Disruptive Behavior Disorders in Children and Adolescents (Comprehensive Concise)

Disruptive Behavior Disorders

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)

• Classified under disruptive, impulse control, and conduct disorders.
• Characterized by problems with self-control of emotions or behavior, leading to conflict with societal norms (CD) or authority figures (ODD).
• ODD diagnostic criteria include symptoms like angry/irritable mood, argumentative/defiant behavior, and vindictiveness.
• CD diagnostic criteria include aggression, destruction of property, deceitfulness, and rule violations.
• Symptoms must be outside normal limits for age, gender, and culture and cause significant distress or impairment.

Definition of ODD

• Symptoms are categorized into three main clusters:
  • Angry/Irritable Mood: frequent temper outbursts and being easily annoyed.
  • Argumentative/Defiant Behavior: Stubbornness and unwillingness to compromise with adults or peers.
  • Vindictiveness: Spiteful or vindictive behavior occurring at least twice in the past 6 months.
• Diagnosis requires exhibiting four of eight possible symptoms over the past 6 months, outside of interactions with siblings.
• For children under 5, behaviors should occur most days of the week.
• For those over 5, behaviors should occur at least once a week.

History of ODD

• Emerged as a distinct diagnosis in DSM-III, evolving from the concept of childhood oppositional personality.
• DSM-5-TR groups symptoms into angry/irritable mood, argumentative/defiant behavior, and vindictiveness categories.
• The angry/irritable dimension is associated with emotional disorders, the argumentative/defiant dimension with ADHD, and vindictive symptoms with CU traits.
• Historically controversial due to the commonality of oppositional behaviors in normally developing children, and frequent comorbidity with other disorders.

Comparative Nosology

• ICD-11 classifies ODD separately, similar to DSM-5-TR, defining it as a persistent pattern of defiant, disobedient, provocative, or spiteful behavior.
• ICD-11 uses specifiers to designate the presence or absence of chronic irritability-anger and limited prosocial emotions (LPE).

Epidemiology

• DSM-5-TR cites an average overall prevalence estimate of 3.3\% for childhood ODD.
• More prevalent in males than females (1.6:1) in middle childhood.
• More prevalent among children from families of low socioeconomic status.

Etiology

• ODD is a transactional disorder involving child characteristics and psychosocial context problems.
• Causal theories often involve gene-by-environment interactions and reciprocal interactions between child and caregivers.
• A "difficult temperament" characterized by emotional hyper-reactivity, poor behavioral control, and low adaptability is a risk factor.

Psychological Factors

• Harsh, coercive, and inconsistent parenting is consistently linked with ODD.
• Coercion theory explains how oppositional behavior develops through negative reinforcement in parent-child interactions.

Sociologic Factors

• Ecologic variables such as parental depression, family discord, stress, and poverty increase the risk of ODD through their effects on parental discipline.

Diagnosis and Clinical Features

• Diagnosis is not limited to a particular age group, but most commonly emerges between ages 4 and 8.
• Impairment depends on the number of settings in which behaviors are present.
• Clinical evaluation should include multiple reporters (parents and teachers) and a comparison of the child’s behavior to normative standards.

Pathology and Laboratory Examination

• No laboratory tests are available; assessments are based on clinical examination and history.
• Validated rating scales document symptom severity.

Differential Diagnosis

• Children with ODD often have comorbid diagnoses of ADHD and CD.
• ODD is added to ADHD when the child shows active defiance and noncompliance not solely attributed to impulsive acts.
• DMDD shares symptoms with ODD, but differs in the frequency, intensity, and pervasiveness of negative mood between temper outbursts.

Comorbid Conditions

• The most common comorbid diagnosis with ODD is ADHD (60% to 80% of children with ODD).
• Approximately 15% to 20% of clinically referred children with ODD have comorbid depression, bipolar disorder, anxiety disorders, or language disorders.

Course and Prognosis

• The combination of ADHD and ODD increases risk for progression to CD.
• Approximately 30% of children with ODD will eventually develop CD.
• Children with the angry/irritable mood symptoms of ODD are at risk for developing anxiety and mood disorders later in life.

Treatment

• Treatment of ODD is critical to prevent the later development of CD, ASPD, and anxiety and depressive disorders.
• Parent management training (PMT) is most effective, based on social learning principles.
• PMT programs teach parents how to develop structured contingency management programs and use effective discipline strategies.

Conduct Disorder (CD) Definition

• CD involves a repetitive and persistent pattern of behavior violating the rights of others or major age-appropriate societal norms or rules.
• At least 3 of 15 criterion behaviors must be present during the past 12 months

Subtypes and Specifiers of Conduct Disorder

• Subtypes are based on the age of onset of symptoms and the presence of LPE.
• Childhood-onset type: At least one CD symptom prior to age 10 years. More aggressive and likely to continue problem behaviors into adulthood.
• Adolescent-onset type: All symptoms begin after 10 years of age. Less likely to show aggressive and violent behavior into adulthood.
• With limited prosocial emotions (LPE): Presence of significant and pervasive levels of CU traits, such as lack of remorse or guilt, callousness, unconcerned about performance, and shallow affect.

