Oppositional Defiant Disorder and Conduct Disorder



Oppositional Defiant Disorder and Conduct Disorder


Francheska Perepletchikova PhD I



Introduction

Oppositional defiant disorder (ODD) and conduct disorder (CD) encompass a range of dysfunctional behaviors that emerge over the course of childhood. Both ODD and CD include hostile and defiant behavior toward authority, such as disobedience, temper tantrums, argumentativeness, and refusal to comply with requests. However, individuals with ODD do not exhibit the more severe and persistent behavior patterns of CD, such as aggression toward others, destruction of property, theft, and deceit. Although this chapter covers both ODD and CD, greater attention is accorded to the latter disorder. Much more is known about the onset, clinical course, and long-term outcomes of CD. Also, CD has more deleterious consequences for the individual, the family, and the society at large.

Disruptive behaviors encompass a variety of acts that reflect social rule violations and actions against others. Many of these behaviors such as argumentativeness, temper tantrums, resentfulness, lying, fighting, and bullying others are relatively common among children over the course of normal development. Formal ODD and CD diagnoses are reserved for instances in which disruptive behaviors lead to impairment in everyday functioning, as reflected in unmanageability at home and at school or disorderly acts that affect others.

Contemporary diagnosis, as reflected in the 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), has recognized an increased number of disorders among children and adolescents. Antisocial, disruptive, obstreperous, oppositional, unmanageable, and delinquent child behavior has been acknowledged throughout history even though their identification as psychiatric disorders is quite recent. The behaviors have been attributed to possession by the devil, criminality, and only quite recently mental illness. Extreme measures often have been allowed. For example, early in the history of the United States, Massachusetts had a law that such children could be killed if their parents so approved. The fact that conduct problems represent dysfunction that warrants intervention has not been questioned. The challenge and advances within the past 25 years have been to delineate the disorders of conduct and to identify ways for their treatment or prevention.


Clinical Features

As Rowe and colleagues have shown, ODD and CD are closely related. Several somewhat different models of the nature of this relationship have been proposed. Because all features of ODD are evident in CD, ODD is usually viewed as its precursor. CD is also seen as a more severe form of the same underlying disorder. Furthermore, ODD is sometimes viewed as a subtype of CD. Finally, because these disorders are closely similar in etiology, the distinction between CD and ODD itself has been questioned. In short, the precise nature of the relationship between these disorders is still a matter of debate and empirical attention.









TABLE 5-1 Major Diagnostic Symptoms of Oppositional Defiant Disorder







  1. Often loses temper



  2. Often argues with adults



  3. Often actively defies or refuses to comply with adult’s 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 or resentful



  8. Is often spiteful or vindictive



Diagnostic Criteria for Oppositional Defiant Disorder

DSM-IVdelineates ODD as a recurrent pattern of negativistic, hostile, and defiant behavior. Table 5-1 lists the main symptoms. A diagnosis of ODD is provided if (1) the individual shows at least four symptoms (2) within the past 6 months. To meet the criteria, the behavior must occur more frequently than is typically observed in individuals of compatible age and developmental level, and must be associated with impaired functioning.


Diagnostic Criteria for Conduct Disorder

Current diagnosis using the DSM-IV delineates CD as the violation of basic rights of others and age-appropriate societal norms as the essential features. Table 5-2 lists the main symptoms. A diagnosis of CD is provided if (1) the individual shows at least three symptoms (2) within the past 12 months (3) with at least one of the symptoms evident in the last 6 months. To meet the criteria, the behaviors must be repetitive and persistent and be associated with impaired functioning.

Many ways of subtyping have been proposed. Historically, the greatest evidence has accumulated for aggressive and nonaggressive subtypes. These are characterized by youth who engage primarily in fighting as opposed to stealing. Some youth are of a mixed type, show
symptoms of both, and have a particularly untoward prognosis. In current research, another way of delineating subtypes has focused on age of onset. Two types are distinguished that vary in the nature of conduct problems: developmental course and prognosis, and gender ratio.








