CHAPTER 21

The term disruptive behavior disorder describes “socially disruptive behavior that is generally more disturbing to others than to the person initiating the behavior.”1 Disruptive and oppositional behaviors occur on a continuum, with normal toddler resistance and tantrums at one end and more severe, maladaptive behaviors warranting a medical diagnosis at the other end.² While it is very important for primary pediatric health care professionals to screen for and address any challenges related to disruptive behaviors, the focus of this chapter will primarily be on those behaviors significant enough to constitute a medical diagnosis.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),³ disruptive behavior disorders are described in the chapter titled, “Disruptive, Impulse-Control, and Conduct Disorders.” The diagnoses described include oppositional defiant disorder (ODD); conduct disorder (CD); intermittent explosive disorder; other specified disruptive, impulse-control and conduct disorder; unspecified disruptive, impulse-control and conduct disorder; pyromania; and kleptomania. This categorization is new for DSM-5, as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)⁴ categorized ODD and CD in a chapter separately from intermittent explosive disorder. While all 3 of these disorders involve problems in both behavioral and emotional regulation, the criteria for CD focus mainly on poorly controlled behaviors, the criteria for intermittent explosive disorder focus mainly on poorly controlled emotions, and the criteria for ODD are more evenly distributed between behavioral and emotional symptoms.³ The challenges in behavioral and emotional regulation present in all 3 of these conditions warrant inclusion when discussing disruptive behavior disorders.

This chapter focuses on ODD, CD, and intermittent explosive disorder, as they are more common in children and adolescents, compared to pyromania (which describes multiple episodes of deliberate and purposeful fire setting) and kleptomania (which describes recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value).³ Although attention-deficit/hyperactivity disorder (ADHD) may be considered a disruptive behavior disorder, it is discussed in detail in Chapter 18, ADHD.

Oppositional Defiant Disorder

The DSM-5 states that a child who meets criteria for a diagnosis of ODD must have “a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months.”3 In addition, the child must display 4 or more irritable, defiant, and/or vindictive behaviors. The child’s age and developmental level must be taken into consideration, and the disturbance in behavior must cause clinically significant impairment in academic, social, or occupational functioning. A child is precluded from being diagnosed with ODD if the behaviors occur exclusively during the course of substance use, a mood or psychotic disorder, or if the child also meets criteria for disruptive mood dysregulation disorder.³

Conduct Disorder

The DSM-5 describes the diagnosis of CD as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.”³ Children with CD must have met at least 3 criteria in the past 12 months, with at least one criterion present in the past 6 months, from any of the following categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. The behaviors must result in clinically significant impairment in academic, social, or occupational functioning, and criteria cannot be met for antisocial personality disorder.³

In the DSM-5, the diagnosis of CD is coded based on age at onset. An individual with “CD, childhood-onset type” is described as having the presence of at least one criterion characteristic of CD prior to 10 years of age. An individual with “CD, adolescent-onset type” is described as having the absence of any criterion of CD prior to 10 years of age. An individual with “CD, unspecified onset” has an unknown age of onset.³

Intermittent Explosive Disorder

The DSM-5 describes intermittent explosive disorder as “recurrent behavioral outbursts representing a failure to control aggressive impulses.”³ This can manifest as either verbal aggression or physical aggression occurring twice weekly, on average, for a period of 3 months. To meet criteria for the diagnosis, there must be 3 behavioral outbursts involving damage, destruction of property, and/or physical assault within a 12-month period. An individual with intermittent explosive disorder must have a chronological age (or equivalent developmental level) of at least 6 years. The recurrent outbursts are not premeditated, are grossly out of proportion to any trigger, are associated with significant impairment in functioning, and are not better explained by another mental health or medical disorder.³

Other Specified Disruptive, Impulse-Control, and Conduct Disorder and Unspecified Disruptive, Impulse-Control, and Conduct Disorder

The diagnosis of other specified disruptive, impulse-control, and conduct disorder applies to presentations in which symptoms characteristic of disruptive, impulse-control, and conduct disorder cause significant impairment but do not meet full criteria for any of the diagnoses in this category, and the clinician chooses to indicate the specific reason the diagnostic criteria are met.3 The diagnosis of unspecified disruptive, impulse- control, and conduct disorder also applies to presentations in which criteria are not fully met, but in this case the clinician chooses not to indicate the reason for which the diagnostic criteria were met.³ Much of the information applicable for ODD, intermittent explosive disorder, or CD can be useful in caring for a child who is diagnosed with either the other specified or unspecified categorizations. Therefore, this chapter primarily focuses on disruptive behavior disorders categorized by ODD, CD, and intermittent explosive disorder.

