Disruptive Behavior Disorders
James C. Harris
Disruptive behavior disorder is the most recent designation for socially disruptive behavior that is generally more disturbing to others than to the person initiating the behavior. The impairment or disability is in the effects of the behavior on others rather than primarily in distress experienced by the child. This chapter discusses conduct disorder and oppositional defiant disorder. Attention deficit hyperactivity disorder is often associated with disrupted behavior and is discussed in Chapter 113. The co-occurrence of other disorders frequently leads to multiple diagnoses for a disruptive child in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), system. It leads to the use of mixed diagnostic categories in The International Classification of Diseases, Tenth Edition (ICD-10), such as hyperkinetic conduct disorder and mixed disorder of conduct and emotions. In ICD-10, oppositional defiant disorder is categorized under conduct disorder. The categories conduct disorder confined to the family context and depressive conduct disorder are also included in ICD-10. The general terms externalizing symptoms, such as overactivity and aggression, and internalizing symptoms, such as anxiety and depression, have been introduced from factor analytic studies and may be derived from parent rating scales, such as the Achenbach Child Behavior Checklist.
CONDUCT DISORDERS
In both community and university clinics, the broad categories of conduct and aggressive problem behavior or of emotional symptoms constitute the primary reasons for referral for treatment. The distinction between emotional and conduct disorders is well validated. The conduct symptoms are externalizing symptoms and are of more concern to the parent than to the child. Furthermore, these are often chronic disorders that may, in a small but significant number of cases, be complicated in adolescence by substance abuse, delinquency, and alcoholism or antisocial personality in adulthood. These future risks involve the physician in the effort to intervene and work with other nonmedical professionals to help prevent the frequently poor psychosocial outcome of these conditions.
Disruptive behavior and delinquency have been a particular focus of attention since the initiation of the juvenile court system at the beginning of this century, when psychiatrists, psychologists, and social workers were drawn together to consult in the legal assessment of behaviorally disordered children and adolescents. This early legal concern with the prevention of antisocial behavior was a major factor in the initiation of the child guidance movement in the United States. Following these early efforts in intervention, Hewitt and Jenkins (1946) carried out the first systematic description of aggressive conduct disorder. Their early work suggested the usefulness of distinguishing socialized from unsocialized conduct disorders in children with disruptive behavior. Other investigators have suggested a useful distinction between aggressive and nonaggressive forms and between aggressive and delinquent or antisocial behavior.
In evaluating disruptive behavior, the child’s age, gender, and life circumstances must be taken into account. The frequency and persistence of the problems are reviewed, as are specific or generalized situations in which they occur. Symptoms presenting in multiple settings (home, school, community) have a poorer prognosis. An early intervention for conduct problems confined to the home (family context) may prevent subsequent difficulties in other settings.
Conduct disorder is characterized by a repetitive and persistent behavior that violates the basic rights of others or major age-appropriate social norms or rules. As shown in Box 102.1, conduct-disordered behaviors are divided into four main groupings: (a) aggressive threats or behaviors that result in physical harm to people or animals (criteria A1 through A7), (b) nonaggressive behavior that results in property loss or damage (criteria A8 and A9), (c) deceitful behavior or theft (criteria A10 through A12), and (d) serious violation of parental or school rules, such as runaway behavior and truancy (criteria A13 through A15). To establish the diagnosis, at least three of these criteria must be present in the past 12 months, with at least one criterion present in the past 6 months. Moreover, to establish the diagnosis, the behavior leads to clinically significant impairment in social, academic, or occupational functioning and is present in several settings.
Childhood-onset and adolescent-onset subtypes are designated, differing in regard to the type of presenting conduct problems, gender ratio, developmental course, and prognosis. As indicated in Box 102.1, these subtypes are rated as mild, moderate, or severe. In the childhood-onset type, at least one criterion presents before 10 years of age. Affected children are more often boys than girls, frequently are aggressive toward others, commonly have disturbed peer relationships, and may have been diagnosed with oppositional-defiant disorder at an earlier age.
