DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS
DSM-5 (American Psychiatric Association 2013) placed oppositional defiant disorder and conduct disorder into a new chapter that also includes intermittent explosive disorder (very rarely used in youth) and antisocial personality disorder (limited to adults).
OPPOSITIONAL DEFIANT DISORDER
Oppositional defiant disorder (ODD) is often considered the less severe, developmental precursor of conduct disorder (CD), although most children with ODD do not develop CD. Children with ODD demonstrate argumentative, disobedient, and defiant behavior, without serious violation of the rights of other people. These children are stubborn, negativistic, and provocative. Anger-related symptoms are typically directed at parents and teachers. A lesser degree of angry outbursts may be seen in peer relationships.
DSM-5 defines ODD as a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, during which at least four of the behavioral criteria are present at a frequency greater than that typical for the child’s age and developmental level. The diagnostic symptom criteria are divided into three categories (see Table 14–1), whose prognostic implications differ. The argumentative/defiant and vindictive symptoms more likely predict development of conduct disorder, whereas the angry-irritable mood symptoms more likely predict later mood and anxiety disorders (Stringaris and Goodman 2009).
Data from a community survey provide guidance in determining when a behavior occurs more frequently than expected for age (Angold and Costello 1996). DSM-5 symptom criteria and epidemiological suggested cutoff frequencies are listed in Table 14–1. DSM-5 has slightly different recommended frequencies: that symptoms occur “most days” for children under 5 years and at least once a week for children older than 5 years (American Psychiatric Association 2013, p. 462). For a diagnosis of ODD to be made, the symptoms must not occur exclusively during the course of a psychotic, substance use, or mood disorder and must cause distress (in patient or others) or impair functioning.
Suggested cutoff frequency
1. Often loses temper
Twice a week
2. Is often touchy or easily annoyed
Twice a week
3. Is often angry and resentful
Four times a week
4. Often argues with authority figures or, for children and adolescents, with adults
Twice a week
5. Often actively defies or refuses to comply with requests from authority figures or with rules
Twice a week
6. Often deliberately annoys others
Four times a week
7. Often blames others for his or her mistakes or misbehavior
Once in 3 months
8. Has been spiteful or vindictive at least twice within the past 6 months
Once in 3 months
A crucial feature of ODD is the antagonistic stance that these children take in arguments. They may be willing to lose something they want (a privilege or toy) rather than lose a battle or lose face. The oppositional struggle takes on a life of its own in the child’s mind and becomes more important than the reality of the situation. The child may experience “rational” interventions as continuing arguments. Disobedience can take the form of overt defiance and provocation or dawdling and procrastination, as well as “sneaky” behavior. Parents, and sometimes teachers, become exhausted, frustrated, and angry. As a result, discipline veers between being overly punitive and hopelessly lax. By the time of clinical referral, symptoms are the result of an interactive, negative spiral between parents and child.
The changing criteria for ODD have prevented consistent prevalence estimates. DSM-5 reports prevalence ranging from 1% to 11%, with an average estimate of 3.3%, with equal or slightly higher rates in boys than girls. ODD is common in psychiatric clinics and in special education classrooms. It often occurs concurrently with attention-deficit/hyperactivity disorder (ADHD).
Several psychosocial etiological models have been proposed with a common theme of reciprocal, negative interaction between parent and child resulting in inconsistent discipline, structure, and limit-setting that reinforces oppositional behavior in the child.
Marital problems are common in the parents of children with ODD, but it is difficult to distinguish a contributing factor from the effect of raising a difficult child. Genetic, neurobiological, and temperamental factors may also contribute. The features of ODD and difficult temperament (see Chapter 2, “Evaluation and Treatment Planning”) overlap significantly and may be hard to distinguish. Environmental factors such as poverty, family dysfunction, child abuse, and parental mental illness have also been associated with an increased risk of ODD.
Course and Prognosis
Some children with ODD develop CD, but many do not. In one sample of 7- to 12-year-old clinic-referred boys with ODD, 44% developed CD over a 3-year period (Loeber et al. 1995). Risk factors for progression of ODD to CD include poverty and parental characteristics such as a mother who is young when her first child is born and parents who abuse substances, discipline children inconsistently, and supervise children inadequately. Risk factors in the child are low IQ, physical aggression, and resistance to parental discipline. Many children with ODD subsequently develop anxiety and mood disorders (Loeber et al. 2009).
