Disruptive Behavior Disorder is an expression used to describe a set of externalizing negativistic behaviors that co-occur during childhood and which are referred to collectively in the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV) as: "Attention-Deficit and Disruptive Behavior Disorders".
There are three subgroups of externalizing behaviors:
• Attention Deficit Hyperactivity Disorder (ADHD)
• Conduct Disorder (CD)
• Oppositional Defiant disorder (ODD)
Treatment for Oppositional Defiant disorder and CD at the clinic is based on the premise that these behaviors are the result of a combination of a metabolic dysfunction and environmental factors. We approach treatment in a similar way to our treatment of kids and teens with ATTENTION DEFICIT HYPERACTIVITY DISORDER. There is however an added emphasis on Counseling and Behavior Modification techniques. Please read our treatment model for ATTENTION DEFICIT HYPERACTIVITY DISORDER.
Oppositional Defiant Disorder—
Oppositional Defiant Disorder consists of a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following behaviors are present:
• Is often angry and resentful
• Is often spiteful or vindictive
• Is often touchy or easily annoyed by others
• Often actively defies or refuses to comply with adults' requests or rules
• Often argues with adults
• Often blames others for his or her mistakes or misbehavior
• Often deliberately annoys people
• Often loses temper
Each of the above is only considered diagnostic if the behavior occurs more frequently than is typically observed in kids of comparable age and developmental level and if the behavior causes clinically significant impairment in social, academic, or occupational functioning.
Oppositional Defiant disorder is not diagnosed if the behaviors occur exclusively during the course of a Psychotic or Mood Disorder or if CD is diagnosed.
Conduct Disorder (CD)—
CD is very common among kids and teens in our society. This disorder not only affects the individual, but his or her family and surrounding environment. CD appears in various forms, and a combination of factors appears to contribute to its development and maintenance. A variety of interventions have been put forward to reduce the prevalence and incidence of CD. The optimum method appears to be an integrated approach that considers both the youngster and the family, within a variety of contexts throughout the developmental stages of the youngster and family's life.
The DSM-IV categorizes CD behaviors into four main groupings:
1. aggressive conduct that causes or threatens physical harm to other people or animals
2. non- aggressive conduct that causes property loss or damage
3. deceitfulness or theft
4. serious violations of rules
CD consists of a repetitive and persistent pattern of behaviors in which the basic rights of others or major age-appropriate norms or rules of society are violated. Typically there would have been three or more of the following behaviors in the past 12 months, with at least one in the past 6 months:
Aggression to people and animals:
• has been physically cruel to animals
• has been physically cruel to people
• has forced someone into sexual activity
• has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
• has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
• Often bullies, threatens, or intimidates others
• Often initiates physical fights
Destruction of property:
• has deliberately destroyed others' property (other than by fire setting)
• has deliberately engaged in fire setting with the intention of causing serious damage
Deceitfulness or theft:
• has broken into someone else's house, building, or car
• has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
• Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
Serious violations of rules:
• has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
• is often truant from school, beginning before age 13 years
• Often stays out at night despite parental prohibitions, beginning before age 13 years
Subtypes of Conduct Disorder (CD)—
There are two subtypes of CD outlined in DSM-IV, and their diagnosis differs primarily according to the nature of the presenting problems and the course of their development.
The first, childhood-onset type is defined by the onset of one criterion characteristic of CD before age 10. Kids with childhood-onset CD are usually male, and frequently display physical aggression; they usually have disturbed peer relationships, and may have had oppositional defiant disorder during early childhood. These kids usually meet the full criteria for CD before puberty, they are more likely to have persistent CD, and are more likely to develop adult antisocial personality disorder than those with the teen-onset type (American Psychiatric Association, 1994).
The second, the teen-onset type, is defined by the absence of CD prior to age 10. Compared to individuals with the childhood-onset type, they are less likely to display aggressive behaviors. These individuals tend to have more normal peer relationships, and are less likely to have persistent CDs or to develop adult antisocial personality disorder. The ratio of males to females is also lower than for the childhood-onset type (American Psychiatric Association, 1994).
Severity of symptoms—
CD is classified as "mild" if there are few, if any, conduct problems in excess of those required for diagnosis and if these cause only minor harm to others (e.g., lying, truancy and breaking parental rules). A classification of "moderate" is applied when the number of conduct problems and effect on others are intermediate between "mild" and "severe". The "severe" classification is justified when many conduct problems exist which are in excess of those required for diagnosis, or the conduct problems cause considerable harm to others or property (e.g., rape, assault, mugging, breaking and entering) (American Psychiatric Association, 1994).
