Children who exhibit disruptive behaviors such as chronic defiance and provocation of classmates are commonly seen in primary care. Disruptive behaviors put children at greater risk for serious injury and illness, affect a child’s success and cause great frustration for parents and teachers.1 Such children often are labeled and dismissed as “bad,” reflecting the moral judgments of others. Families commonly feel desperate and vulnerable because of their child’s disruptive behaviors. The primary care provider’s nonjudgmental approach can foster a more thorough and informative evaluation, helping restore hope to patients and their families.
There are two main disruptive behavior disorders diagnosed in children: oppositional defiant disorder (ODD) and conduct disorder (CD). ODD is a disorder characterized by a “recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures for at least 6 months.”2 CD is a more severe form of social oppositionality than ODD, and involves a “pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.”2 Such behaviors include violence, stealing, deception and serious violation of age-related obligations such as attending school, and obeying curfew.
Determination of Normal Behaviors
Because some degree of oppositional and disruptive behavior is developmentally normal in children, determining if the behavior is abnormal requires an overall assessment of the child’s developmental stage, the problem behavior’s context and the degree of impact on functioning.
The frequency of normal oppositional and defiant behaviors changes predictably throughout development. Child first learn to express anger and frustration by 2 to 6 months of age,3 but they cannot begin to modulate their expression of anger and frustration until about 2 years of age.4 Increased compliance with authority figures progresses with 4- to 5-year-olds being twice as likely to comply with requests than 2- to 3-year-olds.5 In the early elementary school years, children learn how to use improved language skills effectively to manage their frustrations.6 Conflict between child and parent about the child’s autonomy rises to a peak in early adolescence, with a natural decline thereafter.7
A disruptive behavior disorder diagnosis before elementary school or during the very early stages of adolescence should only be made if the symptoms clearly go above and beyond those of same age peers. Also, since it is normal for boys to exhibit oppositional symptoms in early childhood, such behavior exhibited by girls during the early preschool and elementary ages is of greater concern. This gender difference disappears by adolescence.8
Aggression, a common characteristic in disruptive syndromes, is also not necessarily pathologic. Aggression peaks in frequency during toddlerhood, becomes progressively less common in adolescence,8 and is comparatively rare in girls of all ages. Hence, physical aggression in an older boy or in a girl of any age should be seen as more pathologic.
In adolescence, some risk taking and experimentation is normal, and may be related to observed discrepancies in the maturation of the prefrontal cortex (responsible for rational thought) and the limbic system (responsible for emotional thought) that leads to adolescents prioritizing emotional incentives over rational motivations.9 It is estimated that 80% of all adolescents have been involved in at least some antisocial behaviors. Most of these behaviors, such as isolated acts that lead to negligible damage or harm, are not predictive of a disruptive behavior disorder.10 Symptoms that suggest greater pathology include: having many different types of disruptive behavior symptoms; having proactive or planned aggression; cruelty; use of a weapon; and disruptive behavior outside of a reinforcing social context (non-mainstream peer pressure, gangs, etc).11
Prevalence of Disruptive Behavior Disorder
Disruptive behavior disorders are fairly common, with prevalence of up to 16% in some community samples with great variability depending on age and gender.12 The prevalence can be as high as 50% in mental health treatment populations.11 Boys more commonly exhibit aggression, property offenses, and violations of age-defined societal rules, such as truancy and curfew. Therefore, CD is up to four times as common in boys as girls, while ODD is not consistently found to be different between the genders.11 However, some have suggested that if “relational” aggression (alienation, character defamation, ostracism) were considered equivalent to physical aggression, there would be parity between the genders in CD prevalence.13
Both ODD and CD are thought to be highly persistent; the odds ratio of late-childhood diagnosed ODD and CD continuing into adolescence are 8.3 and 13.9, respectively.14 Of adolescents diagnosed with CD, 88% continue to have the diagnosis 3 years later.15
Evaluation and Diagnosis
The history of a patient suspected to have a disruptive behavior disorder should optimally be gathered from multiple sources, beginning with the child, and including the parents, extended family, teachers, therapists, social workers, and if appropriate, any parole/probation officers.
