Chapter 27 Disruptive Behavioral Disorders
The disruptive behavior disorders are a group of mental health problems in children and adolescents characterized by out-of-control anger and/or behavior. These disturbances exist on a dimensional spectrum ranging from subsyndromal (i.e., some symptoms are present, but not enough to meet full diagnostic criteria) to syndromal (i.e., full diagnostic criteria are met).
Description
Oppositional defiant disorder is characterized by a persistent pattern of angry outbursts, arguing, vindictiveness, and disobedience, generally directed at authority figures (such as parents and teachers). To meet the diagnosis, ≥4 of these types of behavior must be more frequent and more severe than children of a given developmental stage normally exhibit (especially when tired, hungry, or under stress), must be present at least 6 mo, and must impair the youth’s function at home, at school, or with peers (Table 27-1).
Table 27-1 DSM-IV-TR DIAGNOSTIC CRITERIA FOR OPPOSITIONAL DEFIANT DISORDER
Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Washington, DC, 2000, American Psychiatric Association.
Conduct disorder is characterized by a persistent pattern of serious rule-violating behavior, including behaviors that harm (or have the potential to harm) others. The patient with conduct disorder typically shows little concern for the rights or needs of others. The symptoms of conduct disorder are divided into 4 major categories: physical aggression to people and animals including bullying, fighting, weapon carrying, cruelty to animals, and sexual aggression; destruction of property, including firesetting and breaking and entering; deceitfulness and theft; and serious rule violations, including running away from home, staying out late at night without permission, and truancy. To meet the diagnosis, ≥3 of these symptoms must be present at least 1 year (1 or more in the past 6 mo) and must impair the youth’s function at home, at school, or with peers (Table 27-2).
Table 27-2 DSM-IV-TR DIAGNOSTIC CRITERIA FOR CONDUCT DISORDER
Aggression to People and Animals
Specify Type Based on Age at Onset:
Specify Severity:
From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Washington, DC, 2000, American Psychiatric Association.
Disruptive behavior disorder, not otherwise specified (subsyndromal disruptive behavior) is diagnosed when some symptoms of disruptive behavior disorders are present, but not enough to meet full diagnostic criteria for oppositional defiant disorder or conduct disorder.
Estimates of the prevalence of the disruptive behavior disorders vary according to the methodologic characteristics of the study. Recent surveys using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria suggests a point prevalence of oppositional defiant disorder and conduct disorder together of 5%. The male:female ratio is estimated at 3 : 1 to 5 : 1. Both disorders are believed to be more common in sociodemographically disadvantaged, urban populations.
Although oppositional defiant disorder and conduct disorder share a number of characteristics, oppositional defiant disorder can be distinguished from conduct disorder by the absence of physical aggression and other severe forms of antisocial behavior. When the youth’s pattern of behavior meets the criteria for both oppositional defiant disorder and conduct disorder, the diagnosis of conduct disorder takes precedence. Other diagnoses to consider in the differential include attention-deficit/hyperactivity disorder (ADHD) (Chapter 30), bipolar disorder (Chapter 24), developmental disorders (Chapter 28), and communication disorders (Chapter 32), in which anger and disruptive behavior can be associated symptoms.
ADHD, anxiety (Chapter 23), depression and bipolar disorders, post-traumatic stress disorder (Chapter 23), substance abuse (Chapter 108), and impulse control, learning, and communication disorders commonly co-occur with oppositional defiant disorder and conduct disorder. Treating comorbidities when they occur enhances the treatment of the disruptive behavior disorders.
Oppositional behavior can occur in all children and adolescents from time to time, particularly during the toddler and early teenage periods when autonomy and independence are developmental tasks (see 27.1). Oppositional behavior becomes a concern when it is intense, persistent, and pervasive and when it affects the child’s social, family, and academic life.
Some of the earliest manifestations of disruptive behavioral symptoms are stubbornness (3 yr), defiance and temper tantrums (4-5 yr), and argumentativeness (6 yr). Teachers’ reports suggest that most disruptive symptoms peak between 8 and 11 years and then decline in frequency.
Approximately 65% of children with oppositional defiant disorder exit from the diagnosis after a 3-yr follow-up. Earlier age at onset of oppositional symptoms conveys a poorer prognosis; preschool children with oppositionality are at heightened risk for the development of other psychiatric disorders (most commonly, ADHD, mood disorders, and anxiety disorders) several years later. An estimated 30% of children with oppositional defiant disorder progress to conduct disorder; the risk of progression is higher with comorbid ADHD.