History

• CD was first recognized as a mental health disorder in the DSM-II in 1968.
• The DSM-III introduced subtyping individuals with CD according to whether or not they were (a) aggressive and (b) considered “socialized”

Comparative Nosology

• The ICD-11 description of conduct-dissocial disorder strongly resembles diagnostic criteria for CD in DSM-5-TR.
• The ICD-11 definition includes specifiers based on the age of onset (childhood or adolescence) and level of prosocial emotions (limited or typical).

Epidemiology

• The worldwide prevalence of CD is estimated to be 2% to 2.5%, with about 10% of individuals affected at some point during childhood or adolescence.
• Overall, boys show higher prevalence rates of CD than girls at approximately a 2:1 male-to-female ratio.

Etiology

• The development of CD typically results from a host of risk factors in both the child’s biologic and genetic background, as well as problems in their social environment.

Biologic Factors

• Heritable Factors: There is a genetic influence on CD.
• Physiologic Factors: CD in children with elevated CU traits is associated with reduced physiologic arousal to various emotional stimuli.
• Neuroendocrinologic Factors: Those with elevated CU traits tend to show blunted cortisol activity in response to a stressor.
• Neurotransmitter Factors:Associations between methylation of specific sties on the oxytocin receptor genes and lower levels of circulating oxytocin in children with elevated CU traits.
• Neuroanatomic Factors: In youth with CD reduced neural activity in the amygdala, anterior insula, and ACC. Reduced Cortical thickness in the ventromedial prefrontal/orbitofrontal cortex.
• Prenatal and Perinatal Factors: Maternal smoking, drinking, drug use, and stress during pregnancy are the most consistently documented prenatal risk factors for CD. Also birth complications and malnutrition.

Psychological Factors

• Cognitive Factors: Lower intelligence, particularly verbal intelligence, and executive functioning deficits, are some of the most frequently studied cognitive correlates of CD, particularly for childhood- onset CD.
• Family Factors: parental substance use and depression are also consistently linked to CD.
  • Low levels of positive parenting (i.e., infrequent use of positive reinforcement, low parental involvement, and low parental warmth and sensitivity) and high levels of negative parenting (i.e., poor monitoring and supervision of the child, inconsistent discipline, and use of coercive and harsh physical discipline).
    Childhood physical abuse, sexual abuse, and a history of neglect are associated with an increased risk for the development of a wide variety of mental health problems, including CD

Sociologic Factors

• Neighborhood and Cultural Factors: Living in neighborhoods where the child might be exposed to high rates of community violence. poverty, low socioeconomic class, unemployment, poor housing, and overcrowded living conditions have all been linked to CD.
• Peer Factors: Children with CD are rejected by their peer group and are more likely to be excluded from activities with peers compared to typically developing children. Often the instigator of aggression, they are also more likely to be the victim of aggression from others.

Diagnosis and Clinical Features

• The assessment of CD involves 3 primary goals: determining the presence and severity of the primary symptoms of CD, including their pervasiveness and the degree of harm they cause others; determining the presence of key indicators of the distinct developmental pathways to CD (i.e., the age of onset of the first CD symptom and the presence of CU traits); and assessing common comorbidities and key risks and maintaining factors that should be the target of treatment.
• Information should be obtained from multiple informants, including the child, their parents, and their teacher.
  Clinical to screen for the presence of common comorbid psychiatric conditions such as ADHD, depression, bipolar disorder, substance use disorders, and learning disabilities (e.g., reading, speech, and language delays) that frequently accompany a diagnosis of CD.

Pathology and Laboratory Examination

• No laboratory tests are useful or required for making the diagnosis of CD.
  Early-onset sexual activity may lead to the possibility of early pregnancy. Due to the association with learning disabilities, psychoeducational testing to assess potential academic difficulties is also necessary.

Differential Diagnosis

• Isolated instances of conduct problem behaviors that do not cause substantial daily impairment need to be differentiated from a consistent pattern of rule-breaking and violations of the rights of others that may constitute a disorder.
  When diagnostic criteria are met for both ODD and CD, both diagnoses may be assigned.

Comorbid Conditions

• Children and adolescents meeting diagnostic criteria for CD often meet criteria for other psychiatric diagnoses. ADHD frequently co-occurs with CD, particularly childhood-onset CD.
  Substance use disorders and learning disorders are also common among individuals with CD.

Course and Prognosis

• Childhood-onset CD is typically preceded by ODD and ADHD in early childhood.
• Individuals who follow the adolescent-onset trajectory do not start showing significant behavior problems until they approach adolescence, at which point they start showing a range of problems involving symptoms of both ODD and CD.

Treatment

• Successful treatment of ADHD, such as with CNS stimulants has also been shown to reduce conduct problems in children with comorbid diagnoses of ADHD and either ODD or CD.
• PMT interventions are also effective for young children who have begun to show CD.
• Given that most children who develop childhood-onset CD show ADHD and ODD prior to developing CD, successful treatment of these conditions can be considered secondary prevention of CD.
  For older children and adolescents with CD, interventions that are multi- component and can be tailored to the unique needs of the youth appear most effective. Such interventions recognize that CD is often caused and maintained by multiple factors, and the causal processes may differ across youths with CD.
• Two treatment models Functional family therapy (FFT) and multisystemic therapy (MST) proven to be quite effective in treating adolescents with CD in randomized controlled trials.