Evaluation and Differential Diagnosis
Psychiatric evaluation of the child and family is needed to rule out alternative or comorbid disorders and to identify family and psychosocial contributing factors. The ODD symptoms are generally reported by parents and caregivers. The children may not view themselves as defiant or argumentative and often blame parents, authority figures, and peers. Symptoms are more prominent when the child is with familiar people.
Although these behaviors can be normal for children in phases during toddlerhood and adolescence, the 6-month duration criterion of ODD and specification that in children younger than 5 years the symptoms occur on “most days” ordinarily exclude these developmental phenomena. Some children are simply temperamentally stubborn but lack the pattern of more severe disturbance characteristic of ODD. Children with ODD are often annoying or spiteful but stop short of the pattern of serious behavior problems seen in conduct disorder. DSM-5 now allows for ODD and CD to be concurrently diagnosed if symptoms of both disorders are present. Severe separation anxiety disorder, panic disorder, or obsessive-compulsive disorder may lead to temper tantrums and dramatic resistance, but in these disorders the problem behavior is restricted to the feared situations, and in most cases these children can verbalize specific triggers of anxiety.
A key to the diagnosis of ODD is its lifelong pattern. Discrete periods of irritability and resistance to adult direction may be secondary to major affective episodes (depression or hypomania), psychosis, or an adjustment disorder. The intentional and provocative noncompliance characteristic of ODD should be differentiated from the noncompliance resulting from impulsivity and inattention in attention-deficit/hyperactivity disorder, although both disorders are often present. If criteria for both ODD and ADHD are met, both are diagnosed.
Oppositional behavior that is restricted to the school context may be a result of intellectual disability, borderline intelligence, a communication or other developmental disorder, academic difficulty secondary to a learning disorder, or lack of training in cultural norms and expectations.
Multimodal programs such as Fast Track can reduce progression to CD in young children identified as at-risk (Conduct Problems Prevention Research Group 2002). Parent management training in behavior modification techniques such as positive reinforcement, giving more effective commands, “time-out,” and token economies can reduce power struggles and modify oppositionality. Maximal improvement may result from combining the use of a social skills, problem-solving, and conflict management training group for the child with a behavior modification training group for parents (Webster-Stratton and Hammond 1997). Interventions have been developed and tested to use technology, including DVDs, online programs, and parent training using interactive software, to replace the therapist for treatment of disruptive behavior. Bibliotherapy (i.e., recommending books to parents) may be useful (see Appendix, “Resources for Parents”).
In children with coexisting ADHD, anxiety, or mood disorder, medication for the comorbid condition may reduce oppositional behavior and improve compliance.
Children and adolescents with CD repeatedly violate important societal rules or the personal rights of others. Youth with CD who exhibit overt physical aggression may be differentiated from those who engage in covert, nonconfrontational behaviors (e.g., stealing and truancy). In addition, whether the aggressive behavior is “predatory” (goal oriented, planned) or “affective” (impulsive, reactive) may have implications for etiology and treatment.
DSM-5 specifies three types of CD: childhood onset, in which at least one criterion is met before age 10 years; adolescent onset; and unspecified onset. Longitudinal studies (Langbehn et al. 1998) have found that childhood onset is associated with male predominance, increased physical aggression, impaired peer relationships, and comorbid ADHD. A typical course for this subtype starts with ODD in early childhood, which develops into full-blown CD by puberty, followed by a risk of persistent CD and development of adult antisocial personality disorder. In contrast, individuals with adolescent onset typically have few symptoms before puberty, are less likely to be aggressive, and are more likely to be female than those in the early-onset group. Most of those with adolescent onset have friends in the context of a gang or other delinquent peer group. The prognosis for cessation of conduct problems is better if onset is in adolescence; however, course and outcome may be influenced by the nature of the delinquent group and the availability of alternative social supports.
Long-term consequences of conduct disorder include loss of interest in school, school failure and dropout, and eventual unemployment. Youth with CD are at increased medical risk for early pregnancy; sexually transmitted diseases; physical injury from fighting, accidents, rape, or murder; and the sequelae of smoking, drinking, and drug abuse. Rates of suicidal ideation and behavior are increased, especially in the presence of substance abuse.