Co-morbidities and associated disorders—
Kids with CD are part of a population within which there are higher incidences of a number of disorders than in a normal population. The literature abounds with studies indicating the co morbid relationships between Attention Deficit Hyperactivity Disorder, CD, Oppositional Defiant Disorder, Learning Difficulties, Mood Disorders, Depressive symptoms, Anxiety Disorders, Communication Disorders, and Tourettes Disorder. (American Psychiatric Association, 1994; Biederman, Newcorn, & Sprich, 1991). A high level of co-morbidity (almost 95%) was found among 236 ATTENTION DEFICIT HYPERACTIVITY DISORDER kids (aged 6-16 yrs) with CD, OPPOSITIONAL DEFIANT DISORDER and other related categories (Bird, Gould, & Staghezza Jaramillo, 1994). In an 8 year follow-up study, Barklay and colleagues (1990) found that 80% of the kids with ATTENTION DEFICIT HYPERACTIVITY DISORDER were still hyperactive as teens and that 60% of them had developed Oppositional Defiant or CD.
Prevalence of Conduct Disorder (CD)—
According to research cited in Phelps & McClintock (1994), 6% of kids in the United States may have CD. The incidence of the disorder is thought to vary demographically, with some areas being worse than others. For example, in a New York sample, 12% had moderate level CD and 4% had severe CD. Since prevalence estimates are based primarily upon referral rates, and since many kids and teens are never referred for mental health services, the actual incidences may well be higher (Phelps & McClintock, 1994).
Course of Conduct Disorder (CD)—
The onset of CD may occur as early as age 5 or 6, but more usually occurs in late childhood or early adolescence; onset after the age of 16 years is rare (American Psychiatric Association, 1994). The results of research into childhood aggression have indicated that externalizing problems are relatively stable over time. Richman and colleagues for example, found that 67% of kids who displayed externalizing problems at age 3 were still aggressive at age 8 (Richman, Stevenson, & Graham, 1982). Other studies have found stability rates of 50-70%. However, these stability rates may be higher due to the belief that the problems are episodic, situational, and likely to change in character (Loeber, 1991).
Age of onset of OPPOSITIONAL DEFIANT DISORDER seems to be associated with the development of severe problems later in life, including aggressiveness and antisocial behavior. However, not all CD kids have a poor prognosis. Studies suggest that less than 50% of the most severe cases become antisocial as adults. Nevertheless, the fact that this disorder continues into adulthood for many people conveys that it is a serious and life-long dysfunction (Webster-Stratton & Dahl, 1995).
While not all OPPOSITIONAL DEFIANT DISORDER kids develop CD, and not all CD kids become antisocial adults there are certain risk factors that have been shown to contribute to the continuation of the disorder. The risk factors identified include; an early age of onset (preschool years), the spread of antisocial behaviors across settings, the frequency and intensity of antisocial behaviors, the forms that the antisocial behaviors take, having covert behaviors at an early age and also particular parent and family characteristics. However, these risk factors do not fully explain the complex interaction of variables involved in understanding the continuation of CD in any one individual.
Causes of Conduct Disorder (CD)—
There is evidence from research into causes of CDs that indicates that several biological and environmental factors may contribute to the development of the disorder.
Neurological Dysregulation:
The high co-morbidity rate of CD with ATTENTION DEFICIT HYPERACTIVITY DISORDER, Tourettes syndrome and other disorders known to be due to neurological dysregulation suggests that CD may be a co-manifestation of the same underlying dysregulation. Although there are no studies to our knowledge, which have directly investigated the neurological basis for CD, there is ample clinical evidence indicating that when treating ATTENTION DEFICIT HYPERACTIVITY DISORDER with Neurotherapy, and Nutrient supplementation, CD abates. It appears that Neurotherapy may address the underlying dysregulation and facilitate clinical treatment using cognitive and behavioral interventions. More research is needed in this area to determine whether Neurotherapy is directly responsible for this abatement or whether the resultant improvement in attention and reduction in hyperactivity promotes better self image which in turn improves behavior.
Child Biological Factors:
Considerable research has been carried out into the role of child temperament, the tendency to respond in predictable ways to events, as a predictor of conduct problems. Aspects of the personality such as activity levels displayed by a youngster, emotional responsiveness, quality of mood and social adaptability are part of his or her temperament. Longitudinal studies have found that although there is a relationship between early patterns of temperament, and adjustment during adulthood, the longer the time span the weaker this relationship becomes.
