Disruptive behaviour disorders are impaired patterns of behaviour, occurring in children and adolescents. The two types are conduct disorder and oppositional defiant disorder. In this article, epidemiology, etiology, sign and symptoms, diagnosis, and treatment of disruptive behaviour disorders will be discussed.
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Image: “Schreien Traurig Kinder Trauer Depression Schrei” by markzfilter. License: Public Domain


Definition of Disruptive Behavioral Disorders

Disruptive behavior disorders (DBD) are characterized by impaired patterns of behavior and problematic interactions, which impair social functioning and can negatively affect the child’s development. The impaired patterns of behavior include uncooperative, defiant, and hostile behaviors towards authority figures.

Classification of ODD

DSM-IV classifies disruptive disorders into 2 types :

  1. Oppositional defiant disorder (ODD)
  2. Conduct disorder (CD)

Oppositional Defiant Disorder (ODD)

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), defines oppositional defiant disorder (ODD), as a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness which is present for at least 6 months. 

It is a very common mental health condition diagnosed in childhood.

High yield: ODD patients do not show aggressive or violent behavior and they do not impinge on other people’s rights.

Epidemiology of ODD

Behavioral disruptive disorders are more often seen in males than females (3:1). They are predominantly diseases of children and adolescents.

ODD is prevalent in children and adolescents between 1–11%.  In younger children, before puberty, ODD is more common in boys than girls. But in school-aged children and adolescents the condition is equally common among boys and girls. It is commonly seen (50 %) in children affected with attention deficit hyperactivity disorder (ADHD).

Risk Factors and Etiology of ODD

There are no exact causes of ODD, but a combination of biological, psychological, and social risk factors are responsible for the development of the disorder.

Biological Factors: ODD is more common in children and adolescents if a parent has a history of disruptive behavior disorder, mood disorder, drinking or substance abuse. Other factors responsible are:

  • Any impairment in the part of the brain which hampers reasoning, judgment, and impulse control
  • Factors such as smoking during pregnancy, exposure to toxins and malnutrition during pregnancy have been associated with the development

Psychological Factors/ environmental factors:  these include a poor relationship with the patient’s parents, absent or neglectful parenting and difficulty in making social relationships.

Social Factors: these include poverty, abuse, chaotic environment, uninvolved parents, varying discipline and some family issues such as divorce or frequent moves.

Physical factors: children born of low birth weight or suffered neurological injury are thought to be at a greater risk of developing these disorders.

Symptoms of ODD

The disorder consists of recurrent patterns of:

  • Extreme negativity
  • Hostility
  • Defiance behavior

These symptoms are constant and lasts for at least 6 months. Most of the behavior is usually directed toward an authority figure such as teachers, principal, coach and parents. However, ODD is less severe than conduct disorder.

Symptoms associated with ODD include:

  • Many temper tantrums
  • Angry and annoyed easily
  • Too many arguments with adults
  • Non-compliant to rules
  • Annoys and upsets others
  • Blames others
  • Anger outbursts
  • Resentful and revenge seeking behavior

Diagnosis and DSM-5 Criteria of ODD

ODD disorder is diagnosed if at least four symptoms from the following categories are present for ≥ 6 months:

Angry/Irritable Mood

  • Repeatedly loses temper
  • Frequently touchy/ easily annoyed
  • Gets angry and offended

Argumentative/Defiant Behavior

  • Regularly argues with authority figures such as teachers, principal, coach and parents
  • Non-compliance to rules
  • Purposefully annoys others
  • Blames others

Vindictiveness

The spiteful attitude at least twice within the past 6 months

Tools like National Initiative for Children’s Healthcare Quality (NICHQ) Vanderbilt can evaluate children with suspected or diagnosed ADHD. It has questions that help in the identification of oppositional defiant disorder.

Other tools such as Swanson, Nolan, and Pelham Teacher and Parent Rating Scale, Teacher and Parent Rating Scale for children with ADHD helps to detect oppositional defiant disorder as well as other psychological concerns.

The Pediatric Symptom Checklist tool is not specific for oppositional defiant disorder, however, can screen cognitive, emotional, or behavioral problems, and can identify children who require additional investigation.

Differential Diagnosis of ODD

Conduct disorder: Compared to conduct disorder, the behavior of oppositional defiant disorder is less severe in nature and does not involve aggressive behavior towards people/animals or destruction of property, or theft, etc.

Attention deficit hyperactivity disorder (ADHD): ADHD is a comorbid condition which occurs in patients with oppositional defiant disorder.

Depressive and bipolar disorders: Such disorders involve negative affect and irritability.

Disruptive mood deregulation disorder: Chronic negative mood and temperamental outbursts, can occur both in oppositional defiant disorder and disruptive mood dysregulation disorder. But such symptoms are more severe with disruptive mood dysregulation disorder.