DSM-5 introduced to the conduct disorder diagnosis a specifier, “with limited prosocial emotions,” that is meant to capture the presence of callous-unemotional (CU) traits. The CU traits include a lack of empathy, lack of remorse, shallow affect, manipulativeness, deceitfulness, and grandiosity. These traits have demonstrated significant heritability but are also influenced by environmental factors. Negative, harsh, inconsistent parenting and poor parent-child communication have been associated with elevated levels of CU traits in children and adolescents. Children with high levels of CU traits often exhibit a fearless temperament and are less responsive to punishment for negative behavior. They seem to respond better to warm nurturing parenting styles with positive reinforcement (Kimonis and Frick 2010; Loeber et al. 2009). The presence of CU traits is associated with a more severe and persistent course of conduct disorder and increases the risk of progression to antisocial personality disorder and psychopathy. For children with CU traits, treatment with stimulant medication has also demonstrated some efficacy in reducing conduct problems.
Despite heterogeneity among youth with CD, certain psychological characteristics are common (Table 14–2).
Attention deficits, low frustration tolerance
Learning disorders, especially in reading
Distortions of size and time awareness
Lack of or distorted connection between prior events and consequences
Limited ability to generate, evaluate, and implement alternative problem-solving strategies
Minimization of fear and sadness, exaggeration of anger
Lack of empathy
Lack of guilt
Impaired interpersonal relations
Suspiciousness, with cognitive distortions
Attributional bias: misperception of others’ actions as hostile
Preference for nonverbal, action-oriented, aggressive solutions to problems
DSM-5 cites prevalence estimates of CD among children and adolescents in the United States ranging from 2% to more than 10%. Although the prevalence of CD in girls has increased, boys still outnumber girls by 3–4:1. Less is known about CD in girls than in boys. Boys commit far more violent crimes than girls do (8:1). When self-report data are used, the overall prevalence of misconduct and delinquent behaviors increases, and the male predominance for crime declines to about 2:1. Cultural attitudes toward gender, race, and class may affect the relative likelihood of a youth being identified as having CD. CD is frequent among youth referred to outpatient psychiatric services.
Comorbid psychiatric or neurological disorders are common in association with CD and contribute to its severity and chronicity. ADHD occurs in as many as half of children with CD in community surveys. In psychiatric clinical programs, CD without ADHD is rare. Posttraumatic stress disorder (PTSD) and dissociative disorders are often reported, especially by incarcerated delinquent youth. Hypervigilance, irritability, and flashbacks may contribute to aggression when youth feel threatened. Learning disorders (especially reading disorder and expressive language disorder) are common. Depression or bipolar disorder may be seen. Although it seems counter-intuitive, anxiety and mood disorders are found in many youth with CD, especially girls, with increased rates after puberty. Substance use is often present and can aggravate impulsivity, risk taking, aggression, suicidality, and school failure.
Many factors have been identified as contributing to the development of CD, which is a heterogeneous disorder. Identifying the contributing factors for the individual patient is important in planning treatment. Current views emphasize an interaction among socioeconomic, cultural, family dynamic, temperamental, genetic, neurobiological, and psychiatric factors to explain the development and persistence of CD and its pattern of transmission from one generation to the next.
Data from a study of male twins suggest that, compared with adult antisocial behavior, juvenile conduct problems are more strongly related to environmental factors and less strongly related to genetic factors (Lyons et al. 1995). The interaction of inadequate and often abusive parenting with characteristics intrinsic to the child results in noncompliant and aggressive behaviors and deficient academic and social skills. Temperamental characteristics such as negative emotions, intense reactions, and inflexibility are associated with a higher risk of CD. Multiple studies have found that birth complications combined with early maternal rejection (i.e., unwanted pregnancy, attempt to abort fetus, and placement outside the home before age 1 year), poor parenting, and parental mental illness increase the likelihood of violent criminal behavior (Raine 2002). Patterson and colleagues (1989) emphasized the importance of a parent–child negative spiral of ever-increasing aversive and coercive behaviors. In effect, these children train their parents to use harsh but inconsistent discipline, and the parents train the children in noncompliant, defiant, and antisocial behaviors. Although less is known about girls with CD, some data suggest that their families are even more dysfunctional than those of boys with CD. Rejection by peers and school failure encourage affiliation with similarly troubled peers. One naturalistic study found that approximately one-third of prepubertal children with depressive mood disorders developed a DSM-III diagnosis of CD by age 19 years (Kovacs et al. 1988).
Although multiple risk factors appear to have a cumulative effect, most children with risk factors do not develop CD. Divorce does not appear to be a major risk factor; family discord rather than separation appears to mediate the risk for CD. Protective factors are not well understood, but an easy or behaviorally inhibited temperament, areas of competence, adequate supervision at home, or a good relationship with one parent or another adult can reduce an at-risk child’s chance of developing CD. Associating with nondelinquent peers and attending a school with a positive environment also offer some protection.
