WISCONSIN UNITED
for MENTAL HEALTH

Disruptive disorders, such as oppositional defiant disorder and conduct disorder, are characterized by antisocial behavior. These behaviors are also frequently found in children who suffer from attention-deficit/hyper-activity disorder (also a disruptive disorders). Several psychosocial interventions can effectively reduce antisocial behavior in disruptive disorders.

Children who develop the more serious conduct disorders often show signs of these disorders at an earlier age. Although it is common for a very young children to snatch something they want from another child, this kind of behavior may herald a more generally aggressive behavior and be the first sign of an emerging oppositional defiant or conduct disorder if it occurs by the ages of 4 or 5 and later. However, not every oppositional defiant child develops conduct disorder, and the difficult behaviors associated with these conditions often remit.

Attention Deficit/Hyperactivity Disorder (ADHD) is characterized by two distinct sets of symptoms: inattention and hyperactivity-impulsivity. Although these problems usually occur together, one may be present without the other to qualify for a diagnosis. Inattention or attention deficit may not become apparent until a child enters the challenging environment of elementary school. The symptoms of hyperactivity may be apparent in very young preschoolers and are nearly always present before the age of 7. However, in children with ADHD they occur very frequently and in several settings, at home and at school, or when visiting with friends, and they interfere with the child’s functioning. Children suffering from ADHD may perform poorly at school; they may be unpopular with their peers, if other children perceive them as being unusual or a nuisance; and their behavior can present significant challenges for parents, leading some to be overly harsh. Treatment includes, pharmacological treatment and psychosocial treatment, particularly behavioral modification.

Oppositional defiant disorder (ODD) is diagnosed when a child displays a persistent or consistent pattern of defiance, disobedience, and hostility toward various authority figures including parents, teachers, and other adults. ODD is characterized by such problem behaviors as persistent fighting and arguing, being touchy or easily annoyed, and deliberately annoying or being spiteful or vindictive to other people. Children with ODD may repeatedly lose their temper, argue with adults, deliberately refuse to comply with requests or rules of adults, blame others for their own mistakes, and be repeatedly angry and resentful. Stubbornness and testing of limits are common. These behaviors cause significant difficulties with family and friends and at school or work (DSM-IV). Oppositional defiant disorder is sometimes a precursor of conduct disorder (DSM-IV).

In preschool boys, high reactivity, difficulty being soothed, and high motor activity may indicate risk for the disorder. Marital discord, disrupted child care with a succession of different caregivers, and inconsistent, unsupervised child-rearing may contribute to the condition.

Children or adolescents with conduct disorder behave aggressively by fighting, bullying, intimidating, physically assaulting, sexually coercing, and/or being cruel to people or animals. Vandalism with deliberate destruction of property, for example, setting fires or smashing windows, is common, as are theft; truancy; and early tobacco, alcohol, and substance use and abuse; and precocious sexual activity. Girls with a conduct disorder are prone to running away from home and may become involved in prostitution. The behavior interferes with performance at school or work, so that individuals with this disorder rarely perform at the level predicted by their IQ or age. Their relationships with peers and adults are often poor. They have higher injury rates and are prone to school expulsion and problems with the law. Sexually transmitted diseases are common. If they have been removed from home, they may have difficulty staying in an adoptive or foster family or group home, and this may further complicate their development. Rates of depression, suicidal thoughts, suicide attempts, and suicide itself are all higher in children diagnosed with a conduct disorder.

The prevalence of conduct disorder in 9- to 17-year-olds in the community varies from 1 to 4 percent. Children with an early onset of the disorder, i.e., onset before age 10, are predominantly male. The disorder appears to be more common in cities than in rural areas (DSM-IV).

The etiology of Conduct Disorder is not fully known. Studies of twins and adopted children suggest that conduct disorder has both biological (including genetic) and psychosocial components. Social risk factors for conduct disorder include early maternal rejection, separation from parents with no adequate alternative caregiver available, early institutionalization, family neglect, abuse or violence, parents’ psychiatric illness, parental marital discord, large family size, crowding, and poverty. These factors are thought to lead to a lack of attachment to the parents or to the family unit and eventually to lack of regard for the rules and rewards of society. Physical risk factors for conduct disorder include neurological damage caused by birth complications or low birthweight, attention-deficit/hyperactivity disorder, fearlessness and stimulation-seeking behavior, learning impairments, autonomic underarousal, and insensitivity to physical pain and punishment. A child with both social deprivation and any of these neurological conditions is most susceptible to conduct disorder.

Since many of the risk factors for conduct disorder emerge in the first years of life, intervention must begin very early. Training parents of high-risk children how to deal with the children’s demands may help. Parents may need to be taught to reinforce appropriate behaviors and not harshly punish transgressing ones, and encouraged to find ways to increase the strength of the emotional ties between parent and child.

Treatment
Several psychosocial interventions can effectively reduce antisocial behavior in disruptive disorders. Two well-established treatments, both directed at training parents, succeeded in reducing problem behaviors. No drugs have been demonstrated to be consistently effective in treating conduct disorder.