A more important determinant of whether or not temperamental qualities persist has been shown to be the manner in which moms and dads respond to their kids. "Difficult" infants have been shown to be especially likely to display behavior problems later in life if their parents are impatient, inconsistent, and demanding. On the other hand "difficult" infants, whose parents give them time to adjust to new experiences, learn to master new situations effectively. In a favorable family context a "difficult" infant is not at risk of displaying disruptive behavior disorder at 4 years old.
Cognitions may also influence the development of CD. Kids with CD have been found to misinterpret or distort social cues during interactions with peers. For example, a neutral situation may be construed as having hostile intent. Further, kids who are aggressive have been shown to seek fewer cues or facts when interpreting the intent of others. Kids with CD experience deficits in social problem solving skills. As a result they generate fewer alternate solutions to social problems, seek less information, see problems as having a hostile basis, and anticipate fewer consequences than kids who do not have a CD (Webster-Stratton & Dahl, 1995).
School-Related Factors:
A bidirectional relationship exists between academic performance and CD. Frequently kids with CD exhibit low intellectual functioning and low academic achievement from the outset of their school years. In particular, reading disabilities have been associated with this disorder, with one study finding that kids with CD were at a reading level 28 months behind normal peers (Rutter, Tizard, Yule, Graham, & Whitmore, 1976).
In addition, delinquency rates and academic performance have been shown to be related to characteristics of the school setting itself. Such factors as physical attributes of the school, teacher availability, teacher use of praise, the amount of emphasis placed on individual responsibility, emphasis on academic work, and the student teacher ratio have been implicated (Webster-Stratton & Dahl, 1995).
Parent Psychological Factors:
It is known that a youngster's risk of developing CD is increased in the event of parent psychopathology. Maternal depression, paternal alcoholism and/or criminal and antisocial behavior in either parent have been specifically linked to the disorder.
There are two views as to why maternal depression has this effect. The first considers that moms who are depressed misperceive their youngster's behavior as maladjusted or inappropriate. The second considers the influence depression can have on the way a parent reacts toward misbehavior. Depressed moms have been shown to direct a higher number of commands and criticisms towards their kids, who in turn respond with increased noncompliance and deviant child behavior. Webster-Stratton and Dahl suggested that depressed and irritable moms indirectly cause behavior problems in their kids through inconsistent limit setting, emotional unavailability, and reinforcement of inappropriate behaviors through negative attention (Webster-Stratton & Dahl, 1995).
Familial Contributions--
Divorce, Marital Distress, and Violence:
The inter-parental conflicts surrounding divorce have been associated with the development of CD. However, it has been noted that although some single parents and their kids become chronically depressed and report increased stress levels after separation, others do relatively well. Forgatch suggested that for some single parents, the events surrounding separation and divorce set off a period of increased depression and irritability which leads to loss of support and friendship, setting in place the risk of more irritability, ineffective discipline, and poor problem solving outcomes. The ineffective problem solving can result in more depression, while the increase in irritable behavior may simultaneously lead the youngster to become antisocial.
More detailed studies into the effects of parental separation and divorce on child behavior have revealed that the intensity of conflict and discord between the parents, rather than divorce itself, is the significant factor. Kids of divorced moms and dads whose homes are free from conflict have been found to be less likely to have problems than kids whose moms and dads remained together but engaged in a great deal of conflict, or those who continued to have conflict after divorce. Webster noted that half of all those kids referred to their clinic with conduct problems were from families with a history of marital spouse abuse and violence.
In addition to the effect of marital conflict on the youngster, conflict can also influence parenting behaviors. Marital conflict has been associated with inconsistent parenting, higher levels of punishment with a concurrent reduction in reasoning and rewards, as well as with moms and dads taking a negative perception of their youngster's adjustment.
Family Adversity and Insularity:
Life stressors such as poverty, unemployment, overcrowding, and ill health are known to have an adverse effect on parenting and to be therefore related to the development of CD. The presence of major life stressors in the lives of families with CD kids has been found to be two to four times greater than in other families.
Moms' perception of the availability of supportive and social contact has also been implicated in child contact disorder. Moms who do not believe supportive social contact is available are termed "insular" and have been found to use more aversive consequences with their kids than non-insular moms (Webster-Stratton & Dahl, 1995)
Parent-Child Interactions:
Research has suggested that moms and dads of kids with CD frequently lack several important parenting skills. Parents have been reported to be more violent and critical in their use of discipline, more inconsistent, erratic, and permissive, less likely to monitor their kids, as well as more likely to punish pro-social behaviors and to reinforce negative behaviors. A coercive process is set in motion during which a youngster escapes or avoids being criticized by his or her parents through producing an increased number of negative behaviors. These behaviors lead to increasingly aversive parental reactions which serve to reinforce the negative behaviors.
