▪ Oppositional Defiant and Conduct Disorders
For developing children, the ability to learn to postpone gratification and to modulate aggressive impulses are important development tasks. This effort is fostered by the social context of the family; appropriate modeling by parents and others; and the child’s own increased capacities for symbolic thinking, forward planning (appreciation of consequences), and moral development. For most children, this process goes forward relatively smoothly as the child learns to channel aggressive feelings in appropriate ways and learn the complex rules that govern aggressive behavior (e.g., on the sports field). For some children, this process does not go so smoothly, and aggressive behavior is a major clinical problem that may persist into adulthood (see Blader & Jensen, 2007, for a review).
BACKGROUND
Conduct disorder (CD) and oppositional defiant disorders (ODDs), sometimes termed the disruptive behavior disorders, represent a major challenge for society in general and the mental health system in particular. Historically referred to as juvenile delinquency, the study of criminal behavior and antisocial acts of children is more than a century old and yet remains an important area for both research and clinical work.
In many, but not all, cases, children with these problems go on to have similar problems in adulthood. Early attempts to understand such behavior led to early speculation that such behavior represented a failure in moral development and was potentially genetic. The term psychopathy was used by Cleckley to describe individuals without remorse, who did not have close relationships, and whose inner levels were impoverished. Interest in children with these difficulties increased in the early 1900s with the establishment of clinics to help juvenile courts rehabilitate children. Interest in early experience led John Bowlby and others to study early attachments of such children. In one critically important longitudinal study, Lee Robins (1966) was able to document the long-term stability of such behaviors from childhood to adulthood. Early distinctions within this category had to do with the nature of the conduct problems, such as aggressive (fighting) versus nonaggressive (property destruction) and group versus individual behavior.
The term conduct disorder was introduced in the Diagnostic and Statistical Manual (DSMIII) to describe a condition in which children persistently violated the rights of other or social rules and norms. The term oppositional defiant disorder has been used for children whose
difficulties included problems with authority figures, provocative behavior, negativity, and so forth. In reality, ODD and CD share many features. Many children who go on to have CD “begin” with ODD, although other children will not do so.
difficulties included problems with authority figures, provocative behavior, negativity, and so forth. In reality, ODD and CD share many features. Many children who go on to have CD “begin” with ODD, although other children will not do so.
DEFINITION AND CLINICAL DESCRIPTIONS
Guidelines for the diagnosis with a comparison of the somewhat different approaches in DSMIV and International Classification of Diseases (ICD-10) are listed in Table 9.1. These systems have major similarities and some important differences. In both systems, a diagnosis of CD precludes a diagnosis of ODD. The ICD-10 approach is explicit in suggesting that ODD is a milder form of CD. Similarities in criteria are noteworthy, but differences arise because of requirements for symptom duration and exclusionary features. As a practical matter, the DSMIV approach is more stringent, possibly too much so. In addition to categorical approaches, dimensional methods using rating scales and checklists have been extensively used in the study of children with conduct problems (see Chapter 3). Such methods have many advantages for research purposes. Attempts have also been made to identify specific subtypes of CD. Instead of the current approach (of less severe ODD and the more severe CD), the DSM-III subdivided CD into three subtypes depending on the presence or absence of socialization and aggressive behavior (e.g., one subtype was unsocialized aggressive). Another approach in DSM-III-R was to distinguish solitary versus group types. In DSM-IV, there is provision for differentiating childhood versus adolescent onset.
The problem of comorbidity (see Chapter 3) is particularly an issue for CD and ODD. It is clear that rates of several other disorders are markedly increased in association to these conditions, notably attention-deficit/hyperactivity disorder (ADHD (10-fold increase), major depression (sevenfold increase) and substance abuse (fourfold increase). It remains unclear which of the two (DSM-IV vs. ICD-10) competing approaches works best. Whereas the DSMIV encourages multiple diagnoses, the ICD-10 discourages this practice. As a result, the ICD-10 provided codes for mixed categories. This is not a trivial issue because boys with both ADHD and CD have early onset of problem behaviors and worse outcome than those with CD alone.
Children with CDs exhibit a range of problem behaviors sometimes starting from an early age. In contrast to the normative “terrible twos” for whom negativism and defiance is a passing phase, young children with CD repeatedly lose their tempers, are angry, are readily annoyed by others, and are typically defiant. The signs of ODD usually appear relatively early with persistent stubbornness by age 3 years and temper tantrums by 5 years; the signs of CD appear somewhat later (e.g., lying may appear around age 8 years, bullying by age 9 years, and stealing by around 12 years of age). Although aggressive behaviors can be observed before puberty, the severity of such behaviors often markedly increases thereafter. Antisocial behaviors such as stealing and truancy also become more prevalent over time, particularly in adolescence. Some children exhibit decreases in problem behaviors over time, although in general, the symptoms of CD are relatively stable.
