As noted previously, the new Disruptive, Impulse-Control, and Conduct Disorders chapter includes a number of disorders previously categorized in the Impulse Control Disorders Not Elsewhere Classified and the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapters of the DSM-IV-TR. As with all diagnostic categories within the DSM-5, the Disruptive, Impulse-Control, and Conduct Disorders chapter has criteria for other specified disruptive, impulse-control, and conduct disorder and unspecified disruptive, impulse-control, and conduct disorder. Although ODD and CD have been included in diagnostic nosology since the second edition of the DSM, conceptualizations of these disorders have been modified considerably from edition to edition (Pardini et al., 2010). Although the DSM-5 did not have any significant changes to these diagnoses, this is the first time all mental health disorders marked by disruptive behavior and impulse-control problems, including those which go against social norms (i.e., pyromania and kleptomania), have been clustered together in the same section.

Categorizing these disorders according to common phenomenology has both clinical utility and heuristic value. Because many of these disorders are similar enough to be grouped together but distinct enough to subsist as separate disorders, counselors can more easily distinguish them from one another. For example, including IED and ODD in the same diagnostic classification allows counselors to more easily identify marked differences between these diagnoses. Second, because these disorders are grouped according to symptomatology, researchers can more easily create testable theoretical explanations for disruptive, impulse-control, and conduct-based disorders.

Aside from being an entirely new chapter, there are relatively few changes to the disorders within this section. There have been no changes to diagnostic criteria for CD, but an additional specifier of with limited prosocial emotions has been added (APA, 2013a). This is indicated when numerous sources (i.e., parents, teachers, extended family members, peers) report a lack of remorse or guilt, callous behavior, indifference to poor performance, or a lack of emotional expression or superficial affect (APA, 2013a). Placement of CD follows ODD and IED, thus reflecting the developmental relationship between ODD and CD (Paris, 2013).

ODD includes a new clustering of symptoms and new language to further clarify frequency and persistence of observed behavior. Whereas the DSM-IV-TR did not allow one to diagnose ODD if CD was present, the DSM-5 has no such restriction. Consistent with the DSM-5‘s focus on dimensional rather than categorical assessment, ODD also includes new severity specifiers.

Note

The questionable “rule” that individuals diagnosed with CD cannot be diagnosed with ODD has been removed in the DSM-5. Whereas ODD symptoms are undoubtedly associated with CD symptoms over time, individuals with angry or irritable symptoms are more likely to develop emotional disorders such as depressive, anxiety, or substance use disorders. Likewise, individuals with headstrong symptoms (i.e., argues with authority figures) are likely to be diagnosed with ADHD. On the other hand, spiteful or hurtful behavior such as aggression or callousness has been found to be most strongly associated with CD.

Finally, IED includes three new criteria for consideration: The recurrent aggressive outbursts must be impulsive and not premeditated, must cause marked distress in occupational or interpersonal functioning, and may not be diagnosed until after the age of 6 (APA, 2013a). As mentioned, counselors should note that pathological gambling—renamed gambling disorder—previously included in the Impulse Control Disorders Not Elsewhere Classified chapter of the DSM-IV-TR has been moved to the Substance-Related and Addictive Disorders chapter, and trichotillomania (hair-pulling disorder) has been moved to the Obsessive-Compulsive and Related Disorders chapter.

It is not uncommon for individuals diagnosed with ODD or CD to also exhibit symptoms of ADHD (APA, 2013a; Paris, 2013). ASPD, because of its close association with CD, is cross-listed in this chapter as well as the Personality Disorders chapter. Symptoms of disruptive, impulse-control, and conduct disorders have commonly been misdiagnosed as pediatric bipolar disorder. Given the addition of DMDD to the DSM-5, counselors are advised to consider carefully whether temper outbursts are related to an underlying mood concern such as DMDD or behavior disorders such as IED, ODD, and CD. Although rare, counselors should carefully consider the nurturing environment of any child diagnosed with ODD to rule out RAD (Widom, Czaja, & Paris, 2009).

Disorders in this chapter have high comorbidity with substance use disorders as well as depressive disorders and anxiety disorders (de Ancos & Ascaso, 2011; Nock et al., 2007). Aside from ADHD, disruptive behavior disorders are the most common reason for mental health referrals for children and adolescents (Merikangas et al., 2009). Counselors can differentiate disruptive, impulse-control, and conduct disorders from other disorders by attending to key features of each disorder. For example, IED is related to impaired ability to control one’s emotions, ODD tends to be related to one’s attitude toward others, and CD may be more intentional and is related to engagement in behavior that violates the rights of others. Whereas ADHD and substance use disorders involve difficulties with impulse management, this is not the primary feature of these other disorders (Ploskin, 2007).

