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Disruptive Behavioral Disorders

by Josephine Elia, MD

Disruptive behavioral disorders are so-named because affected children tend to disrupt people around them, including family members, school staff, and peers.

The most common disruptive behavioral disorder is attention-deficit/hyperactivity disorder (see Attention-Deficit/Hyperactivity Disorder (ADHD, ADD)).

Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is a recurrent or persistent pattern of negative, defiant, or even hostile behavior directed at authority figures. Diagnosis is by history. Treatment is with individual psychotherapy combined with family or caregiver therapy. Occasionally, drugs may be used to reduce irritability.

Prevalence estimates of ODD vary widely because the diagnostic criteria are highly subjective; prevalence in children and adolescents may be as high as 15%. Before puberty, affected boys greatly outnumber girls; after puberty, the difference narrows.

Although ODD is sometimes viewed as a mild version of conduct disorder, similarities between the 2 disorders are only superficial. The hallmark of ODD is an interpersonal style characterized by irritability and defiance. However, children with a conduct disorder seemingly lack a conscience and repeatedly violate the rights of others (eg, bullying, threatening or causing harm, being cruel to animals), sometimes without any evidence of irritability.

Etiology of ODD is unknown, but it is probably most common among children from families in which the adults engage in loud, argumentative, interpersonal conflicts. This diagnosis should not be viewed as a circumscribed disorder but rather as an indication of underlying problems that may require further investigation and treatment.

Symptoms and Signs

Typically, children with ODD tend to frequently do the following:

  • Lose their temper easily and repeatedly

  • Argue with adults

  • Defy adults

  • Refuse to obey rules

  • Deliberately annoy people

  • Blame others for their own mistakes or misbehavior

  • Be easily annoyed and angered

  • Be spiteful or vindictive

Many affected children also lack social skills.

Diagnosis

ODD is diagnosed if children have had 4 of the above symptoms for at least 6 mo. Symptoms must also be severe and disruptive.

ODD must be distinguished from the following, which may cause similar symptoms:

  • Mild to moderate oppositional behaviors: Such behaviors occur periodically in nearly all children and adolescents.

  • Untreated attention-deficit/hyperactivity disorder (ADHD): The ODD-like symptoms often resolve when ADHD is adequately treated.

  • Mood disorders: Irritability caused by depression can be distinguished from ODD by the presence of anhedonia and neurovegetative symptoms (eg, sleep and appetite disruption); these symptoms are easily overlooked in children.

  • Anxiety disorders and OCD: In these disorders, the oppositional behaviors occur when children have overwhelming anxiety or when they are prevented from carrying out their rituals.

Treatment

  • Behavior modification therapy

  • Sometimes drugs

Underlying problems (eg, family dysfunction) and coexisting disorders (eg, ADHD) should be identified and corrected. However, even without corrective measures or treatment, most children with ODD gradually improve over time.

Initially, the treatment of choice is a rewards-based behavior modification program designed to make the child’s behaviors more socially appropriate. Many children can benefit from group-based therapy that builds social skills.

Sometimes drugs used to treat depressive or anxiety disorders (see Treatment) may be beneficial.

Conduct Disorder

Conduct disorder (CD) is a recurrent or persistent pattern of behavior that violates the rights of others or violates major age-appropriate societal norms or rules. Diagnosis is by history. Treatment of comorbid disorders and psychotherapy may help; however, many children require considerable supervision.

Prevalence of some level of CD is about 10%. Onset is usually during late childhood or early adolescence, and the disorder is much more common among boys than girls.

Etiology is likely a complex interplay of genetic and environmental factors. Parents of adolescents with CD often have engaged in substance abuse and antisocial behaviors and frequently have been diagnosed with ADHD, mood disorders, schizophrenia, or antisocial personality disorder. However, CD can occur in children from high-functioning, healthy families.

Symptoms and Signs

Children or adolescents with CD lack sensitivity to the feelings and well-being of others and sometimes misperceive the behavior of others as threatening. They may act aggressively, by bullying and making threats, brandishing or using a weapon, committing acts of physical cruelty, or forcing someone into sexual activity, and have few or no feelings of remorse. Sometimes their aggression and cruelty is directed at animals. These children or adolescents may destroy property, lie, and steal. They tolerate frustration poorly and are commonly reckless, violating rules and parental prohibitions (eg, by running away from home, being frequently truant from school).

Aberrant behaviors differ between the sexes: Boys tend to fight, steal, and vandalize; girls are likely to lie, run away, and engage in prostitution. Both sexes are likely to use and abuse illicit drugs and have difficulties in school. Suicidal ideation is common, and suicide attempts must be taken seriously.

Diagnosis

CD is diagnosed in children or adolescents who have demonstrated 3 of the following behaviors in the previous 12 mo plus at least 1 in the previous 6 mo:

  • Aggression toward people and animals

  • Destruction of property

  • Deceitfulness, lying, or stealing

  • Serious violations of parental rules

Symptoms or behaviors must be significant enough to impair functioning in relationships, at school, or at work.

Prognosis

Usually, disruptive behaviors stop during early adulthood, but in about one third of cases, they persist. Many of these cases meet the criteria for antisocial personality disorder (see Antisocial personality disorder). Early onset is associated with a poorer prognosis. Some children and adolescents subsequently develop mood or anxiety disorders, somatic symptom or related disorders, substance-related disorders, or early adult–onset psychotic disorders. Children and adolescents with CD tend to have higher rates of physical and other mental disorders.

Treatment

  • Drugs to treat comorbid disorders

  • Psychotherapy

  • Sometimes placement in a residential center

Treating comorbid disorders with drugs and psychotherapy may improve self-esteem and self-control and ultimately improve control of CD. Drugs may include stimulants, mood stabilizers, and atypical antipsychotics, especially short-term use of risperidone.

Moralization and dire admonitions are ineffective and should be avoided. Individual psychotherapy, including cognitive therapy and behavior modification, may help. Often, seriously disturbed children and adolescents must be placed in residential centers where their behavior can be managed appropriately, thus separating them from the environment that may contribute to their aberrant behavior.

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