For some children, features of ODD symptoms begin when they are infants and then evolve into CD after puberty. For others, these symptoms do not progress to CD; this may be more likely in girls. For some children, the problem behaviors are restricted to one context (e.g., the home), but for others, the behavioral difficulties occur in multiple contests and situations.
EPIDEMIOLOGY
As expected, prevalence estimates of both ODD and CD vary considerably depending on various factors. Table 9.2 summarizes recent studies using the DSM-IV approach and reveal generally consistent results with about 5% of children (6-18 years old) meeting criteria for either one of these conditions in the previous 3 to 6 months. It is clear that ODD and CD are increased at least two- to threefold in boys. Epidemiologic studies also reveal that ODD is not necessarily more prevalent in children and CD in adolescence; in fact, the prevalences are rather similar in both groups.
TABLE 9.1 DIAGNOSTIC GUIDELINES FOR OPPOSITIONAL DEFIANT DISORDER (ODD) AND CONDUCT DISORDER (CD) ACCORDING TO THE DIAGNOSTIC AND STATISTICAL MANUAL (DSM-IV-TR) (21) AND INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-10) (20) | |||||||||||||||||||||||||||||||||
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Fire Setting
Fire setting is a particularly problematic behavior with potential danger both for the child and others placed at risk. Unfortunately, about half of individuals arrested for arson are younger than 18 years of age, with boys more likely than girls to set fires. Many children have an interest in fire and matches and benefit from education and modeling of safe behaviors and supervision. For other children, fire setting occurs in the context of psychiatric problems. Children with an early interest in fire setting can move along several different pathways, with factors in the school, family, and community all impacting fire setting activity (Barreto, et al., 2007). Treatment is typically multimodal, including aspects of education and attention to associated psychiatric and behavioral problems. It is important that professionals specifically inquire about fire-setting activities.
Case Report: Oppositional Defiant Disorder
Jason, age 7 years, was brought to the child guidance clinic by his mother with a chief complaint that he was “out of control.” Jason was exhibiting frequent (usually daily) temper tantrums, which had been escalating in frequency and duration over the past year. The real precipitating event for the visit was that, for the first time, his mother was concerned that he might hit her during their most recent argument (although he did not actually do so).
Jason was living in a single-parent household. The youngest of two sons, he had no contact with his father, who was serving a 20-year sentence for armed robbery. Jason had some trouble in school as academic demands had increased. He has a few, but not many friends, because he has trouble tolerating the demands of others. His mother works two jobs, and he is left either with various babysitters or in the school’s after-school program because his much older brother also is working, partly to save money for vocational school. His mother reports that developmental milestones were within normal limits, although he spoke “on the late side.”
On examination, Jason tends to minimize his troubles and blames his mother and “deadbeat” father for his problems. He often interrupts his mother when present with her. When seen by himself, he is personable but irritable and angry. He complains that his older brother is the favorite one who can do nothing wrong. He denies feelings of depression or anxiety and appears to have adequate language and attentional skills. He and his mother confirm that it is at home where he has the most difficulty.
Comment: As in this case, children with ODD usually present clinically before about age 8 years. It is more typical for problems to be confined to one setting (often the home). Problems tend to be most noteworthy, and parents, other family members, and the child may appear well organized during the clinical interview. As symptoms become more severe, the likelihood of persistence into conduct disorder increases.
Case Report: Conduct Disorder
Timmy, age 13 years, was brought to the emergency department by the police. He had been truant from school for several days and then ran away from home. This has happened several times during the past year. When contacted by phone, his mother’s first comment is, “He is in trouble again.” She relates a history of long-standing problems in behavior going back to his first year in school, when he stole some money from a teacher’s purse. He has been picked up by the police several times, including once, at age 11 years, for shoplifting in the local mall.
Timmy is an only child. His mother reports that his early developmental milestones were normal but that he was a fussy and demanding infant “just like his father,” who she has not seen in 10 years. Timmy had special services in school, and the question of attention-deficit disorder was raised in the past, although his mother refused medications for it. His mother indicates that he is now failing school, which she says is not a surprise because “he never goes to class.” She mentions that he hangs out with older kids on the street, and she suspects he is starting to “do drugs.” His mother also notes that she was referred to child protective services when Timmy was 8 years old but that nothing came of this.
On examination, Timmy is an angry teenager who appears to just be going through puberty. He minimizes his troubles and explains that life is better on the street than at home. He reports that school is a “drag”, and he does not want to have any part of it. Although angry and somewhat dismissive of the psychiatrist, his speech is logically organized. He denies substance abuse, but toxicology screen results are positive.
Comment: Timmy exhibits a history with multiple risk factors for conduct disorder. In addition, his problems with attention and now with substance abuse are fairly frequent in children with conduct problems. As noted by Robins (1966), these problems are, compared with many other psychiatric difficulties, some of the most difficult to treat and can be very persistent.
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