The onset of conduct disorder can occur in early childhood but usually occurs in late childhood or adolescence. In a majority of patients, the disorder remits by adulthood. A substantial fraction of patients develop antisocial personality disorder as adults. Early onset of conduct disorder, along with high frequency of diverse antisocial acts across multiple settings, predicts a worse prognosis and increased risk for antisocial personality disorder. Patients with conduct disorder also are at risk for the development of mood, anxiety, somatoform, and substance-use disorders as they move into adulthood.
The disruptive behavior disorders are associated with a wide range of psychiatric disorders in adulthood and with many other adverse outcomes such as suicidal behavior, delinquency, educational difficulties, unemployment, and teenage pregnancy. The disruptive behaviors often trigger a chain of adverse events (e.g., parental hostility, peer rejection) that heighten the risk for additional adverse events (e.g., conflict with authority, deviant peers) extending through adolescence into adulthood.
Biologic, psychologic, and social factors all play a role in the etiology and/or course of the disruptive behavior disorders. Among the social risk factors, ineffective parenting strategies is one of the strongest. Ineffective parenting strategies include authoritarian parenting, in which the parent may be harsh and demanding, and inconsistent parenting, in which the parent may give in to the child when the child’s demands become coercive. Other social risk factors include ecologic factors such as poverty, social disorganization, community violence, and exposure to stressful life events; peer factors such as association with antisocial friends; and parent/family factors such as parental antisocial behavior, substance use, or depression, lack of parental supervision and involvement, coercive family processes, problematic sibling relationships, marital conflict, family instability, inconsistent discipline, neglect, and outright abuse.
Among the biologic risk factors are a family history of disruptive behavior, ADHD, substance use, and mood, somatization, and personality disorders; prenatal, perinatal, and postnatal insults; cognitive and linguistic impairment (including impaired intellectual capacity, executive function, memory, judgment, and pragmatic language); difficult temperamental characteristics (e.g., inflexibility to change, low threshold for and low tolerance of frustration, a rigid cognitive style, relative imperviousness to rewards and consequences; mood lability, and sensitivities to hunger, fatigue, and sensory inputs): and certain personality characteristics (e.g., impulsivity, novelty seeking, reduced harm avoidance, reduced reward dependence). Neurochemical abnormalities in the serotoninergic, noradrenergic, and dopaminergic systems and low cortisol levels have also been implicated.
Among the psychologic risk factors are impaired attachment to the primary caregiver, impaired social information processing (i.e., habitually misattributing hostile intent), and impaired impulse control.
A reliable sequence of events leads to the progression of subsyndromal disruptive behavior to oppositional defiant disorder to conduct disorder. This sequence often occurs in the context of a disadvantaged environment and begins with ineffective parenting strategies, followed by academic failure, parental hostility, and peer rejection, which leads to depressed mood, conflict with authority, and involvement in a deviant peer group. Children with difficult temperamental characteristics are more vulnerable to this sequence of events. Prevention efforts that intervene early in this sequence have the greatest chance of success.
In children predisposed to the development of disruptive behavioral disorders, repeated requests for compliance from authority figures often results in escalating anger and argumentativeness until the authority figure relents, thus inadvertently reinforcing the negative behavior. Parenting and teaching these children requires a high level of skill that can be enhanced by child development specialists who can teach parents and teachers effective behavior-management skills. Child-focused social-emotional skills training, which focuses on self-regulation, interpersonal regulation, problem-solving, and decision-making, also can be helpful and can be administered universally to at-risk populations such as disadvantaged preschoolers and students in inner city elementary schools.
All children should be screened for out-of-control behavior. A typical screening question would be “Does [name] have trouble controlling [his/her] anger or behavior?” If the question is answered affirmatively, a symptom-rating scale designed for parent report can be administered to standardize the assessment (Chapter 18). If the screening indicates clinically significant behavior symptoms, the pediatric practitioner should refer to a qualified mental health clinician for a comprehensive diagnostic evaluation to determine the presence of disruptive behavioral and other comorbid psychiatric and medical disorders. The evaluation must include assessment of the potential for harm to self or others.
The treatment for oppositional defiant disorder with the strongest evidence base is parent management training directed at the child’s caregivers. Parent management training includes understanding social learning principles, developing a warm, supportive relationship with the child, encouraging child-directed interaction and play, providing a predictable, structured household environment, setting clear and simple household rules, consistently praising and materially rewarding positive behavior, consistently ignoring annoying behavior (followed by praise when the annoying behavior ceases), and consistently giving consequences (such as time out or loss of privileges) for dangerous or destructive behavior. Other important targets for parenting training include understanding developmentally appropriate moods and behavior, managing difficult temperamental characteristics, and obtaining treatment and school-based remediation for comorbid disorders (especially ADHD and learning disorders).
