Disruptive Behavior Disorders: Oppositional Defiant Disorder and Conduct Disorder

OPPOSITIONAL DEFIANT DISORDER

In oppositional defiant disorder, a child’s temper outbursts, active refusal to comply with rules, and annoying behaviors exceed expectations for these behaviors for children of the same age. The disorder is an enduring pattern of negativistic, hostile, and defiant behaviors in the absence of serious violations of social norms or of the rights of others.

Epidemiology

Oppositional, negativistic behavior, in moderation, is developmentally normal in early childhood and adolescence. Epidemiological studies of negativistic traits in nonclinical populations found such behavior in 16 to 22 percent of school-age children. According to the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), prevalence rates for this disorder range from 2 to 16 percent. Although oppositional defiant disorder can begin as early as 3 years of age, it typically is noted by 8 years of age and usually not later than adolescence. Oppositional defiant disorder has been reported to occur at rates ranging from 2 to 16 percent. The disorder seems more prevalent in boys than in girls before puberty, and the sex ratio appears to be equal after puberty. One authority suggests that girls are classified as having oppositional disorder more frequently than boys because boys more often receive the diagnosis of conduct disorder. No distinct family patterns have been noted, but many parents of children with the disorder are overly concerned with issues of power, control, and autonomy.

Etiology

The ability of a child to communicate his or her will and oppose others’ will is crucial to normal development as a route toward establishing autonomy, forming an identity, and setting inner standards and controls. The most dramatic example of normal oppositional behavior peaks between 18 and 24 months, the “terrible twos,” when toddlers behave negativistically as an expression of growing autonomy. Pathology begins when this developmental phase persists abnormally, authority figures overreact, or oppositional behavior recurs considerably more frequently than in most children of the same mental age.

Children exhibit a range of temperamental predispositions to strong will, strong preferences, or great assertiveness. Parents who model more extreme ways of expressing and enforcing their own will may contribute to the development of chronic struggles with their children that are then reenacted with other authority figures. What begins for an infant as an effort to establish self-determination may become transformed into an exaggerated behavioral pattern. In late childhood, environmental trauma, illness, or chronic incapacity, such as mental retardation, can trigger oppositionalism as a defense against helplessness, anxiety, and loss of self-esteem. Another normative oppositional stage occurs in adolescence as an expression of the need to separate from the parents and to establish an autonomous identity.

Classic psychoanalytic theory implicates unresolved conflicts as fueling aggressive behaviors targeting authority figures. Behaviorists have suggested that oppositionality is a reinforced, learned behavior through which a child exerts control over authority figures; for example, by having a temper tantrum when an undesired act is requested, a child coerces the parents to withdraw their request. In addition, increased parental attention—for example, long discussions about the behavior—can reinforce the behavior.

Diagnosis and Clinical Features

Children with oppositional defiant disorder often argue with adults, lose their temper, and are angry, resentful, and easily annoyed by others. Frequently, they actively defy adults’ requests or rules and deliberately annoy other persons. They tend to blame others for their own mistakes and misbehavior. Manifestations of the disorder are almost invariably present in the home, but they may not be present at school or with other adults or peers. In some cases, features of the disorder from the beginning of the disturbance are displayed outside the home; in other cases, the behavior starts in the home but is later displayed outside. Typically, symptoms of the disorder are most evident in interactions with adults or peers whom the child knows well. Thus, a child with the disorder is likely to show little or no sign of the disorder when examined clinically. Usually, these children do not regard themselves as oppositional or defiant but justify their behavior as a response to unreasonable circumstances. The disorder appears to cause more distress to those around the child than to the child. DSM-IV-TR diagnostic criteria for oppositional defiant disorder are given in Table 40-1.

Chronic oppositional defiant disorder almost always interferes with interpersonal relationships and school performance. These children are often friendless and perceive human relationships as unsatisfactory. Despite adequate intelligence, they do poorly or fail in school, as they withhold participation, resist external demands, and insist on solving problems without others’ help. Secondary to these difficulties are low self-esteem, poor frustration tolerance, depressed mood, and temper outbursts. Adolescents may abuse alcohol and illegal substances. Often, the disturbance evolves into a conduct disorder or a mood disorder.

Table 40-1 DSM-IV-TR Diagnostic Criteria for Oppositional Defiant Disorder

A.	A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
	(1)	often loses temper
	(2)	often argues with adults
	(3)	often actively defies or refuses to comply with adults’ requests or rules
	(4)	often deliberately annoys people
	(5)	often blames others for his or her mistakes or misbehavior
	(6)	is often touchy or easily annoyed by others
	(7)	is often angry and resentful
	(8)	is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
B.	The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C.	The behaviors do not occur exclusively during the course of a psychotic or mood disorder.
D.	Criteria are not met for conduct disorder, and, if the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.

