For developing children, the abilities to learn self-control and to modulate aggressive impulses are important developmental tasks. This learning is fostered by the social contexts of the family, school, and peers as well as by the child’s own increased capacities for symbolic thinking, appreciation of consequences, and social development. For most children, this process goes forward relatively smoothly as they learn to channel anger and frustration in appropriate ways and acquire the complex norms that govern socially approved forms of aggression such as during various contact sports. However, for some children, this process does not go so smoothly, and emotional and behavioral problems such as inappropriate anger outbursts, physical aggression, and persistent noncompliance may continue throughout childhood and into adulthood.
Oppositional defiant disorder (ODD) and conduct disorder (CD), sometimes termed disruptive behavior disorders
, represent a major challenge for society, in general, and the mental health system in particular. In their historical account of CD, Jane Costello and Adrian Angold (2000)
traced the questions of defining and dealing with out-of-control children to Greek philosophers and described the major changes in legal, educational, and medical views of this topic. Around the turn of the 19th
century, the courts in England and the United States started to recognize that the criminal acts committed by children and adults should be treated differently, and a system of juvenile courts was established. Historically referred to as juvenile delinquency
, the study of the criminal behavior and antisocial acts of children is more than a century old and still remains an important area for both research and clinical work. One of the earliest medical approaches was advanced from the psychodynamic perspective by August Aichhorn, the author of Wayward Youth
). The psychodynamic approach then dominated the treatment of conduct problems in the child guidance clinics in the United States for several decades. Also starting in the 1930s, developmental trajectories of anger and aggression in typically developing children were described in the work of Florence Goodenough (Goodenough, 1935
) and Arnold Gesell (Gesell, 1948
). Current standards for diagnosis and treatment of disruptive behavior are based on the recognition that many forms of disruptive behavior are developmentally appropriate. For example, physical aggression is
normative during the first 3 years of life and can have a communicative role prior to the emergence of language. This stage is followed by a period of reduction in physical aggression between the ages of 3 and 7 years, which is paralleled by rapid acquisition of language and social-emotional skills, such as empathy and perspective taking. As the frequency of physically aggressive behavior decreases, verbally mediated disruptive behaviors such as argumentativeness and relational aggression can emerge in middle childhood. Then, as with most developmental transitions, adolescence either heralds the acquisition of social competencies that can modulate excessive aggression or sets the stage for the escalation of childhood aggression into juvenile delinquency.
In many, but not all, cases, children with disruptive behavior problems go on to have similar problems in adulthood. Early attempts to understand disruptive behavior led to speculations that such behavior represented a failure in moral development and was potentially genetic. The term psychopathy
was used by Harvey Cleckley in 1941 to describe individuals without remorse, who had no close relationships and whose inner lives were impoverished (Cleckley, 1941
). Interest in children with these difficulties increased in the early 1960s following the work of John Bowlby on early attachments of children. In an important longitudinal study, Lee Robins documented long-term stability of disruptive or “deviant” behaviors from childhood to adulthood (Robins, 1966
). 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 second edition of the Diagnostic and Statistical Manual (DSM-II) in 1968 to describe a condition in which children persistently violated the rights of others or social rules and norms. The term oppositional defiant disorder was introduced 12 years later in DSM-III and used for children whose difficulties included problems with authority figures, provocative behavior, negativity, and so forth. ODD and CD share many features, and, historically, ODD was viewed as a developmental precursor to more serious conduct problems. This view has been challenged in more recent longitudinal studies showing that angry mood in childhood can be a risk factor for mood and anxiety disorders in adulthood.
DIAGNOSIS, DEFINITION, AND CLINICAL FEATURES
Current guidelines for the DSM-5
diagnoses of ODD and CD are listed in Table 11.1
. The main feature of ODD is a frequent and persistent angry or irritable mood and argumentative/defiant behavior with parents and other authority figures. The symptoms of ODD can be present in only one setting, most commonly the home. A child may show enough symptoms and be sufficiently impaired in their family functioning to meet criteria for the diagnosis. However, many symptoms of ODD can also be viewed as commonly occurring childhood behaviors so that in order to meet criteria for the disorder, the symptoms must be frequent, impairing, and present for at least 6 months. Severity of ODD can range from mild to moderate to severe, based on the number of settings (such as family, school, and peer groups) where the child’s life and functioning are impaired by the ODD symptoms.
