Conduct Disorder and Oppositional Defiant Disorder

Essential Concepts

A behavior disorder must be differentiated from normal oppositionality as a child gains more autonomy, a consequence of another disorder, or a comorbid disorder.
ODD and CD are clinical diagnoses based on careful history taking, clinical examination, and information from multiple sources and multiple settings (school, home, community).
Concomitant learning disabilities and comorbid psychiatric disorders should be evaluated.
There are evidence-based psychosocial treatments for CD that should be utilized.

The disruptive behavior disorders (also sometimes called “externalizing disorders”) include oppositional defiant disorder (ODD), conduct disorder (CD), and attention deficit hyperactivity disorder (ADHD). ODD and CD are closely related, with ODD being viewed as a precursor, milder form, or subtype of CD. These disorders characterize children and adolescents whose behaviors reflect social rule violations and inappropriate actions against others. Often the behaviors are much more upsetting to those around them than to the child or adolescent that is displaying the behaviors. It is important to note that many preadolescents and adolescents are oppositional, and this, in and of itself, is not considered a disorder. It is when the behaviors occur much more frequently than is typically observed with individuals of comparable age and developmental level and when it is functionally impairing that it becomes a disorder. I also find it essential to thoroughly investigate for other primary disorders or comorbidities. Many traumatized, mood disordered (depressed or bipolar), psychotic, or developmentally disabled youth will engage in very bad behaviors. ODD or CD should not be diagnosed
separately if symptoms occur exclusively during the course of these other disorders.

The disruptive behavior disorders are a serious public health problem in the United States. Conduct symptoms are the reason for inpatient and outpatient psychiatric treatment of one-third to one-half of youth using these services. CD has been identified as the most costly mental health problem in the United States. Children with serious conduct symptoms are likely to become involved in multiple services systems (e.g., mental health, juvenile justice, special education), and this may continue throughout childhood and well into adulthood.

Clinical Description

Table 7.1 summarizes the diagnostic criteria for ODD and CD.

There must be at least three symptoms within the past year, and at least one of the symptoms evident in the last 6 months to make a CD diagnosis. The symptoms must be repetitive, persistent, functionally impairing, and present in a variety of life settings (home, school, work, etc.). If the individual is 18 years or older, he or she does not meet criteria for antisocial personality disorder. Conduct disorder is subdivided by age of onset (childhood onset with at least one criterion before the age of 10; adolescent onset with no symptoms prior to the age of 10; unspecified onset when the age of onset is not known).

Table 7.1 Diagnostic Criteria of ODD and CD

Oppositional Defiant Disorder
When children and adolescents are oppositional and defiant they act like REAL BADS. For ODD, the individual must show at least four of eight symptoms within the past 6 months. This is a mnemonic to recall the criteria for the oppositional defiant disorder: Resentful Easily annoyed Argues with adults Loses temper Blames others for his or her misbehavior Annoys people deliberately Defies rules or requests Spiteful
Conduct Disorder
The behaviors of Conduct Disorder are BAD FOR A BUSINESS. This mnemonic covers the criteria for conduct disorder (3 of 15 in past year and 1 in past 6 months): Bullying Animal cruelty Destroying others’ property Fighting Out late at night Running away from home Actively forcing sex Being cruel to people Using a weapon Setting fires Into someone’s house, building, or car Not going to school Everyday lying or conning others Stealing while confronting a victim Stealing without confronting a victim
Adapted from American Psychiatric Association (2000), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. Washington, DC. American Psychiatric Association.