Another treatment for oppositional defiant disorder that has some evidence supporting its effectiveness is social-emotional skills training directed at the child. Social-emotional skills training is targeted at modifiable cognitive, social, and emotional etiologic risk factors for disruptive behavior disorders. Training typically includes introducing a skill, verbally instructing the skill, modeling the skill for the child to observe, role-playing to practice the skill, coaching by the clinician during skill practice, summarizing the skill, and giving homework to practice the skill outside the training situation.
The primary evidence-based treatment for youths with conduct disorder is multisystemic therapy. Multisystemic therapy assumes that antisocial behavior becomes embedded in the life space of the patient; thus treatment involves extensive contact between the therapist and the multiple life contexts of the patient, especially the family, school, and peer group, with the goal of developing competencies and rewarding adaptive behavior. Interventions include social competence training, parent and family skills training, medications, academic engagement and skills building, school interventions and peer mediation, mentoring and after-school programs, and involvement of child-serving agencies.
The role of medication in the treatment of the disruptive behavior disorders primarily is limited to the treatment of comorbidities. There is an emerging evidence base for the utility of stimulants, selective serotonin reuptake inhibitors (SSRIs), valproate, and atypical antipsychotics for reactive, affective, defensive, and impulsive aggression. Because all of these medications are associated with significant side effects, careful monitoring of baseline and follow-up indices is imperative. Side effects include cardiac for stimulants; suicide, behavioral activation for SSRIs; hematologic, hepatic, ovarian, teratogenic for valproate; weight gain, metabolic aberrations (diabetes, hyperlipidemia), and cardiac for the atypical antipsychotics. The dosages for the stimulants, SSRIs, atypical antipsychotics, and valproate used in the treatment of aggression are similar to those used in the treatment of other psychiatric disorders in youths.
Most children and adolescents with a disruptive behavior disorder can be safely and effectively treated in the outpatient setting. Youths with intractable conduct disorder may benefit from residential or specialized foster care treatment.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry. 36(10 suppl), 1997.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:126-141.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000.
Collett BR, Ohan JL, Myers KM. Ten-year review of rating scales. VI. Scales assessing externalizing behaviors. J Am Acad Child Adolesc Psychiatry. 2003;42:1143-1170.
Pappadopulos E, MacIntyre JCII, Crismon ML, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY), part II. J Am Acad Child Adolesc Psychiatry. 2003;42:145-161.
Schur SB, Sikich L, Findling RL, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY), part I: a review. J Am Acad Child Adolesc Psychiatry. 2003;42:132-144.
27.1 Age-Specific Behavioral Disturbances
Temper tantrums and breath-holding spells are common during the 1st yrs of life and are age-typical expressions of frustration or anger. Parents who respond to toddler defiance with punitive anger can reinforce oppositional behavior. Parents are best advised to attempt to avert defiance by giving the child choices; once the child has begun a tantrum, the child can be given a time-out. It is useful to advise parents to tell their child, once he or she is calm, that the reasons for frustration are understandable, but that defiance is not acceptable.
Parents are occasionally concerned about breath-holding spells. Although some children hold their breath until they lose consciousness, sometimes leading to a brief seizure, there is no increased risk of seizure disorders in children who have had a seizure during a breath-holding spell. Parents are best advised to ignore breath holding once it has started. Without sufficient reinforcement, breath holding generally disappears.
The first key to the office management of temper tantrums and breath-holding spells is to help parents to intercede before the child is highly distressed. The pediatrician should advise parents to intercede early in defiant behavior by calmly placing the child in time-out for 2-3 min. Iron supplements might reduce recurrent breath-holding spells if anemia is present. When breath holding does not respond to the parent’s coaching or is accompanied by head banging or high levels of aggression, referral for a mental health evaluation is indicated.
If behavioral measures such as time-out fail, pediatricians must assess how the parents handle anger before making further recommendations about how to approach the child. Children can be frightened by the intensity of their own angry feelings and by angry feelings they arouse in their parents. Parents should model the anger control that they wish their children to exhibit. Some parents are unable to see that they lose control themselves; their own angry behavior does not help their children to internalize controls. Advising parents to calmly provide simple choices will help the child to feel more in control and to develop a sense of autonomy. Providing the child with options also typically helps reduce the child’s feelings of anger and shame, which can later have adverse effects on social and emotional development.
Lying can be used by 2-4 yr olds as a method of playing with the language. By observing the reactions of parents, preschoolers learn about expectations for honesty in communication. Lying can also be a form of fantasy for children, who describe things as they wish them to be rather than as they are. To avoid an unpleasant confrontation, a child who has not done something that a parent wanted may say that it has been done. The child’s sense of time and reason does not permit the realization that this only postpones a confrontation.