Differences in affect have also been noted in CD kids. In general their affect is less positive, they appear to be depressed, and are less reinforcing to their parents. These attributes can set the scene for the cycle of aversive interactions between parents and kids.
Other Family Characteristics:
Birth order and size of the family have both been implicated in the development of CD. Middle kids and male kids from large families have been found to be at an increased risk of delinquency and antisocial behaviors.
Psycho-physiological and Genetic Influences—
Studies have found that neurological abnormalities are inconsistently correlated with CD (Kazdin, 1987). While there has been interest in the implication of the frontal lobe limbic system partnership in the deficits of aggressive kids, these problems may be the consequence of the increased likelihood for kids with CD to experience abuse and subsequent head injuries (Webster-Stratton & Dahl, 1995).
While twin studies have found greater concordance of antisocial behavior among monozygotic rather than dizygotic twins, and adoption studies have shown that criminality in the biological parent increases the likelihood of antisocial behavior in the youngster, genetic factors alone do not account for the development of the disorder.
While the risk factors outlined have been shown to be implicated in the development of CD, it is important to note that not all kids exposed to these factors develop a CD. Rather, the evidence suggests that in those kids who do develop CDs have an etiology comprised of a combination of these factors (Webster-Stratton & Dahl, 1995). There is strong evidence that 75% of ATTENTION DEFICIT HYPERACTIVITY DISORDER kids with hyperactivity develop behavioral problems including 50% CD and 21% antisocial behavior (Klein & Mannuzza, 1991).
Treatment—
A number of interventions have been identified which are useful in reducing the prevalence and incidence of CD. Interventions consist of prevention and treatment, although these should not be considered as separate entities. Prevention addresses the onset of the disorder, although the youngster has not manifested the disorder, and treatment addresses reduction of the severity of the disorder. In mainstream Psychology, prevention and treatment for CD primarily focuses on skill development, not only for the youngster but for others involved with the youngster, including the family and the school environments. As previously discussed there may be clinical advantages in applying nutritional supplementation and Neurotherapy where appropriate with CD clients, if the client appears to respond to this form of neurological intervention, followed by cognitive and behavioral intervention. The following paragraphs considers three interventions, that assist in preventing and treating CD; child training, family training, and school and community interactions.
Child Training:
Child training involves the teaching of new skills to facilitate the youngster's growth, development and adaptive functioning. Research indicates that as a means of preventing child CD there is a need for skill development in the area of child competence. Competence refers to the ability for the youngster to negotiate the course of development including effective interactions with others, successful completion of developmental tasks and contacts with the environment, and use of approaches that increase adaptive functioning (Kazdin, 1990). It has been found that facilitating the development of competence in kids is useful as a preventative measure for kids prior to manifestation of the disorder rather than as a treatment (Webster-Stratton & Dahl, 1995).
Additionally, treatment interventions have been developed to focus on altering the youngster's cognitive processes. This includes teaching the youngster problem solving skills, self control facilitated by self statements and developing pro-social rather than antisocial behaviors. Pro-social skills are developed through the teaching of appropriate play skills, development of friendships and conversational skills. The social development of kids provides them with the necessary skills to interact positively in their environment. A youngster's development of cognitive skills provides a sound basis from which to proceed. However, cognitive development should not be considered in isolation, but as part of a system, which highlights the need to include the family in the training process.
Family Intervention:
A youngster's family system has an important role in the prevention and treatment of CD. The youngster needs to be considered as a component of a system, rather than as a single entity. Research supports the notion that moms and dads of CD kids have underlying deficits in certain fundamental parenting skills. The development of effective parenting skills has been considered as the primary mechanism for change in child CD, through the reduction of the severity, duration and manifestation of the disorder.
A number of parent training programs have been developed to increase parenting skills. Research indicates that the parent training programs have been positive, indicating significant changes in parents' and kid’s behavior and parental perception of child adjustment. Research suggests that parents who have participated in parent training programs are successful in reducing their youngster's level of aggression by 20 - 60 %.
Various training programs have been developed, which focus on increasing parents' skills in managing their youngster's behavior and facilitating social skills development. The skills focused on, include moms and dads learning to assist in administration of appropriate reinforcement and disciplinary techniques, effective communication with the youngster and problem solving and negotiation strategies.