TABLE 5-2 Major Symptoms of Conduct Disorder







  1. Bullying or threatening others



  2. Fighting



  3. Using a weapon that can cause serious physical harm to others



  4. Being physically cruel to people



  5. Being physically cruel to animals



  6. Stealing and confronting a victim (e.g., mugging, purse snatching, extortion, and armed robbery)



  7. Forcing someone into sexual activity



  8. Fire setting



  9. Destroying others’ property



  10. Breaking into someone else’s house, building, or car



  11. Frequent lying or “conning” others



  12. Stealing without confronting a victim



  13. Staying out late at night despite parental prohibitions



  14. Running away from home



  15. Being truant from school


Childhood-onset CD is characterized by aggressive behavior. Symptoms usually emerge early in childhood. Individuals with this subtype are usually male, are aggressive, have disturbed peer relationships, have more persistent CD, and are more likely to develop adult antisocial personality disorder than are those with adolescent-onset CD. These individuals usually have had ODD during early childhood, and have symptoms that meet full criteria for CD before puberty.

Adolescent-onset CD is defined by the absence of CD symptoms prior to age 10. Individuals with this type usually have more normative peer relationships, and are less likely than those with childhood-onset type to display aggressive behaviors, have persistent CD, and develop antisocial personality disorder. Moreover, the adolescent-onset type is more evenly distributed among males and females. Symptoms are more likely to reflect vandalism and illegal behaviors than aggressive acts.

There has been support for the subtypes, but a great deal more work is needed to identify whether there are key characteristics that can be identified to refine this grouping further. Also, age of onset as childhood versus adolescence is not very sensitive to large differences seen clinically. For example, among prepubertal children (all considered childhood-onset types), onset, symptom pattern and severity, family history, and long-term course can vary widely.


Limitations in Contemporary Diagnosis of ODD and CD

There are several limitations to the DSM-IV diagnostic criteria of ODD and CD. First, the criteria for diagnosis of ODD and CD are somewhat arbitrary. For example, there is no firm empirical basis for selecting the minimal number of symptoms or a time period as part of the criteria. Variation in the number or time period on either side of the cutoff points does not appear to be clinically or prognostically meaningful. Furthermore, diagnosis of ODD relies on the subjective estimation of whether the behavior occurs more frequently than if typically observed in normal development. Such decisions are arbitrary because no specific criterion is present or based on evidence that would consider sex, cultural, and ethnic differences. Second, the diagnostic criteria do not include a core set of symptoms. This allows for a vast heterogeneity of symptom pattern within the diagnosis. Indeed, the requirement of at least 3 of 15 criteria yields an astonishing 32,647 ways in which the CD diagnosis may be met. Third, features of ODD and CD are observable in other disorders, which raise concerns about the meaningfulness of the current categorical delineation of disruptive behavior problems. Fourth, diagnosis of CD seems to be age biased. The diagnostic symptoms are the same or applied in the same way across ages. However, some behaviors, such as stealing, running away, and fire setting, may be less evident in younger ages. There is a need for a more flexible system with symptoms varying depending on age. Finally, DSM-IV criteria do not account for sex differences. Diagnostic symptoms of CD focus on aggressive and violent actions that are more likely in boys. Females, on the other hand, are more likely to engage in less obvious acts, such as stealing or lying. Such bias may account for the higher prevalence of CD among boys.


Differential Diagnoses and Comorbid Disorders


Oppositional Defiant Disorder

ODD is comorbid with attention-deficit hyperactivity disorder (ADHD), anxiety disorders, and depressive disorders, as detailed by Angold and Costello. The comorbid condition of ODD and ADHD is associated with greater family conflict, teen management difficulties, rebelliousness, antisocial acts, and earlier substance abuse. Furthermore, symptoms of ODD are sometimes evident in individuals with mental retardation. A diagnosis of ODD is given only
if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable age, gender, and severity of cognitive problems.