Course and Prognosis
The first signs of behavior problems—aggression, impulsivity, and noncompliance—may be seen as early as age 4 years. Several studies have found that the combination of aggression and shyness in first grade predicts adolescent delinquency and substance abuse. Symptoms tend to emerge in a predictable developmental sequence, with milder behaviors followed by more severe ones. Progression may stop at any stage. Early onset; greater frequency, number, and variety of conduct symptoms; and comorbid ADHD are associated with more severe and prolonged CD (Loeber et al. 2000).
CD remits in many youth, but some lead lives of delinquency or develop antisocial personality disorder. Low IQ score and parental antisocial personality disorder predict persistence of CD (Loeber et al. 1995). A relatively small number of chronic offenders account for most juvenile crime. Recidivists are more likely to have early onset, poor school grades, and low socioeconomic status. In a 7-year follow-up of clinic-referred boys ages 7–12 years with CD, the majority showed fluctuating or increasing CD behaviors. At baseline, the minority with a more positive outcome were more likely to have lower severity of CD, fewer symptoms of ADHD, higher verbal IQ, greater family socioeconomic advantage, and biological parents who were not antisocial. Treatment or incarceration did not account for improvement (Lahey et al. 2002).
Despite the high risk for major psychiatric symptoms, substance abuse, functional impairment, and incarceration, many children with CD achieve a favorable adult adjustment. More adaptive social skills, more positive peer experiences, and adolescent onset predict a better long-term outcome. Innovative early childhood programs have been able to reduce delinquent outcomes and improve academic achievement in children at risk for CD, but successful model programs are rarely replicated or disseminated.
Youth with more severe and complex forms of CD benefit from a comprehensive biopsychosocial evaluation by a multidisciplinary team that might include a child and adolescent psychiatrist, a clinical psychologist, a social worker, a pediatrician or specialist in adolescent medicine, a neurologist, an educational diagnostician and school consultant, a speech and language pathologist, occupational and recreational therapists, a legal advisor, and a case manager or probation officer.
Conventional diagnostic interviews may be difficult, because many youth with CD are uncomfortable or hostile when talking with adults in roles of authority and some have a limited ability to express themselves verbally and to think abstractly. Efforts to establish rapport and careful questioning are essential to identify comorbid psychiatric disorders or neurological impairment. Sources of information in addition to the patient are essential, in part because these youth often underreport criminal behaviors. Compared with parents, teenagers generally report more of their covert behaviors, such as lying, stealing, vandalism, and fire setting, whereas parents are more likely to report their child’s overt behaviors, such as aggression. However, parents who are trying to shield their child from legal consequences may not disclose criminal behaviors.
Medical evaluation (especially in adolescents) should consider pregnancy, sexually transmitted diseases, and hepatitis, as well as any untreated medical disorder and a urine screen for drugs. Evaluation of neurological history is needed because of the frequency of head trauma (both contributing to and resulting from the CD) and seizures. Cognitive and educational assessment are indicated because of the frequent association with specific learning disorders and borderline intellectual functioning or intellectual disability. In addition, truancy, comorbid ADHD, and lack of socialization to the value and culture of school may contribute to educational deficits.
CD is a heterogeneous descriptive diagnosis that is made if the symptoms meet the behavioral criteria. Because virtually any psychiatric disorder can present with disturbance of conduct, the clinician must assess the full range of psychiatric diagnoses, cognitive abilities, language and speech functioning, social competence and relationships, and family functioning. During an episode of depression or mania in bipolar disorder, irritability and impaired judgment can lead to behavior problems that can be distinguished from primary CD by their time course and associated mood symptoms. Psychosis in children and adolescents may result in behaviors consistent with CD. Differential diagnosis also includes intermittent explosive disorder and a spectrum of less severe disorders: ODD, adjustment disorder with disturbance of conduct, and child or adolescent antisocial behavior (a DSM-5 V code), as well as typical mischief.