Confidentiality and its limitations, including mandated reporting requirements for unsafe behaviors or abuse, should be discussed before detailing the history. Because of the typically high rate of past trauma and risk behaviors in this population,16 some breaches in confidentiality regarding sensitive information gathered in the assessment may be required to keep the patient safe.
For an ODD diagnosis, the DSM-IV-TR outlines characteristic behaviors (Sidebar 1, see page 508), four of which must be present for at least 6 months.2 ODD includes not just negativistic oppositional and defiant symptoms, but also provocative behavior and irritability (Sidebar 2, see page 508).1 For diagnosis, the behavior must exceed what is developmentally appropriate, cause significant impairment, and not occur exclusively as a result of another psychiatric diagnosis (see Sidebar 3, page 509). For CD, three or more behaviors listed in Sidebar 4 (see page 509) must have occurred in the past 12 months, with at least one in the past 6 months. CD-related behaviors include aggression, destruction of property, deceitfulness, theft, and serious violations of rules. Suggested interview questions for CD are listed in Sidebar 5 (see page 510).17 Similar to ODD, the symptoms of CD must impair social, academic, or occupational functioning.
- Loses temper.
- Argues with adults.
- Actively defies adults’ rules.
- Deliberately annoys people.
- Blames others for his or her misbehavior.
- Irritable or easily annoyed by others.
- Angry and resentful.
- Spiteful or vindictive.
- In the past 3 months, has your child been spiteful or vindictive, or blamed others for his or her mistakes? (“Yes” is a positive response.)
- How often is your child touchy or easily annoyed? (More than once per week is a positive response.)
- How often has your child lost his or her temper, argued with adults, or defied or refused adults’ requests? (More than once per week is a positive response.)
- How often is your child angry and resentful or deliberately annoying to others? (More than three times per week is a positive response.)
- Behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
- Behavior causes clinically significant impairment in social, academic, or occupational functioning.
- Behaviors do not occur exclusively during the course of a psychotic episode or mood disorder.
- Criteria are not met for conduct disorder, and, if age 18 years or older, criteria are not met for antisocial personality disorder.
Destruction of property:
- Bullies, threatens, or intimidates others.
- Often initiates physical fights.
- Has used a weapon that can cause physical harm.
- Physically cruel to people.
- Physically cruel to animals.
- Has stolen from others through threat or aggression (ie “mugging”).
- Has forced someone into sexual activity.
Serious violations of rules:
- Has set a fire, with intention to cause damage.
- Deliberately destroyed another’s property (non-fire).
- Deceitfulness or theft.
- Has broken into a house, building, or car.
- Has lied to obtain goods, favors, or to avoid obligations.
- Has stolen items, not through aggressive confrontation (ie, burglary, shoplifting).
- At younger than 13 years of age, stays out at night, despite parental prohibition.
- Has run away overnight at least twice, or at least once, for a lengthy period of time.
- Record of truancy, beginning before age 13 years.
- Have you had any run-ins with the police? If yes, what were the circumstances?
- Have you been in physical fights? If yes, what were the circumstances? How many?
- Have you been suspended or expelled from school? If yes, what were the circumstances?
- Have you ever run away from home? Overnight? How many times?
- Do you smoke, drink alcohol, or use other drugs? If yes, what is the frequency and duration of your use? Which drugs?
- Are you sexually active?