In school-aged children, lying is generally an effort to cover up something that the child does not want to accept in his or her own behavior. The lie is invented to achieve a temporary good feeling and to protect the child against a loss of self-esteem. Habitual lying also can be promoted by poor adult modeling. Many adolescents lie to avoid adults’ disapproval; lying may be used as a method of rebellion. Chronic lying can occur in combination with several other antisocial behaviors and is a sign of underlying psychopathology or family dysfunction.
Regardless of age or developmental level, when lying becomes a common way of managing conflict, intervention is warranted. Initially, the parents should confront the child to give a clear message of what is acceptable. Sensitivity and support combined with limit-setting are necessary for a successful intervention. If this behavior cannot be resolved through the parents’ understanding of the situation and the child’s understanding that lying is not a reasonable alternative, a mental health evaluation is indicated.
Many children steal something at some point in their lives. When preschoolers and school-aged children steal more than once or twice, the behavior may be a response to stressful environmental circumstances. Stealing can be an expression of anger or revenge for perceived frustrations with parents. In some instances, stealing becomes one way the child or adolescent can manipulate and attempt to control his world. Stealing also can be learned from adults.
It is important for parents to help the child undo the theft by returning the stolen articles or by rendering their equivalent either in money that the child can earn or in services. When stealing is part of a pattern of conduct problems, referral for a mental health evaluation is warranted.
Truancy and running away are never developmentally appropriate. Truancy may represent disorganization within the home, caretaking needs of younger siblings, developing conduct problems, or emotional problems including depression or anxiety. Whereas younger children may threaten to run away out of frustration or a desire to get back at parents, older children who run away are almost always expressing a serious underlying problem within themselves or their family, including violence, abuse, and neglect. Adolescent runaways are at high risk for substance abuse, unsafe sexual activity, and other risk-taking behaviors.
Although interest in fire is common in early childhood, unsupervised fire setting is always inappropriate. Early school-aged children may set fires accidentally, or because of curiosity or latent hostility. These young children usually set fires by themselves within their homes. In adolescence, fire setting can be a sign of delinquency or a signal of traumatic experiences.
Fire setting always requires intervention by mental health clinicians. A thorough mental health evaluation is necessary to plan the components of a successful treatment program.
Aggression and bullying are serious symptoms and are associated with significant morbidity and mortality. Children might not grow out of this behavior; early intervention is indicated for persistent aggressive behavior. Aggressive tendencies are heritable, although environmental factors can promote aggression in susceptible children. Both enduring and temporary stressors affecting a family can increase aggressive behavior in children. Aggression in childhood is correlated with family unemployment, discord, violence, criminality, and psychiatric disorders as well as births to teenage or unmarried mothers. Boys are almost universally reported to be more aggressive than girls. A difficult temperament and later aggressiveness are related, although there is evidence that these children elicit punitive caregiving within the family environment, setting up a cycle of increasing aggression. Aggressive children often misperceive social cues and react with inappropriate hostility toward peers and parents.
Clinically, it is important to differentiate the causes and motives for childhood aggression. Intentional aggression may be primarily instrumental, to achieve an end, or primarily hostile, to inflict physical or psychologic pain. Children who are callous and not empathetic and who are often aggressive require mental health intervention. These children are at high risk for suspension from school and eventual school failure. Learning disorders are common, and aggressive children should be screened. Other forms of psychopathology may be present; in particular, aggressive children with ADHD (Chapter 30) might have oppositional defiant disorder and/or conduct disorder. Some aggressive, impulsive children have bipolar disorder; a family history of bipolar disorder, grandiosity, elation, and cyclic mood disturbance may be evident in the history of these children.
Aggressive behavior in boys is relatively consistent from the preschool period through adolescence; a boy with a high level of aggressive behavior at 3-6 yr of age has a high probability of carrying this behavior into adolescence, especially without effective intervention. The developmental progression of aggression among girls is less well studied. There are fewer girls with physically aggressive behavior in early childhood; interpersonal coercive behavior, especially in peer relationships, is not uncommon among girls and may be related to the development of more physical aggression in adolescence (fighting, stealing).
Children exposed to aggressive models on television, in video games, or in play show more aggressive behavior compared with children not exposed to these models (Chapter 36). Parents’ anger and aggressive or harsh punishment model behavior that children might imitate when they are physically or psychologically hurt. Parents’ abuse may be transmitted to the next generation by several modes: children imitate aggression that they have witnessed, abuse can cause brain injury (which itself predisposes the child to violence), and internalized rage often results from abuse.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry. 36(10 suppl), 1997.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:126-141.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000.
Bloomquist ML, Schnell SV. Helping children with aggression and conduct problems. New York: Guilford Press; 2002.