Children with CD exhibit a range of persistent behaviors that violate the basic rights of other people or major age-appropriate norms and rules. As can be seen in Table 11.1
, these behaviors or symptoms of CD are grouped into four categories: aggression, property damage, deceitfulness or theft, and serious violation of rules. To meet criteria for the disorder, three or more of these symptoms must be present for at least 12 months and cause significant impairment in the child’s life and functioning. Conduct problems that may develop into a full-blown disorder can appear as early as the preschool years. 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 and temper tantrums by age 5; the signs of CD appear somewhat later (e.g., lying may appear around age 8, bullying by age 9, and stealing by around 12 years of age). Although the
frequency of aggressive behavior tends to decrease before puberty, the risk of injury associated with aggression can increase as children grow and become physically stronger. During adolescence, physically aggressive behavior becomes particularly problematic owing to its potentially harmful impact on both the victims and the perpetrators. Antisocial behaviors such as stealing and truancy also become more prevalent in adolescence. Some children with CD exhibit decreases in problem behaviors over time, although, in general, the symptoms of CD are relatively stable.
TABLE 11.1 Diagnostic Guidelines for Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) According to the Diagnostic and Statistical Manual (DSM-5)
Oppositional Defiant Disorder Symptoms
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful
4. Argues with adults
5. Actively defies or refuses to comply with adults’ requests or rules
6. Deliberately annoys people
7. Blames others for their mistakes or misbehavior
8. Spiteful or vindictive
Conduct Disorder Symptoms
Aggression Toward People and Animals
1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon that can cause serious physical harm to others
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage
9. Has deliberately destroyed other’s property (other than by fire setting)
Deceitfulness or Theft
10. Has broken into someone’s house, building, or car
11. Often lies to obtain goods or favors or to avoid obligations (cons others)
12. Has stolen items of nontrivial value without confronting a victim
13. Often stays out at night despite parental prohibitions (beginning before age 13 years)
14. Has run away from home overnight at least twice (or once without returning)
15. Often truant from school (beginning before age 13 years)
DSM-5 ODD: Four or more of symptoms from 1 to 8, lasting at least 6 months; symptoms do not occur exclusively during a psychotic or mood disorder episode.
DSM-5 CD: Three or more symptoms in the past 12 months (at least one present in past 6 months).
Symptoms must be developmentally inappropriate in both ODD and CD. Impairment: Symptoms must cause significant functional impairment.
Adapted with permission from Rey, J. M., Walter, G., & Soutullo, C. (2007). Oppositional defiant and conduct disorders. In A. Martin & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry: A comprehensive textbook (4th ed., p. 456). Lippincott Williams & Wilkins; & Reprinted from Salmanian, M., Mohammadi, M. R., Keshavarzi, Z., & Brand, S. (2018). An update on the global prevalence of conduct disorder (2011-2017). Journal of Forensic and Legal Medicine, 59, 1-3. Copyright © 2018 Elsevier; with permission.
