Disruptive Behavior Disorders

The disruptive behavior disorders are characterized by externalizing behaviors which are alarming, upsetting, and challenging for parents, teachers, and other caretakers.  While all children and adolescents engage in disruptive behaviors at times, the disruptive behavioral disorders constitute more consistent, severe, and impairing patterns of behavior.  Oppositional Defiant Disorder tends to have the greatest impact on adults and peers who are close to the child, which in turn affects the way the child is treated and forms relationships.  Conduct Disorder may impact people at a greater remove from the child or adolescent who engages in destructive, aggressive or criminal behaviors.  

Oppositional Defiant Disorder

Key features

  • Conflict with authority
  • Marked reactions to limit setting
  • Marked reactions to perceived threats to control and autonomy
  • With greater frequency and severity than normative defiance
  • Resulting in significant impairment

Symptoms

At least 4 of the following over 6 months in interaction with at least 1 person who is not a sibling:

Anger and irritability

  • Lose their temper easily.
  • Be touchy and/or easily annoyed by others.
  • Be frequently angry and resentful

Argumentative and defiant behavior

  • Excessively argue with adults or authority figures
  • Actively refuse to comply with requests and rules.
  • Deliberately try to annoy or upset others.
  • Blame others for their own mistakes.

Vindictiveness

  • Being spiteful or vindictive at least twice within the past 6 months

Epidemiology

  • Prevalence is about 3%, with lifetime prevalence about 10%.
  • ODD is slightly more common in boys than girls in childhood; equally common in adolescence.

Etiology & Risk Factors

Biological:  

  • Genetic studies link ODD, CD & ADHD 
  • Higher levels of dehydroepiandrosterone sulfate (DHEAS) in children with ODD than in ADHD or controls
  • Norepinephrine transporter gene NET1 single nucleotide polymorphisms associated with ADHD + ODD compared with ADHD – ODD

Psychological

  • Temperament + environment
  • High reactivity, poor self-regulation
  • Insecure attachment – cuts both ways, as oppositional behavior affects parents

Sociological

  • Parental discord
  • Domestic violence
  • Low family cohesion
  • Poor parenting practices – harsh or inconsistent limit setting, parental feeling of low competence, parental response to normative toddler oppositional behavior
  • Parental mental illness, esp substance abuse and Antisocial Personality Disorder

Parenting and Coercive Behavior

Parents and kids get stuck in cycles of coercive behavior in which they ratchet up each other's frustration level until one or the other gives up.  Being stuck in these cycles makes parents and kids feel hopeless, like they have "tried everything" and nothing ever gets better.  

 

Comorbidity/differential diagnosis

  • ADHD
  • Anxiety – separation, OCD
  • Depression
  • Normative behavior/poor environmental match

Assessment

  • Get the history from multiple informants (parents, teacher, child)
  • Be neutral - kids feel like they are in trouble in your office setting
  • Avoid having child listen to extensive list of parental complaints
  • Rating scales
    • NIHQ Vanderbilt
    • SNAP-IV

Pharmacologic Treatment

No pharmacologic treatment specifically targets ODD.

Treating comorbid ADHD, depression or severe aggression can improve oppositional behavior, especially when combined with parent management training.

Psychotherapeutic Treatment

Conduct Disorder

Key features

  • Conduct disorders is a repetitive pattern of behavior in which the basic rights of others or major age-appropriate societal norms are violated.
  • All the diagnostic criteria are observable behaviors rather than inferred, internal constructs.

Symptoms

At least 3 symptoms in the past 15 months from 4 categories:

  • aggression to people or animals
  • destruction of property
  • deceitfulness or theft
  • serious violations of rules

Specifiers

Conduct Disorder may be of childhood onset (worse prognosis) or adolescent onset (more common).

While the criteria for Conduct Disorder are observable behaviors, a specifier is used to indicate the distinction between kids who engage in anti-social behaviors but may feel remorse or regret, and those with limited prosocial emotions.  Limited prosocial emotions are characterized by at least 2 of the following in multiple relationships and settings:

  • Lack of remorse or guilt
  • Callous-lack of empathy
  • Unconcerned about performance
  • Shallow or deficient affect

Epidemiology

  • Prevalence is about 5%, with lifetime prevalence about 9.5%.
  • Conduct disorder is about twice as common in males than in females.

Etiology & Risk Factors

Biological:  

  • Genetic influences – features of CD (aggression, impulsivity, antisocial behavior, callousness) separately heritable
  • Monoamine oxidase A (MAOA) – low MAOA activity variant = 2x risk for developing CD in abused boys; no risk increase in boys with no abuse history
  • Low CSF 5-hydroxyindoleacetic acid (5-HIAA) and high peripheral blood levels of serotonin are associated with childhood-onset CD.
  • Low sympathetic arousal, low resting heart rate

Psychological

  • Lower IQ
  • Impaired verbal ability
  • Poor attention and executive functioning
  • Poor impulse control
  • Social cognition deficits
  • Limited problem-solving skills
  • Chronic illness, especially CNS disorders; head injury

Sociological

  • Harsh discipline
  • Physical and/or sexual abuse; neglect
  • Parental rejection
  • Parental marital discord, domestic violence, parental mental illness/substance abuse/criminality
  • Neighborhood/community factors
  • Association with delinquent peers/gang involvement
  • Cumulative and sequential nature of risks matters, as does age of exposure

Treatment

Early interventions to reduce social risk factors and build pro-social attachments to family, school, church, clubs, or other structural units may reduce conduct disordered behavior.  Building a sense of efficacy through skill developoment and economic opportunity may also help.

In terms of treatment, the most commonly described model is called Multisystemic Therapy, a 3-month, intensiive home-based program that requires intensive training annd supervision but has been proven cost-effective.

References

Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: Current insight. Psychology Research and Behavior Management, 10, 353–367. https://doi.org/10.2147/PRBM.S120582

Thomas, C.R. Oppositional Defiant Disorder and Conduct Disorder. In Dulcan's Textbook of Child and Adolescent Psychiatry.  Washington DC: American Psychiatric Publishing, Inc.  2022.  pg 197-220