Features of ODD can be evident in other disorders, such as mood disorder, psychotic disorders, and disorders of language comprehension. Differential diagnosis is based on the associated behavioral patterns and accompanying symptoms. Both ODD and CD include hostile and defiant behavior toward authority, such as disobedience, argumentativeness, temper tantrums, and refusal to comply with requests. However, individuals with ODD do not exhibit more severe and persistent behavior patterns such as aggression toward others and destruction of property. When a behavior pattern meets both diagnoses, the diagnosis of CD takes precedence. Oppositional behavior is a common feature of mood and psychotic disorders and should not be diagnosed separately if symptoms occur exclusively during the course of these disorders. ODD should also be distinguished from a failure to follow directions that result from impaired language comprehension, such as in hearing loss and mixed receptive-expressive language disorder.


Conduct Disorder

CD has a high rate of comorbidity over the course of childhood and adolescence, especially with ADHD, depression, anxiety, and substance abuse, as described by Angold and Costello. The combination of ADHD and CD is especially common, with estimates from 45% to 70% of children with one of these disorders also meeting criteria for the other. Children with both diagnoses show high levels of conduct problems, peer rejection, school problems, and conflictual interactions with parents. Comorbid anxiety disorder has been linked to lower levels of aggression and violence (at least in younger children), but higher rates of shyness and social withdrawal. Comorbid among adolescents, depression is strongly associated with suicide, especially when coupled with substance use disorders.

Features of CD are also evident in other disorders, including adjustment disorders, mania, child or adolescent antisocial behavior, antisocial personality disorder, and pervasive developmental disorders (PDD). Differential diagnoses can be discerned from the onset and course of each disorder, associated behavioral patterns, and accompanying symptoms. A manic episode can occur in children and adolescents with conduct problems. The episodic course and accompanying core symptoms of mood elevation distinguish a manic episode from CD. Adjustment disorders with disturbance of conduct are differentiated from CD by an associated psychosocial stressor preceding the conduct problems. Isolated behavior problems that do not meet criteria for CD or adjustment disorder can be coded as child or adolescent antisocial behavior. Antisocial personality disorder is diagnosed when the individual is at least 18 years old, meets criteria for CD before the age of 15 years, and continues antisocial behavior. For individuals over age 18, a diagnosis of CD is given only if the criteria for antisocial personality disorder are not met. Aggression is also a common reason for referral of children with PDD, and CD or ODD can be comorbid with PDD. The severity of CD or ODD symptoms is lower in younger children with PDD than in children with non-PDD disorders. This can be attributed to the withdrawal from social interactions, characteristic of children with Asperger disorder or autism. However, aggressive behaviors in older children and adolescents with PDD represent a greater clinical problem.


Epidemiology

The prevalence of a disorder refers to the percentage of cases in the population at a given point in time. Among school-aged community samples, the prevalence of ODD and CD combined is approximately 2% to 16%. This estimate is conservative in representing the scope of the problem because research suggests that meeting the diagnostic criteria cutoff is not meaningful in relation to ODD and CD course. Children who approach, but do not quite meet, the diagnostic criteria are also likely to have significant impairment in everyday lives and poor long-term prognoses, especially in the case of CD.


ODD is more prevalent in boys than in girls, especially before puberty. Such differences can be explained by more consistent parental expectations and reinforcement of girls, and more unresponsive and rejecting parenting of boys. Parents also tend to tolerate more excessive behaviors from boys. Furthermore, girls may have more difficulty in expressing anger and are more inclined to refrain from behaviors that would negatively affect relationships, such as oppositionality that evokes frustration and annoyance.

Boys also show approximately three to four times higher rates of CD than do girls. The sex difference may also be explained by the above-mentioned factors and by differences in predispositions toward responding in aggressive ways and the base rates in the different symptoms that comprise CD. Age variations reveal interesting patterns in prevalence rates. Rates of CD tend to be higher for adolescents (approximately 7% for youths aged 12 to 16) than for children (approximately 4% for children aged 4 to 11 years). Childhood-onset and adolescentonset of CD are often considered to represent distinguishable patterns in light of the symptom patterns, sex distribution, and long-term course, as highlighted later in text.

The prevalence does not convey the scope of the problem from a clinical or social perspective. Symptoms of CD represent clinically important criteria for referring one third to one half of youth for inpatient and outpatient treatment. Moreover, CD has been identified as the most costly mental health problem, at least in the United States. This is due in large part to the findings that children referred for treatment are likely to become involved in several service systems (e.g., mental health, juvenile justice, and special education), and this may continue throughout childhood and well into adulthood.