Despite the cost of CD to individuals, families, and society, few treatments with proven efficacy are available. The patient is rarely motivated to change, and the family and social environments may lack the necessary resources. Early-onset CD becomes increasingly resistant to treatment as the child enters adolescence; therefore, early intervention with young children is crucial. Treatment may take a variety of forms: family interventions, social support, behavior modification, psychopharmacology, or legal sanctions. The treatment setting may be the home; a school, clinic, hospital, or residential treatment program; or a specialized delinquency program. In complex cases of CD, youth often need (but rarely receive) lengthy multimodal therapeutic interventions. The environment in which the patient is living or to which he or she will return must be considered. Comorbid conditions also require attention.
A containment structure and effective limit setting must be established quickly to provide a safe and stable environment for treatment. Limit setting at home may be compromised by parental conflict, parental absence, inconsistent discipline, vague or low expectations for appropriate behavior, or parental depression, substance abuse, or other psychiatric illness. Creating or reinforcing limits for the child with CD may require counseling of parents, treatment of parents’ psychiatric problems, increased supervision at home, surveillance at school, and/or use of legal mechanisms. Guardianship, hearings before judges, supervision by parole officers, or brief incarceration may be required for effective limit setting and communicating the significance of behavioral violations. Families may need concrete assistance with income, housing, legal matters, or medical care. If there are significant comorbid psychiatric disorders, hospitalizing the youth briefly may be useful for containment and intensive evaluation, perhaps including a trial of medication. More stringent criteria for “medical necessity” have essentially eliminated hospitalization for pure CD, in part because hospitalization is not effective as definitive treatment.
Several treatments based on behavioral and family systems principles have shown efficacy, when youth and families can be motivated to participate in and complete treatment programs. In many cases, however, even with treatment, the problem behavior remains outside the normal range.
Parent management training (PMT) and functional family therapy (FFT) can be helpful for relatively motivated and intact families. Principles of behavior modification and family systems theory are used to improve communication and negotiation skills, encourage positive reinforcement, correct dysfunctional parent–child interaction patterns, and promote more effective and less damaging methods of discipline. Younger children are more likely than adolescents to benefit from parent training interventions. Multisystemic therapy (MST) (see the book by Henggeler et al. in “Additional Reading”), a comprehensive treatment combining home-based systemic family therapy with behavior modification and direct intervention in the youth’s social system, is an effective treatment of delinquency in youth, even those from chaotic, multiproblem families. It improves adjustment of patients and family members and reduces future criminal behavior. The therapist empowers parents; enlists social service agencies; and actively reaches out into the home, school, and neighborhood. Individual supportive therapy or pharmacotherapy for the identified patient or a family member is added when necessary. For MST to be implemented with fidelity to the model, program funding from government or foundation sources is typically required.
Group therapy, particularly in residential treatment or therapeutic group homes, uses peer pressure to promote positive change and to improve socialization skills. Caution is needed, because treating antisocial youth together in groups can lead to contagion and worsening of problem behaviors. Insight-oriented individual psychotherapy is not useful.
There is no medication treatment for CD, but treatment of comorbid disorder(s) can be useful (see Chapter 17, “Psychopharmacology”). In patients with coexisting ADHD, stimulants can reduce impulsive conduct symptoms, verbal and physical aggression, hyperactivity, and inattention.
CD that is secondary to major depression may remit when the depression is successfully treated. Lithium may be considered in the treatment of severe impulsive aggression, especially when it is accompanied by explosive, irritable, labile affect. In a well-designed controlled study, lithium was shown to be equal or superior to haloperidol in reducing aggression, hostility, and tantrums and to have fewer side effects (Campbell et al. 1995). Lithium may be the first pharmacological choice if the patient with CD has a family history of bipolar disorder.
Patients who have severe impulsive aggression with emotional lability and irritability, an abnormal electroencephalogram, a strong clinical suggestion of epileptic phenomena, or nonresponse to lithium may benefit from a trial of carbamazepine or valproate. Antipsychotic medications may reduce aggression that is secondary to psychosis. Even in nonpsychotic, severely aggressive children, atypical antipsychotics such as risperidone may reduce aggression, hostility, negativism, and explosiveness, although the side-effect profile (cognitive dulling, weight gain, metabolic syndrome, and risk of tardive dyskinesia) may be problematic. Propranolol, a β-adrenergic blocker, may be useful in patients with otherwise uncontrollable rage reactions and impulsive aggression, especially in those with evidence of organicity.
School and Juvenile Justice Interventions
School interventions include special attention to behavior control; individualized educational programming; vocational training; and remediation of language, speech, and other specific learning disorders. Despite their mainstream popularity, “boot camps” are not effective in reducing future crimes committed by juvenile delinquents (Henggeler and Schoenwald 1994).
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