siegler: The most common ones are diagnoses those kids may already have, in particular attention deficit hyperactivity disorder (ADHD). In some cases, there’s enough evidence that I can gather from history, from the child’s behavior in the assessment, from multiple collateral reporters. There may be a history of mood disorder, either depression or disruptive mood dysregulation disorder. A lot of kids are self-medicating with marijuana, so they could be seen as having cannabis use disorder mild to severe. What I find interesting is that the vast majority of kids that say they use marijuana give me a hard “No!” when asked about alcohol use or prescription pills. They really see marijuana is an acceptable thing. Self-medicating is related to trying to find a way to manage their self-regulation.

Those are the main ones. Occasionally, I’ve seen maybe one or two kids every couple of years where I think, “This youngster may have autism spectrum disorder and needs to have that type of an evaluation because their behaviors got so out of control and so dangerous before they came to the attention to the system.” I see the occasional unspecified psychotic disorder but that is usually related to the substance use. But those are rare. To summarize, the vast majority are ADHD or mood disorders like depression.

Snyder: Great, thank you. A few more things about assessment. How much weight do you put on the court related presentation? What types of collateral do you need to really understand the child?

Siegler: Well, a guardian or teacher, definitely. I cannot make that diagnosis solely on the affidavit of probable cause for the child’s offense. There has to be some information about the child’s functioning that would reflect their attitude towards authority outside of the session with me and outside of their interaction with the police. So, ideally, the parent would be able to say “He’s fine when he’s at home, but after he goes out the door, I’m afraid.” But then when I probe, I can drill down that he’s fine at home because the parents have given up on trying to hold them accountable. Then parents that are hostile or distrusting in the system will insist that their kid is fine at home but he’s getting railroaded. I have to have something to go on.

And it may even be their interaction with authority figures at the end, the detention center but I always try and get school information. I want to know where he went to school, since kindergarten, how many absences, how many suspensions. Parents are incredibly sensitive to your interest in their child’s ability to function academically, so establishing that as a priority helps with them being generally cooperative and giving consent. And if they had to choose between their kid behaving at home and behaving at school, 90% of them would choose school because they know that’s the kid’s future. It comes back again to basic principles and understanding what parents value, and getting that information is key. It doesn’t necessarily require having a teacher fill out a rating scale; it can be perspectives on things like why he got suspended or how often he cuts class.

Snyder: There’s the story that’s important. I’m thinking about when teachers rate the children on those rating scales; is the observation accurate? How helpful are those ratings, especially if you see all scores at the max rating with no variance?

Siegler: There are a couple different levels of analysis of those forms that we call “the cry for help.” When everything is labeled as a three, the teacher could have written, “Help me” across the form. It could be that bad for a number of reasons, like the child could be struggling that much in the classroom. It can depend on the school. The other issue could be if this is a really bad fit for this child in that classroom. Or is that teacher a very good fit? Behavior rating scales are really good for initial rating of what’s going on, but teachers take a while to change their opinion about a child. I encourage the clinician to look past the actual T scores and say, “I think I need to talk to this teacher or somebody to figure out what’s going on,” because if the child’s that bad, I would be saying I’d want to talk to somebody at school and ask, “Have you called crisis?”

Snyder: It would seem that the child is causing a whirlwind of sorts, and it may inhibit good decision making on a school’s part, or it may mask something else.

Siegler: Initially, it is the parent who is caught in a very serious cycle of coercive interaction and that has now generalized the child’s relationship with authority figures at school. There may also be other factors at play, including overlooked learning issues and speech language issues. 70% of kids with disruptive behavior disorders also have an expressive or receptive language problem that’s diagnosable. The effectiveness of the interventions for the disruptive behavior disorder is a lot better after the kids have speech language therapy.

Snyder: Right, it’s like with differentials: understand if there is another etiology to the disorder before jumping to a purely behavior problem.

Siegler: And conceptual functioning is key, along with other adaptive functioning domains.

Snyder: So, after engagement and assessment, do you find yourself going to common intervention approaches?

Siegler: Well, the research for conduct disorder kids and kids with serious ODD is a combination of problem-solving skills training and parent training. The problem-solving training can be successful, even if the parents refuse to participate in the parent training. With younger kids, parent training is critical. Family based, systemic interventions engage with the parent, changing the relationship between the parent and the child to be at least as positive as it can be, and working with the parent to increase their confidence. It has a spirit of motivational intervention, where we are in the position of guiding the person, not pulling them along or following them. It’s talking about change in a way that is helpful. And what we want to do is to coach the parent and to engage in those types of conversations with their child.

Snyder: Functional family therapy centers on family motivation before behavior change.

Siegler: Yes, and with FFT and MST, there has to be consistent support for the clinicians with training, consultation, and supervision in order for these interventions to be effective. Therapists have enough resilience to actually work with the family to meet them where they are; it is really key.

Snyder: Investment in the clinicians and investment in children will have the best return on investment.

Siegler: Well, I think you got to build your own balance. You have to maintain your own resilience and not get worn down by the stress associated with the work; that’s number one. Number two is that working in this population, you cannot do work in this population in spite of the community, in spite of the systems that may be involved. You have to do what you can do to engage them and communicate with them. It doesn’t guarantee a good outcome, but not engaging and communicating with them pretty much guarantees a bad outcome or unequivocal outcome at best. We have to work very hard to experience occasional success, where we can see the success at the point that we’re still involved. Because the decks really stacked against these kids and their families. You may need to think about systems that may not be specifically mental health that can provide some of those missing pieces, like a safe place to play, getting another responsible adult involved, or, most importantly for older adolescents, the chance to give back. When you talk to some of these kids about the idea of volunteering, they look at you like you got three heads, but there are those that have had the experience of doing that, not just to work off their community service, but to have the experience of seeing someone value something they can create. That is a restorative experience for them, not just in a sense that it may restore some harm they’ve done to someone else, but it may restore their sense of their own humanity.

Snyder: At the end of the day, it sounds like it’s just putting things in place to allow kids to be kids; it’s allowing opportunity for resilience and for youth to develop. Thanks for your thoughts, John; these ideas are needed to have a person-centered approach to youth with disruptive behavior disorders!

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