Etiology and Pathogenesis


Risk Factors

There is no single defining set of symptoms that constitute ODD or CD. Children who meet the diagnosis for either of these disorders may not share any symptoms, in light of the heterogeneity of the current diagnostic criteria. Consequently, on a priori grounds, it is unlikely that there would be a simple etiology. The diagnosis may require finer distinctions in terms of subgroups, time of onset, and clinical course before advances will be made. A great deal is known about the onset of CD, which has been studied much more thoroughly than ODD.

Rather than etiology, research focuses on multiple risk factors that contribute to the onset. This shift is in recognition that there are multiple factors that contribute to CD and multiple paths. Risk factors refer to characteristics, events, or processes that increase the likelihood (risk) for the onset of a problem or dysfunction. Risk factors, as antecedents to the dysfunction, may provide clues as to the development and progression of CD, possible mechanisms and processes through which the dysfunctions come about, and foci for possible intervention. Several factors that predispose children and adolescents to behavior problems are highlighted in Table 5-3.


Protective Factors

Even under very adverse conditions with multiple risk factors present, many individuals will not experience adverse outcomes. Protective factors refer to characteristics, events, or processes that decrease the impact of a risk factor and likelihood of an adverse outcome. Protective factors are identified by studying individuals known to be at risk (who show several risk factors) and by delineating subgroups of those who do, versus those who do not, later develop CD. Among a high-risk sample, children are less likely to develop CD if they are first born, are perceived by their mothers as affectionate, show high self-esteem and locus of control, and have alternative caretakers in the family (in addition to the parents) and a supportive same-sex model who played an important role in their development. Other factors that reduce or attenuate risk include above-average intelligence, competence in various skill areas, getting along with peers, and having friends.









TABLE 5-3 Factors That Place Youths at Risk for the Onset of Oppositional Defiant Disorder and Conduct Disorder

















Child factors




  • Child temperament. A more difficult child temperament (on a dimension of “easy-to-difficult”), as characterized by more negative mood, lower levels of approach toward new stimuli, and less adaptability to change.



  • Neuropsychological deficits and difficulties. Deficits in diverse functions related to language (e.g., verbal learning, verbal fluency, and verbal IQ), memory, motor coordination, integration of auditory and visual cues, and “executive” functions of the brain (e.g., abstract reasoning, concept formation, planning, and control of attention).



  • Subclinical levels of CD. Early signs of mild (subclinical) levels of unmanageability and aggression, especially with early age of onset, multiple types of antisocial behaviors, and multiple situations in which they are evident (e.g., at home, in school, and in the community).



  • Academic and intellectual performance. Academic deficiencies and lower intellectual functioning


Parent and family factors




  • Prenatal and perinatal complications. Pregnancy-and birth-related complications including maternal infection, prematurity, low birth weight, impaired respiration, and minor birth injury.



  • Psychopathology and criminal behavior in the family. Criminal behavior, antisocial personality disorder, and alcoholism of the parent.



  • Poor parental practices. Coercive parent-child communications, inconsistent disciplining, harsh or corporal punishment, and permissive or overcontrolling parenting.



  • Monitoring of the child. Poor supervision, lack of monitoring of whereabouts, and few rules about where youth can go and when they can return.



  • Quality of the family relationships. Less parental acceptance of their children; less warmth, affection, and emotional support; and less attachment.



  • Marital discord. Unhappy marital relationships, interpersonal conflict, and parental aggression.



  • Family size. Larger family size, that is, more children in the family.



  • Sibling with antisocial behavior. Presence of a sibling, especially an older brother, with antisocial behavior.



  • Socioeconomic disadvantage. Poverty, overcrowding, unemployment, receipt of social assistance (welfare), and poor housing.


School-related factors




  • Characteristics of the setting. Attending schools where there is little emphasis on academic work, little teacher time spent on lessons, infrequent teacher use of praise and appreciation for schoolwork, little emphasis on individual responsibility of the students, poor working conditions for pupils (e.g., furniture in poor repair), unavailability of the teacher to deal with children’s problems, and low teacher expectancies.