Pathology and Laboratory Examination.

No specific laboratory tests or pathological findings help diagnose oppositional defiant disorder. Because some children with the disorder become physically aggressive and violate the rights of others as they get older, they may share some of the same characteristics under investigation in violent people, such as low serotonin levels in the central nervous system (CNS).

Differential Diagnosis

Because oppositional behavior is both normal and adaptive at specific developmental stages, these periods of negativism must be distinguished from oppositional defiant disorder. Developmental-stage oppositional behavior, which is of shorter duration than oppositional defiant disorder, is neither considerably more frequent nor more intense than that seen in other children of the same mental age.

Oppositional defiant behavior occurring temporarily in reaction to a stress should be diagnosed as an adjustment disorder. When features of oppositional defiant disorder appear during the course of conduct disorder, schizophrenia, or a mood disorder, the diagnosis of oppositional defiant disorder should not be made. Oppositional and negativistic behaviors can also be present in attention-deficit/hyperactivity disorder (ADHD), cognitive disorders, and mental retardation. Whether a concomitant diagnosis of oppositional defiant disorder should be made depends on the severity, pervasiveness, and duration of such behavior. Some young children who receive a diagnosis of oppositional defiant disorder go on in several years to meet the criteria for conduct disorder. Some investigators believe that the two disorders may be developmental variants of each other, with conduct disorder being the natural progression of oppositional defiant behavior when a child matures. Most children with oppositional defiant disorder, however, do not later meet the criteria for conduct disorder, and up to one fourth of children with oppositional defiant disorder may not meet the diagnosis several years later.

The subtype of oppositional defiant disorder that tends to progress to conduct disorder is one in which aggression is prominent. Most children who have ADHD and conduct disorder develop conduct disorder before the age of 12 years. Most children who develop conduct disorder have a history of oppositional defiant disorder. Overall, the current consensus is that two subtypes of oppositional defiant disorder may exist. One type, which is likely to progress to conduct disorder, includes certain symptoms of conduct disorder (e.g., fighting, bullying). The other type, which is characterized by less aggression and fewer antisocial traits, does not progress to conduct disorder.

Jared, age 8 years, was brought to the clinic for evaluation of misbehavior by his mother. She complained that he has frequent tantrums, usually in response to limits on his behavior or not getting his way. She describes the tantrums as consisting of shouting, cursing, crying, slamming doors, and sometimes throwing books or objects on the floor. She states that these outbursts occur almost daily. She feels that sometimes it seems as though he is trying to provoke her. Recently, he was kicking his foot against his mother’s chair and she asked him to stop. He looked at her and continued to kick her chair. She says that she has given up on asking him to pick up his room or help with chores, because it inevitably results in an argument. Jared appears sullen and irritable on interview. He says that it was his mother’s fault and she is always after him about one thing or another. He interrupts her several times during the joint interview, saying that she was lying or giving his version of events. His grades at school are excellent, and there are no reports of any behavior problems or disobedience at school. His mother says that he does not have many friends because he has difficulty sharing his things and tends to be bossy. He had a series of ear infections as an infant and occasionally experiences seasonal allergies, but is otherwise in good health, with normal physical development. His mother describes him as being fussy as an infant and difficult to comfort when upset. He is an only child, and his parents separated and divorced when he was 3. He has had no contact with his father since then. His mother was depressed for a year after the divorce until she sought treatment. She has always felt guilty that his father is not in his life and worries that he blames her for not having his father around. She believes his behaviors have become worse since she recently started dating again. (Courtesy of Christopher R. Thomas, M.D.)

Course and Prognosis

The course of oppositional defiant disorder depends largely on the severity of the symptoms and the ability of the child to develop more-adaptive responses to authority. The stability of oppositional defiant disorder varies over time. Persistence of oppositional defiant symptoms poses an increased risk of additional disorders, such as conduct disorder and substance use disorders. Positive outcomes are more likely for intact families who can modify their own expression of demands and give less attention to the child’s argumentative behaviors.

About one fourth of all children who receive the diagnosis of oppositional defiant disorder do not continue to meet diagnostic criteria over the next several years. It is not clear in these cases whether the criteria captured children whose behavior was not developmentally abnormal or the disorder spontaneously remitted. Patients in whom the diagnosis persists may remain stable or go on to violate the rights of others and, thus, develop conduct disorder. Such patients should receive guarded prognoses.

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