Diagnosis of either ODD or CD should rely on information from multiple sources, including children, parents, and teachers to confirm the presence and frequency of symptoms across various contexts. Of note, although anger and irritability are the essential features of ODD, many children who meet criteria for this disorder do not endorse experiencing emotions of anger or frustration with any greater frequency than unaffected children. Instead, children with ODD may perceive others as being annoying or at fault for various problems. Similarly, children with CD may deny any wrongdoing, and clinical diagnosis of CD must rely on history and information from multiple sources. There are also minor differences in diagnoses of ODD and CD in the DSM-5
and the International Statistical Classification of Diseases and Related Health Problems
). The ICD-10
(Salmanian et al., 2018
) approach is explicit in suggesting that ODD is a milder form of CD. Similarities in the DSM-5
criteria for diagnoses of disruptive behavior disorders are noteworthy, but differences arise because of requirements for symptom duration and exclusionary features. In addition to categorical approaches, dimensional methods using rating scales and checklists have been used extensively in the study of children with conduct problems. Attempts have also been made to identify specific subtypes of CD. For example, instead of the current approach (of the less severe ODD and the more severe CD), the DSMIII
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 (American Psychiatric Association, 2013
The problem of comorbidity is particularly an issue for CD and ODD. Rates of several other disorders are markedly increased in association with these conditions, notably attentiondeficit/hyperactivity disorder (ADHD; tenfold increase), major depression (sevenfold increase), and substance abuse (fourfold increase). It remains unclear which of the two (DSM-5
) competing diagnostic approaches works best for understanding and documenting co-occurring disorders. Whereas the DSM-5
encourages multiple diagnoses, the ICD-11
discourages this practice. As a result, the ICD-11
provided codes for mixed categories (World Health Organization, 2019-2020
). This is not a trivial issue because boys with both ADHD and CD have early onset of problem behaviors and worse outcomes than those with CD alone.
EPIDEMIOLOGY AND DEMOGRAPHICS
The prevalence estimates of both ODD and CD vary depending on the study population, diagnostic criteria, assessment instruments, and informants (Moore et al., 2017
; Salmanian et al., 2018
). Table 11.2
summarizes recent studies using the DSM-IV
diagnostic criteria and reveal generally consistent results, with about 5% of children and adolescents meeting criteria for either one of these conditions in the previous 3-6 months. Regarding sex differences in prevalence rates, ODD and CD rates are increased at least two- to threefold in boys relative to girls. Boys are also more likely to have an earlier age of onset of ODD/CD symptoms, with the incidence rates increasing sharply from ages 4 to 6, leveling off from ages 6 to 8, and then slowly declining from ages 8 to 14. In girls, incidence rates remain low until 11 years of age, followed by a sharp increase from age 11 to a peak at age 14. Epidemiological studies also reveal that ODD is not necessarily more prevalent in children and CD in adolescence; in fact, the prevalence estimates are rather similar in both groups.
The issue of time-related changes (cohort effects) in prevalence is of interest for these disorders given the common perception that children, particularly girls, have more recently exhibited higher rates of OCD and CD. However, the classic Isle of Wight study from the 1960s reported a rate of CD (4.2% in 10- to 11-year-old children) similar to those noted in Table 11.2
. Questions about differences across countries and cultures are hard to examine in epidemiological studies, but questionnaire data on delinquent and aggressive behavior have been consistent across countries (Boxes 11.1
TABLE 11.2 Point Prevalence (Percent) Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in Recent Epidemiological Studies
Oppositional Defiant Disorder
3171 Australian children ages 6 to 17 years (Sawyer et al., 2006)
1420 children from North Carolina ages 9 to 13 years (Costello et al., 2003)
10,438 British children ages 5 to 15 years (Ford et al., 2003)
1886 children ages 4 to 17 years in Puerto Rico (Canino et al., 2004)
1251 children ages 7 to 14 years in Brazil (Fleitlich-Bilyk et al., 2004)
6150 children, ages 7 to 9 years in Norway (Munkvold et al., 2011)
10,148 US adolescents, ages 13 to 17 years (Kessler et al., 2012)
1049 school students, ages 6 to 16 in Spain (Lopez-Villalobos et al., 2014)
Average across studies
a 9-12 years of age.
b 13-16 years of age.
c 5-12 years of age.
d 13-15 years of age.
Adapted with permission from Rey, J. M., Walter, G., & Soutullo, C. (2018). Oppositional defiant and conduct disorders. In A. Martin, M. H. Bloch, & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry: A comprehensive textbook (5th ed., p. 391). Wolters Kluwer.
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