The patient’s clinical situation can be determined by constructing a timeline that includes: symptom onset, variation in symptoms, and exacerbations in condition all in relation to occurrences of major stressors or changes in the social environment. The relationship between behavior changes and pertinent events may point to instigating factors and guide treatment. Addressing stressors that preceded the problem behavior may dramatically help the situation. For example, uncharacteristic aggression that occurs only just before taking math tests could suggest that a learning disability is the primary issue. Furthermore, determining the age of onset is important prognostically; conduct disorder with symptoms before age 10 years is specified as the “childhood-onset type,” which suggests a different clinical trajectory.2
A complete biopsychosocial evaluation should include a reckoning of both the strengths and weaknesses of the child and family18 to prioritize realistic treatment objectives while reinforcing what is already working well. This part of the assessment may entail screening for intellectual disability, and language and learning disorders. Children with a history of academic difficulty, developmental aberrations, or brain trauma, may benefit from a more detailed psychological evaluation. The social history should focus on items that can lead to, complicate, or exacerbate disruptive behavior. Family information can include the child’s level of supervision, adults involved in care, family finances, discord or stress in the home, and presence of abuse or physical discipline. Community variables include: type of peers; gang affiliation; legal issues; condition at the child’s school; presence of educational resources; protective services or foster placement; community violence; participation in prosocial activities; and religious/cultural involvement. Biologically, the medical examination involves a routine physical exam, review of systems, and possibly laboratory screening if medical illness, such as lead toxicity, is suspected.
Risk Factors and Etiology
Important psychological risk factors include impulsivity, disordered attachment with caregivers, egocentricity, irritability, inconsolability, and impaired social responsiveness. Prenatal maternal smoking, malnutrition, use of intoxicating substances, and birth complications have also been associated with these disorders.16 Low intellectual functioning has been considered a risk factor, but this finding has not been consistently replicated. However, reading problems do predict disruptive behavior disorders, and a high verbal IQ is protective. Comorbid psychiatric conditions, particularly attention-deficit/hyperactivity disorder (ADHD), can also be considered risk factors, since they occur in more than half of the cases.16 Comorbid illness and learning disorders pose less of a risk when addressed appropriately.16
A single-parent home, family antisocial behavior, parental substance abuse, parent psychiatric illness, marital conflict, abuse, and neglect all predict disruptive behavior disorders.16 The parenting style employed in the home can also be a risk factor. This can be evaluated by assessing the degree of parental involvement, child monitoring, and the presence of harsh or inconsistent discipline. Physical discipline has been linked to the development of childhood aggression.16
Both CD and ODD are more common in low socioeconomic status communities; more than any other mental illness, disruptive behavior disorders are more related to disadvantaged neighborhoods.16 A child’s peer group can also indicate a predisposition to ODD. A deviant peer group can promote the development from ODD to CD, while a positive peer group can “buffer” the effect of most other risk factors, even parental maltreatment. A child with ODD or CD will characteristically react antisocially in peer relationships, and will respond aggressively to rejection. Furthermore, organized and supervised activities (athletics, scouts, church groups) tend to protect against the negative influence of peers.19
The etiology of the disruptive behavior disorders is thought to be multifactorial, as the behavioral, psychological, and social factors can interact with biological vulnerabilities.19 A predisposition can come from both genetics and the fetal environment.19 Twin studies have demonstrated a strong genetic component to the etiology of ODD and CD,20 with a family history of ODD, CD and antisocial personality disorder common findings in patients with disruptive behavior.
Physiologic idiosyncrasies have also been identified, with decreased baseline autonomic reactivity (pulse, skin conductance) hypothesized to drive the increased sensation seeking behavior.16 Abnormalities in brain structure and function have been implicated in aggression, impulsivity, and antisocial behavior, specifically the orbitofrontal lobe, temporal lobe and the amygdala. Decreased serotonin turnover in the central nervous system, as evidenced by low levels of metabolites and higher blood levels, has also been associated with aggression and violence in certain populations.16
Comorbidities of Disruptive Behavior Disorders
There are various other serious mental health issues to consider when evaluating a child for ODD or CD. Children with disruptive behavior disorder are four times as likely to be diagnosed with substance abuse or dependence.21 Intoxication can lead to disruptive behavior, and a drug-using lifestyle may promote antisocial acts because of peer influence and the drive to procure more drugs. Clinicians can screen for substance abuse using the CRAFFT questions22 listed in Sidebar 6 (see page 510). Additionally, individuals with ODD have more social maladjustment, family dysfunction, and psychiatric comorbidity than children with other psychiatric conditions.23 Children with CD are at high risk for comorbid psychiatric illness and are frequently involved in multiple systems of care.24 They have increased rates of accidents, health problems, substance abuse, promiscuity, sexually transmitted diseases, early pregnancy,24 as well as aggression and violence.25 This population also uses 10 times the amount of public services (welfare, residential treatment, juvenile justice, health care, and mental health services) than do other populations.26
Have you ever ridden in a CAR driven by someone (including yourself ) who was under the influence of alcohol or drugs?R:
Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?A:
Do you ever use alcohol/drugs while you are by yourself (ALONE)?F:
Do you ever FORGET things you did while using alcohol or drugs?F:
Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?T:
Have you ever gotten into TROUBLE while you were using alcohol or drugs?