Note: The list of risk factors highlights major influences. Identified factors are generally stronger predictors of CD than of ODD. The number of factors and the relations of specific factors to risk are more complex than the summary statements noted here.


See Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry. 2002;41:1275-1293; Hendren RL. Disruptive behavior disorders in childhood and adolescents. In: Oldham JM, Riba RM, eds. Review of Psychiatry, Washington, DC: American Psychiatric Press; 1999; Kazdin AE. Conduct Disorder in Childhood and Adolescence. 2nd ed. Thousand Oaks, CA: Sage; 1995.


The mechanisms through which risk and protective factors may exert their influence are not known. As an exception, parenting practices (e.g., harsh punishment and attending to aggressive child behavior) have been well studied. These practices directly contribute to aggressive and antisocial behavior. Moreover, Reid and colleagues have shown that altering these practices reduces aggressive and antisocial child behavior.


Antisocial behavior runs in families. Twin and adoption studies indicate a genetic influence on antisocial behavior and deviance in general. Advances in the molecular genetics will no doubt lead to breakthroughs that move closer to understanding mechanisms of action and subgroups of youths. For example, Caspi and colleagues found that children who are maltreated are especially likely to develop antisocial behavior if they have the genotype coding for low monoamine oxidase A activity. Further research relating genotype of vulnerability to subsequent risk factors will add considerably to identifying subgroups and pathways involved in CD.


Clinical Course

Typically, ODD becomes evident before age 8 years. In a significant proportion of cases, ODD is a developmental precursor of CD. Little is known, however, about the outcomes of children with ODD who do not develop antisocial and aggressive symptoms. As discussed earlier in text, CD can emerge in childhood or in adolescence. Adolescent-onset CD is more common and is more equally distributed among boys and girls. Childhood-onset CD is considered to be a more severe form as it usually leads to more severe outcomes. Longitudinal studies show that CD in childhood predicts aggressive and antisocial behavior up to 30 years later. Among CD youths identified in childhood, slightly less than 50% continue their CD into adulthood. If all comorbid diagnoses are considered, apart from CD, slightly over 80% are likely to show a psychiatric disorder as adults. Psychiatric disorder in adulthood is only one of many untoward prognostic features. As highlighted in Table 5-4, individuals with a history of CD evince a broad range of negative outcomes.


Assessment

ODD and CD are usually evaluated using multiple assessment modalities. These modalities have been described in detail by Kazdin as well as by Sommers-Flanagan and Sommers-Flanagan.








TABLE 5-4 Long-Term Prognosis of Youths Identified as Conduct Disordered: Major Characteristics Likely to be Evident in Adulthood





























Major Characteristics

Prognosis


Psychiatric status

Greater psychiatric impairment including antisocial personality, alcohol and drug abuse, and isolated symptoms (e.g., anxiety and somatic complaints); also, greater history of psychiatric hospitalization


Criminal behavior

Higher rates of driving while intoxicated, criminal behavior, arrest records and conviction, and period of time spent in jail


Occupation adjustment

Less likely to be employed; shorter history of employment, lower status jobs, more frequent change of jobs, lower wages, and depend more frequently on financial assistance (welfare); served less frequently and performed less well in the armed services


Educational attainment

Higher rates of dropping out of school, lower attainment among those who remain in school


Marital status

Higher rates of divorce, remarriage, and separation


Social participation

Less contact with relatives, friends, and neighbors; little participation in organizations such as church


Physical health

Higher mortality rate, higher rate of hospitalization for physical problems


Note: These characteristics are based on comparisons of clinically referred children identified for CD relative to control clinical referrals or normal controls or from comparisons of delinquent and nondelinquent youths.


See Pepper DJ, Rubin KH. The Development and Treatment of Childhood Aggression. Hillsdale, NJ: Erlbaum; 1991; Peters RD, McMahon RJ, Quinsey VL. Aggression and Violence Throughout the Life Span. Newbury Park, CA: Sage; 1992.

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Jul 5, 2016 | Posted by in PSYCHIATRY | Comments Off on Oppositional Defiant Disorder and Conduct Disorder

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