Epidemiology of Disruptive Behavior Disorders

It may not be possible to determine the prevalence of disruptive behaviors because many do not cause sufficient impairment to warrant a medical diagnosis. However, noncompliant and oppositional behaviors comprise some of the most common concerns among parents and are the most frequently reported behavior problems seen by primary care pediatricians.⁵ Overall, about 5% of children between the ages of 6 and 18 years meet DSM-IV criteria for either ODD or CD at any given time, while the combined prevalence of these disorders is approximately 7% according to DSM-5.^3,6 The lifetime prevalence rates of each are slightly higher, ranging from 9% to 13% for ODD and 3% to 16% for CD.^7,8 In a US population survey of adolescents, the lifetime prevalence rate of DSM-IV intermittent explosive disorder was reported to be 7.8%.⁹ The diagnosis of ODD, intermittent explosive disorder, or CD is more common in boys, although oppositional behavior per se may be equally common between both genders.¹⁰

Assessment of Children With Disruptive Behaviors

Primary pediatric health care professionals care for children with varying levels of disruptive behaviors. Therefore, it is important for clinicians to evaluate the child’s behaviors and the parents’ responses to determine if the parent-child interaction may be inadvertently perpetuating the child’s negative behaviors. Parents often place demands on their children, such as cleaning up their toys, and some of these demands may seem aversive to the child. The child may respond to this aversive event by displaying a coercive response, such as yelling or having a tantrum. Parents may respond to the coercive response by removing the original aversive demand, and this negatively reinforces the child’s noncompliant behavior. The child is likely to continue to yell or have a tantrum when future demands are placed because the child has learned that he will get his own way by doing so. Another response the parent could make to the yelling or tantrum is to try to comfort the child and explain the reason for the request. This parental attention positively reinforces the child’s noncompliant behavior, and thus the child may continue to manifest these coercive responses because he has learned that he will get attention for them. Alternatively, the parent may respond to the child’s coercive response by presenting another aversive event, such as yelling or loudly repeating the request. The child may ultimately respond to the parent’s demand, but the child learns to respond only to the parent’s more aversive demands, such as yelling or stating commands loudly. If any of these maladaptive parent-child interactions continue over time, a persistent and worsening pattern of noncompliance and defiance may develop.11 When the primary pediatric health care professional recognizes that the parent-child interaction is heading in a negative direction, he or she can play a crucial role in providing guidance and offering effective techniques that the parent can use. A more effective parent response to a child’s protests may include a simple and single repetition of the request, followed by verbal acknowledgment that complying with the request may be difficult from the child’s perspective, and firm limit setting on worsening behavior (see Chapter 7, Basics of Child Behavior and Primary Care Pediatric Management of Common Behavioral Problems).

In addition to intervening when problem behaviors are described, the primary pediatric health care professional should evaluate the disruptive behaviors to determine if a medical diagnosis such as ODD, CD, or intermittent explosive disorder should be made. While specific antisocial acts occur in up to 80% of youths,¹² children who meet criteria for a diagnosis of ODD, CD, or intermittent explosive disorder display a persistent history of multiple problem behaviors.