ODD vs. ADHD
Disruptive behavior disorders frequently occur along with ADHD. About half of the children with ODD or CD have ADHD, and about half of children with ADHD have disruptive behavior disorders.27 ADHD is characterized by symptoms of inattention, impulsivity, and hyperactivity, all of which can promote or be construed as disruptive behavior. For example, an inattentive child with ADHD may appear stubborn or oppositional due to their distractibility. Impulsive or hyperactive behaviors may be seen as defiant if they do not abate despite repeated cues from a teacher. ADHD can fuel antisocial acts when the characteristic impulsivity overpowers inhibitions to shoplift or act out aggressively, making conduct disorder behaviors more common.
However, ODD and CD are distinct entities from ADHD,11 and treatment planning requires that a distinction be made between the disruptive behavior disorders, ADHD, and a combination of the two conditions. For example, ODD with comorbid ADHD may improve with medication, while ODD may not. Use of ADHD rating scales, such as the Vanderbilt ADHD Rating Scale,28 collected from multiple sources can help make this distinction. If there is consensus that both oppositional and ADHD symptoms occur, there is likely to be this comorbidity.
Also, the presence of irritable symptoms, such as being spiteful or vindictive, is part of ODD and not ADHD. Children with both ADHD and a disruptive behavior disorder have worse outcomes and functioning compared with disruptive behavior disorders alone. They tend to have more aggressive behavior, more persistent behavior problems, more rejection from peers, and greater academic struggles.18
ODD and Mood Disorders
Mood disorders are also more common for individuals with disruptive behavior disorders, particularly for girls. Children with ODD are two times as likely to have major depressive disorder or bipolar disorder,23 while children with CD are three times as likely to develop an emotional condition.29 Depressed individuals may present with less motivation, social withdrawal, and decreased concentration, all of which could be seen as oppositional in certain settings. Additionally, depressed mood, a chief symptom of ODD, is commonly exhibited as irritability in the pediatric population.
During a manic episode, bipolar patients will have uncharacteristic increased impulsivity and goal-directed behavior that is often disruptive and can go against societal norms. Therefore, diagnoses of ODD and CD should be made cautiously in individuals with mood disorders.
A key distinguishing factor is the episodic nature of symptoms in mood disorders. A diagnosis of ODD and CD should only be made if the disruptive symptoms occur outside of a disordered mood episode. Prognostically, depression along with either CD or ODD increases the risk of suicide and substance abuse substantially.11
ODD, Anxiety Disorders, and Trauma
The relationship between disruptive behavior disorders and anxiety is complex. Adolescent anxiety disorders may reduce the risk of CD, but the presence of CD in an adolescent can increase the risk of a later anxiety disorder.11 Although social withdrawal and social anxiety can appear similar, as both can lead to an inhibited, shy appearance, they have contrasting effects on the development of delinquency. Inhibition from anxiety can be protective while social withdrawal is a risk factor for delinquency.11
New onset disruptive and irritable behavior also can be a clue that a child has been traumatized and possibly suffers from an acute or posttraumatic stress disorder. Screening for recent stresses as well as for nightmares, intrusive memories or images, hypervigilance, and avoidance can provide more clues.
Attachment disorders can also present with symptoms that can mimic ODD; disinhibited or dysregulated interactions with caregivers are characteristics of both.