BOX 102.1 Diagnostic Criteria for Conduct Disorder
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., bat, brick, broken bottle, knife, gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
7. Has forced someone into sexual activity.
Destruction of property
8. Has deliberately engaged in fire setting with the intention of causing serious damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking or entering; forgery).
Serious violations of rules
13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
14. 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).
15. Is often truant from school, beginning before age 13 years.
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
If the individual is age 18 years or older, criteria are not met for antisocial personality disorder (see Diagnostic and Statistical Manual of Mental Disorders, 4th ed.).
Specify type based on age at onset:
Childhood-onset type: Onset of at least one criterion characteristic of conduct disorder before age 10 years.
Adolescent-onset type: Absence of any criteria characteristic of conduct disorder before age 10 years.
Specify severity:
Mild: Few, if any, conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others.
Moderate: Number of conduct problems and effect on others intermediate between mild and severe.
Severe: Many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others.
Footnote
Reprinted with permission from
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.
Individuals with a childhood onset of behavior problems have a greater likelihood for their disturbed conduct to persist and to have antisocial personality disorder as adults than if the onset occurred during adolescence. Those with the adolescent-onset type are more likely to have adequate peer relationships; however, conduct problems in consort with others are frequent. Adult outcome is better in regard to antisocial behavior, and the male-to-female ratio is lower than for the childhood-onset type.
The solitary aggressive or unsocialized form of conduct disorder generally is present in multiple settings and is associated with impairment in interpersonal relationships with other children and lack of close friendships. A lack of integration into a peer group is a key feature, as evidenced by isolation or peer rejection, with unpopularity and lack of empathetic relationships with children of the same age group. Relationships with adults are marked by hostility, argument, and resentment. Close, confiding relationships are absent. Problems range from bullying and excessive fighting to frank destructiveness of property or violent assault. Ordinarily, the problems are pervasive and occur in all settings, but occur predominantly at school or outside the home, in the community.
The group-type or socialized conduct disorder applies to conduct disorders occurring in children who are well integrated into their peer group. These individuals participate in antisocial behavior along with others. Relationships tend to be poor with some adults, particularly those in authority, but they may be good with other adults. Stealing, truancy from school, running away from home, and criminal offenses usually occur with a group of companions.
Some children’s behavior does not fit into these categories, but their behavior is disturbed severely enough to require treatment. Conduct disorder symptoms may occur in combination with emotional symptoms, such as anxiety and depression. If the diagnostic criteria for depression also are met, both diagnoses are made in DSM-IV-TR and both are designated in ICD-10 (i.e., depressive conduct disorder). The depressive symptoms must be addressed initially in treatment and may be more responsive to intervention.
Epidemiology
Boys are referred more often than girls, and school-aged boys tend to be unsocialized aggressive, whereas older adolescent boys more often present with a socialized conduct problem. Frequently, an association exists with adverse psychosocial environment, difficult family relations, and poor school performance. The onset may be as early as the preschool years, particularly for the solitary aggression occurring outside a social group, with temperamental traits that are associated with aggressive behavior identified in infancy (i.e., the infant with a “difficult temperament”). Inflexibility reported by the mothers of preschoolers, negative parent–child interactions, and high family stress are strongly associated with behavioral adjustment. Boys identified in the first grade with behavioral traits of aggression and social withdrawal were found on follow-up had increased likelihood of being delinquents and substance abusers in adolescence. Associations with alcoholism, antisocial disorders, and somatization disorders in women occur in adult life. Antisocial personalities have been identified in fathers of affected boys. Affected girls reported more somatic complaints without diagnostic confirmation and more often injured themselves than did boys. The postpubertal onset of solitary aggression is more common in girls. Early onset has been associated with attention deficit hyperactivity disorder, articulation problems and, in some studies, perinatal hypoxia.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