A further component of parental training incorporates behavioral management. This involves providing the family with simple and effective strategies including behavioral contracting, contingency management, and the ability to facilitate generalization and maintenance of their new skills, thus encouraging parents' positive interaction with their youngster.
However, although these interventions assist moms and dads in developing effective parenting skills, a number of families require additional support. There are various characteristics within the family system that can have an impact on parents' ability to cope. This includes depression, life stress and marital distress. Research suggests that family characteristics are associated with fewer treatment gains in parent training programs. As indicated by Webster-Stratton and Dahl (1995), several programs have expanded upon the standard parent training treatment. These programs have incorporated parents' cognitive, psychological, and marital or social adjustment. Through addressing the parent's own issues it assists their ability to manage and interact positively with the youngster.
School and Community Education:
A youngster's' environment plays an active role in the treatment of CD and as a preventative measure. A number of interventions have been developed for schools and the community in relation to CD. The various programs outlined in this paper have a primary focus involving the skill development for the youngster in the areas of problem solving, anger management, social skills, and communication skills.
School based programs:
There are various preventative programs devised which focus on specific cognitive skill development of a youngster. A number of programs developed focus on encouraging the youngster's development in decision making and cognitive process. In addition school based programs have involved teaching the youngster interpersonal problem solving skills, strategies for increasing physiological awareness, and learning to use self talk and self control during problem situations.
In addition to prevention programs, a number of treatment interventions have been developed for kids where CD has manifested. The treatment programs focus on further skill development, including anger management and rewarding appropriate classroom behavior, skill development of the youngster including the understanding of their feelings, problem solving, how to be friendly, how to talk to friends, and how to succeed in school. As Webster and colleagues describe, one school based program has been designed to prevent further adjustment problems, by rewarding appropriate classroom behavior, punctuality, and a reduction in the amount of disciplinary action. In addition, the program provided moms and dads and educators with the opportunity to focus on specific problems of a youngster and for these to be addressed.
Community programs:
Community based interventions have also addressed both treatment and prevention. A number of programs have been developed, and focus on involving the youths in activity programs and providing training for those activities. The kids are rewarded for attendance and participation in the programs.
The treatments discussed are helpful in reducing the prevalence and incidence of CD. In their application it is important to provide an integrated multidisciplinary approach to treatment in multiple settings and by providing relevant nutritional supplements, Neurotherapy and behavior training as appropriate.
==> My Out-of-Control Child: Parenting Children with Oppositional Defiant Disorder (ODD)
References—
1. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). (Fourth ed.). Washington DC: American Psychiatric Association.
2. Barklay, R.A., & Fischer, M., Edelbrock, E.S. & Smallish, L. (1990) The adolescent outcome of hyperactive children diagnosed by research criteria, I: An eight year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 546-557.
3. Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148(5), 564-577.
4. Bird, H. R., Gould, M. S., & Staghezza Jaramillo, B. M. (1994). The comorbidity of ADHD in a community sample of children aged 6 through 16 years. Journal of Child and Family Studies, 3(4), 365-378.
5. Forgatch, M. (1989). Patterns and outcome in family problem solving: The disrupting effect of negative emotions. Journal of Marriage and the Family, 51, 115-124.
6. Kazdin, A. (1987). Treatment of antisocial behaviour in children: Current status and future directions. Psychological Bulletin, 102, 187-203.
7. Kazdin, A. (1990). Prevention of conduct disorder. Paper presented at the National Conference on Prevention Research, NIMH, Bethesda, MD.
8. Klein, R.G. & Mannuzza, S. (1991). Long Term outcome of hyperactive children: A review . Journal of the American Academy of Child and Adolescent Psychiatry, 30, 383-387.
9. Loeber, R. (1991). Antisocial behaviour: More enduring than changeable? Journal of the American Academy of Child and Adolescent Psychiatry, 30, 303-397.
10. Phelps, L., & McClintock, K. (1994). Conduct Disorder. Journal of Psychopathology and Behavioural Assesment, 16(1), 53-66.
Richman, N., Stevenson, L., & Graham, P. J. (1982). Pre-school to school: A behavioural study. London: Academic Press.
11. Rutter, M., Tizard, J., Yule, W., Graham, P., & Whitmore, K. (1976). Research report: Isle of Wight studies. Psychological Medicine, 6, 313-332.
12. Webster-Stratton, C., & Dahl, R. W. (1995). Conduct disorder. In M. Hersen & R. T. Ammerman (Eds.), Advanced Abnormal Child Psychology (pp. 333-352). Hillsdale, New Jersey: Lawrence Erlbaum Associates.