Course of Illness
Approximately one-third of children with ODD will develop CD. Of those children diagnosed with CD, 40% will develop serious and chronic antisocial personality disorder as an adult. The progression to a more severe disorder is more likely when there is comorbid ADHD.11 Cases of CD routinely have concurrent and past ODD symptoms.1 Both disruptive behavior disorders are generally persistent over time.11 Factors associated with a more guarded prognosis include: earlier age of onset; presence of aggression; greater variety of symptoms; absence of a clear provoking stressor or peer influence; comorbid illness; and a disturbed environment. Adolescents with CD have a risk of future arrests, teen pregnancy, homicides, substance use, school dropout, illness, injuries and mortality.24
The efficacy of a treatment plan for a child with ODD or CD depends upon a thorough assessment of environmental stressors, modifiable risk factors, and comorbid conditions. Disruptive behavior may be a symptom of a greater problem in the family, school, or community. It also may be a sign that a child is suffering from a learning disorder or another psychiatric illness. Regardless of how daunting a child’s struggles are, emphasizing the child’s and family’s strengths can empower the patient and improve overall functioning.
Recognition and treatment of ODD and CD can dramatically benefit patients and society, because of the high cost and burden related to these conditions. Appropriate treatment for these children often involves a team of professionals, with the primary care provider playing a pivotal role in care coordination.
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- Sternberg CR, Campos JJ, Emde RN. The facial expression of anger in seven-month-old infants. Child Dev. 1983;54(1):178–184.
- Buss KA, Kiel EJ. Comparison of sadness, anger and fear facial expression when toddlers look at their mothers. Child Dev. 2004; 75(6):1761–1773. doi:10.1111/j.1467-8624.2004.00815.x [CrossRef]
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- Ridgeway D, Waters E, Kuczaj SA. Acquisition of emotion-descriptive language: receptive and productive vocabulary norms for ages 18 months to 6 years. Dev Psychol. 1985;21:901–908. doi:10.1037/0012-16126.96.36.1991 [CrossRef]
- Laursen B, Coy KC, Collins WA. Reconsidering changes in parent-child conflict across adolescence: a meta-analysis. Child Dev. 1998;69:817–832.
- Bongers IL, Koot HM, Van der Ende J, Verhulst FC. Developmental trajectories of externalizing behaviors in childhood and adolescence. Child Dev. 2004;75:1523–1537. doi:10.1111/j.1467-8624.2004.00755.x [CrossRef]
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- Greydanus DE, Pratt HD, Patel DR, Sloane MA. The rebellious adolescent. Evaluation and management of oppositional and conduct disorders. Pediatr Clin North Am. 1997;44(6):1457–1485. doi:10.1016/S0031-3955(05)70569-1 [CrossRef]
- Loeber R, Burke JD, Lahey BB, Winters A, Zera M. Oppositional defiant and conduct disorder: a review of the past 10 years, part I. J Am Acad Child Adolesc Psychiatry. 2000;39(12):1468–1484. doi:10.1097/00004583-200012000-00007 [CrossRef]
- Cohen P, Cohen J, Kasen S, et al. An epidemiological study of disorders in late childhood and adolescence—I. Age- and gender-specific prevalence. J Child Psychol Psychiatry. 1993;34(6):851–867. doi:10.1111/j.1469-7610.1993.tb01094.x [CrossRef]
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- Steiner H, Remsing L. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(1):126–141. doi:10.1097/01.chi.0000246060.62706.af [CrossRef]
- Matthys W, Lochman JE. Oppositional Defiant Disorder and Conduct Disorder in Childhood. West Sussex, UK: John Wiley & Sons Ltd.; 2010:80–87.
- Eaves L, Rutter M, Silberg JL, Shillady L, Maes H, Pickles A. Genetic and environmental causes of covariation in interview assessments of disruptive behavior in child and adolescent twins. Behav Genet. 2000;30(4):321–334. doi:10.1023/A:1026553518272 [CrossRef]
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