The literature is quite abundant with regard to the etiological development of disruptive, impulse-control, and conduct disorders. Researchers have identified biopsychosocial (Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001), environmental (Burke, Loeber, & Birmaher, 2002; Burt, Krueger, McGue, & Iacono, 2001), genetic (Eley, Lichtenstein, & Moffitt, 2003; Waldman & Rhee, 2002), emotional (Morrell & Murray, 2003), and familial (Frick et al., 1992; Joussemet et al., 2008) factors. However, despite being grouped together diagnostically, separate pathways for the development of each disorder are found within the literature. Little genetic evidence has emerged as a causal factor for disruptive behavior disorders (Jacobson, Prescott, & Kendler, 2002). Whereas genetic links to ADHD are quite abundant (A. S. Rowland, Lesesne, & Abramowitz, 2002)—and resulted in its controversial placement within the Neurodevelopmental Disorders chapter of the DSM-5—biological contributions for disruptive or conduct disorders appear to be relatively small. Likewise, psychobiological studies for these disorders are also inconclusive (Hinshaw & Lee, 2003).

Most researchers have emphasized environmental origins for disruptive behaviors (Burke et al., 2002; Burt et al., 2001; Coie & Dodge, 1998; Hinshaw & Lee, 2003). Familial psychopathology, caregiver substance abuse, caregiver criminality, modeling of aggression, low socioeconomic status, family dysfunction, poor parent–child interactions, and abuse and neglect have been identified as high risk factors for the development of these disorders (Coie & Dodge, 1998; Frick et al., 1992; Joussemet et al., 2008; SAMHSA, 2011b). Other associated factors include cognitive deficits (Moffitt & Lynam, 1994), difficulties in social–cognitive information processing (Crick & Dodge, 1994), and peer rejection (Coie & Dodge, 1998). From a neurological perspective, brain structures within the limbic system (associated with emotions and the formation of memories) and the frontal lobe (linked to planning and controlling impulses) have been connected to disruptive and conduct disorders (Burke et al., 2002; Ploskin, 2007).

There is evidence that neurological irregularities and imbalance of testosterone may play a role in the formulation of disruptive behavioral and impulse-control disorders. In one study, children diagnosed with ODD and CD who had lower levels of testosterone pretreatment were 4 times more likely to respond to treatment and maintain gains compared with those with high levels of testosterone (Shenk et al., 2012). Although controversial, studies that indicate women are predisposed to less aggressive types of impulse-control disorders (i.e., kleptomania) and men to more violent and aggressive types (i.e., pyromania and IED) support this evidence. Researchers have also found connections between certain types of seizure disorders and violent impulsive behaviors (Brower & Price, 2001).

Treatment for these disorders is complex because of the heterogeneity of risk factors and etiological origins. Evidence-based treatments for disruptive behavior disorders tend to fall into several primary categories: parent/family interventions, CBT, and psychopharmacological treatment (Clark & Jerrott, 2012; Eyberg, Nelson, & Boggs, 2008; SAMHSA, 2011b). A systematic review of research regarding evidence-based psychosocial treatments for children and adolescents with disruptive behavioral disorders resulted in identification of 15 potentially efficacious treatments and one well-established treatment (Eyberg et al., 2008). Typically, parent training approaches include fostering positive time between parent and child, modeling of behaviors, introducing rewards and consequences, and teaching coping skills for dealing with difficult behavior. Through CBT, counselors can help clients modify cognitive distortions responsible for the disruptive behavior. This approach helps children and adolescents develop problem-solving skills to improve inhibition, recognize social problems and triggers for disruptive behavior, and pursue more effective alternatives. Parental and psychopharmaceutical interventions are also common (Weyandt, Verdi, & Swentosky, 2010).

Eyberg et al. (2008) concluded that parent training should be a primary approach for young children, noting that counselors may use direct interventions with other children who have the capacity to benefit from the often cognitive–behavioral strategies used in group and individual interventions. For cases in which behavior is more chronic or severe, counselors should consider multicomponent treatment approaches that involve parents, teachers, and mental health providers as change agents. Counselors who are interested in a review of evidence-based treatments for disruptive behavior disorders should refer to the SAMHSA’s (2011a) Interventions for Disruptive Behavior Disorders Kit or Eyberg et al.’s (2008) review.

Psychopharmacological treatments have been found to be effective for pyromania (Parks et al., 2005) and kleptomania (Koran, Bodnik, & Dannon, 2010). Although no treatment approaches have conclusively been determined as effective, many varied approaches, such as CBT and dialectical behavior therapy (DBT), have been found helpful (Koran et al., 2010). Verheul et al. (2003) cited DBT as “the treatment of choice for patients with severe, life-threatening impulse-control disorders” (p. 139). Other treatment options include training for parents; behavioral therapies that focus on corrective consequences, contracting, and token reinforcement; problem-solving skills training; relaxation techniques to reduce the “urge” to engage in a behavior; overt sensitization; and specific psychoeducation such as fire safety/prevention and knowledge of legal consequences for shoplifting or theft (Koran et al., 2010). Individual and family therapy have also been found helpful.