Important Points to Consider When Taking the History

Although children may present to the primary pediatric health care professional with any number of disruptive behaviors, the most common referral symptoms for disruptive behavior disorders are fighting, stealing, lying, cruelty, fire-setting, substance abuse, and sexual misconduct.¹ When taking the history, it is important to obtain information from several sources, including the child, parents, and teachers. The primary pediatric health care professional should learn as much as possible about the parenting style, parent-child interactions, and the child’s strengths, as this information can be valuable for treatment planning and implementation of interventions.⁶ The child’s age and gender must be taken into account. At different ages, children display different types of disruptive behaviors, with property and status offenses more prevalent at older ages.¹⁰ Males are more likely to use physical attacks and females are more likely to use indirect, verbal, and relational violence.¹³

Important Questions to Ask in the History

In assessing a child with disruptive behaviors, it is helpful to use the criteria described in the DSM-5 for the diagnoses of ODD, CD, and intermittent explosive disorder to guide the history. For example, in a child who displays aggression, it is important to determine what type of aggression the child shows, such as verbal, physical, etc, and to whom the aggression is directed, such as parents, other children, animals, etc. The clinician should ask how long these behaviors have occurred and if there were any significant changes in the child’s life prior to the onset of the disruptive behaviors. It is also important to ask parents, teachers, and other adult caregivers how disruptive these behaviors are. Individuals with CD are often unable to appreciate other’s welfare and have little or no remorse about harming others.14 Therefore, they may not be able to understand and report how their behaviors are negatively impacting others.

Primary pediatric health care professionals may find the following brief questions helpful in determining whether criteria for the diagnosis of ODD are likely to be met. Research has shown that a positive response for all 3 is 91% specific for meeting DSM-IV criteria on full interview, and a negative response is 94% sensitive for ruling out ODD.^15,16

1.Has your child, in the past 3 months, been spiteful or vindictive, or blamed others for his or her own mistakes? (Any “yes” is a positive response.)

2.How often is your child touchy or easily annoyed, and how often has your child lost his or her temper, argued with adults, or defied or refused adults’ requests? (Greater than or equal to 2 times weekly is a positive response.)

3.How often has your child been angry and resentful or deliberately annoying to others? (Greater than or equal to 4 times weekly is a positive response.)

It is important for primary pediatric health care professionals to be sure to perform a thorough assessment of the child’s psychosocial functioning to assess for comorbidities or alternative diagnoses. Areas to assess include attention, level of activity and impulsiveness, social interactions, and communication skills. Other factors to consider when evaluating a child with disruptive behaviors include anxiety, mood disorders, cognitive and/or learning problems, substance abuse, and history of physical or sexual abuse.

Supplements to Clinical Interview

Standardized questionnaires can aid the primary pediatric health care professional in evaluating disruptive behavior. Two commonly used rating scales for ADHD are the Conners Rating Scales–Revised and the Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales. These include information about oppositional and disruptive behaviors, and thus can be useful.¹⁷ In addition, more broadly based behavioral rating scales, such as the Eyberg Child Behavior Inventory¹⁸ (a parent rating scale), and the Child Behavior Checklist¹⁹ (a child rating scale), can serve as an adjunct to taking a clinical history. Finally, the Modified Overt Aggression Scale²⁰ is another useful supplement to the clinical interview in evaluating disruptive behavior.

The diagnoses of ODD, CD, and intermittent explosive disorder are made clinically. Outside of research purposes or a medical history and physical examination indicating abnormal neurological status, neuroimaging is not recommended. No laboratory work is routinely performed. If active substance abuse is suspected, a urine drug screen should be considered. In addition, if sexual abuse or unprotected sexual activity is present, testing for sexually transmitted infections may be warranted.⁶

Risk Factors for the Development of Disruptive Behavior Disorders

The many known risk factors for the development of disruptive behavior disorders can be classified into the following categories: biological, individual, family, and social/school (Box 21.1).⁶ Rather than 1 risk factor acting in isolation, it seems that the accumulation of risk factors may be critical to the development of disruptive behavior disorders.²¹ Disruptive behavior disorders most likely have a multifactorial etiology, including some degree of genetic vulnerability and environmental and/or social contributors.²² Overall, some of the most commonly cited risk factors include low socioeconomic status, history of rejection or abuse, and parental challenges, including antisocial behaviors, substance abuse, and dysfunctional parenting.

Box 21.1. Risk Factors for the Development of Disruptive Behavior Disorders

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