Intermittent explosive disorder: This disorder involves a lot of anger. But in this disorder, there is serious aggression toward others and this is not part of oppositional defiant disorder.

Treatment of ODD

If another comorbid condition like ADHD is present in children with oppositional defiant disorder (ODD) guanfacine or stimulants can be helpful in altering the behavior of child. Apart from this, parents and other family members should be trained to change the behavior of their children.

Attention should be focused on avoiding harsh punishments and positively interact with the child. Such training can help parents to change the behavior of their children. This is helpful in children of all ages who have this disorder. However, most important is to note that early intervention in the child’s initial stage of this disorder is most helpful.

Conduct Disorder (CD)

Which is also known as delinquency is a more serious disruptive disorder that entails a higher amount of cruelty as children and adolescents with the disease show aggression towards others and willfully destroy property, steal, or may lie.

It is thought that the disruptive disorders occur as a spectrum with CD being the most severe form of the disorders.

Epidemiology of CD

In the United States, prevalence rates ranges from 2–9 %. Conduct disorder is seen in 5 out of every 100 adolescents. There is a high degree of overlap with other disorders, CD, ODD, and ADHD.

Conduct disorder involves aggression in which social norms are often violated. The incidence increases as the child progresses to adolescence stage. It is important to note that 40 % of children diagnosed with conduct disorder will have antisocial personality disorder in adulthood. CD is more common in younger boys ranging from 6-9% of the school children in the united states.

Risk and Prognostic Factors of CD

Temperamental: It includes difficult, uncontrolled infant temperament and lower-than-average intelligence, and especially verbal IQ.

Environmental: Family-level risk factors such as parental rejection and neglect, unpredictable child-rearing practices, very strict discipline, physical/sexual abuse, no supervision, early institutional living, large family size, and parental criminality.

Community level risk factors: Friends rejection, association with a wrong group, and neighborhood, and exposure to violence.

Genetic and physiological: The risk is high in children with a biological or adoptive parent or a sibling with conduct disorder. It is more commonly seen in children of biological parents with:

  • Severe alcohol use disorderza
  • Depressive and bipolar disorders
  • Schizophrenia
  • Parents who have a history of ADHD or conduct disorder

Family history is responsible for the childhood-onset subtype of conduct disorder.

Symptoms of CD

Conduct disorder children are generally impulsive. They are hard to control, and not concerned about the feelings of other people.

Symptoms include:

  • Do not follow rules
  • Aggressive behavior toward people or animals
  • Absence from school
  • Heavy drinking
  • Heavy drug use
  • Destruction of property intentionally
  • Lying to get a favor
  • Running away from home
  • Physical fights

Such children make no effort to hide their aggressive behaviors. They cannot make real friends.

Diagnosis of CD

There is a recurrent behavior in which patients do not comply with the basic rights of others. To confirm a diagnosis, at least 3 behaviors should be present with one year and at least one should have occurred within the past 6 months.

Violent behavior: Bullies or threatens others, begins physical fight, carries a weapon, physically cruel to people and animals, commits robbery, forces someone into sexual activity.

Destruction behavior: Purposefully destroys property.

Theft and lying: Lies to others to get a favor, steals or enters someone else’s home.

Serious breaking of rules:

  • Stays out at night time despite parent’s restrictions.
  • Occurrence of running away from home for at least twice a month and absence from school

These symptoms occur before age 13.

Treatment of CD

Conduct disorder can be treated by a multimodal approach which includes family therapy, behavioral modification and pharmacotherapy. Family therapy is aimed at increasing communication skills and family interaction. Positive attitude and spending more time with children can help alter the patient’s behavior. Behavioral approach includes anger management and social improvement skills.

There is no medication for conduct disorders. Pharmacotherapy is directed at specific symptoms. Symptom-control medications that are generally used are:

  • Selective serotonin reuptake inhibitor (SSRIs)
  • Mood stabilizers
  • Antipsychotics

Review Questions

The correct answers can be found below the references.

1. A 15-year-old boy was brought to the clinic by his mother. His mother said that the boy was suspended from school for assaulting a teacher. Until now he had been suspended 6 times.  He was suspended for fighting, smoking and stealing money from other students’ bags. Which of the following is the most likely diagnosis?

  1. Conduct disorder
  2. ADHD
  3. Tourette’s disorder
  4. Oppositional defiant disorder
  5. Antisocial personality disorder

2. Which of the following is the best approach to treat conduct disorder?

  1. Family therapy
  2. Behavioral modification
  3. Pharmacotherapy
  4. All of the above

3. Which percentage of children diagnosed with conduct disorder will have an antisocial personality disorder in adulthood?

  1. 1 %
  2. 10 %
  3. 40 %
  4. 100 %
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