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These disorders are so-named because affected children tend to disrupt those around them, including family members, school staff, and peers. The most common disruptive behavioral disorder is attention-deficit/hyperactivity disorder (see Learning and Developmental Disorders: Attention-Deficit/Hyperactivity Disorder (ADHD, ADD)).
Oppositional
Defiant Disorder
Oppositional
defiant disorder is a recurrent or persistent pattern of negative,
defiant, or even hostile behavior directed at authority figures. Diagnosis
is by history. Treatment is individual psychotherapy combined with
family or caretaker therapy. Occasionally, drugs may be used to
reduce irritability.
Prevalence estimates vary widely because the diagnostic criteria are highly subjective; prevalence of oppositional defiant disorder (ODD) may be as high as 15% of children and adolescents. Before puberty, affected boys greatly outnumber girls; after puberty, the difference narrows.
Although ODD is sometimes viewed as a “mild version” of conduct disorder, only superficial similarities exist between the 2 disorders. The hallmark of ODD is an interpersonal style characterized by irritability and defiance. A child with a conduct disorder, however, seemingly lacks a conscience and repeatedly violates the rights of others—sometimes without any evidence of irritability. The etiology of ODD is unknown, but it is probably most common in children from families in which the adults model loud, argumentative, interpersonal conflicts. This diagnosis should not be viewed as a circumscribed disorder but rather as an indication of underlying problems that may require further investigation and treatment.
Symptoms,
Signs, and Diagnosis
Children with ODD tend to lose their temper easily and repeatedly, argue with adults, frequently defy adults, refuse to obey rules, deliberately annoy people, blame others for their own mistakes or misbehavior, be easily annoyed and angered, and be spiteful or vindictive. ODD is diagnosed if a child has had ≥ 4 of these symptoms for at least 6 mo. The symptoms must also be severe and disruptive. Caution must be taken to avoid incorrectly diagnosing ODD in response to the mild to moderate oppositional behaviors demonstrated periodically by nearly all children and adolescents.
ODD-like symptoms are often seen in children with untreated attention-deficit/hyperactivity disorder (ADHD). ODD-like symptoms often resolve when ADHD is adequately treated. Additionally, childhood major depressive disorder (MDD) may be mistaken for ODD, because in some children with MDD, the predominant mood is irritability rather than sadness (an important distinction between childhood and adult MDD). Because irritability is also the hallmark of ODD, MDD in these children is identified by the presence of anhedonia and neurovegetative symptoms (eg, sleep and appetite disruption); these symptoms are easily overlooked in children.
Prognosis
and Treatment
Prognosis depends on identifying and successfully treating underlying mood disorders, family dysfunction, and ADHD. Even without treatment, most cases of ODD gradually improve over time.
Initially, the treatment of choice is a rewards-based behavior modification program designed to shape the child's behaviors in a more socially appropriate direction. In addition, many of these children lack social skills and can benefit from group-based, skills-building therapy. Sometimes, drugs used for depressive disorders (see Mental Disorders in Children and Adolescents: Prognosis and Treatment) may be beneficial.
Conduct
Disorder
Conduct
disorder is a recurrent or persistent pattern of behavior that violates
the rights of others or major age-appropriate societal norms or
rules. Diagnosis is by history. No treatment has been proven effective,
and many children require considerable supervision.
The prevalence of some level of conduct disorder (CD) is about 10%. Onset is usually in late childhood or early adolescence, and the disorder is much more common in boys than girls. The etiology is likely a complex interplay of genetic and environmental factors. Parents of adolescents with CD often have engaged in substance abuse and antisocial behaviors, and frequently have been diagnosed with ADHD, mood disorders, schizophrenia, or antisocial personality disorder. However, CD can occur in children from high-functioning, healthy families.
Symptoms,
Signs, and Diagnosis
Children or adolescents with CD lack sensitivity to the feelings and well-being of others and sometimes misperceive the behavior of others as threatening. They may demonstrate aggression by bullying and making threats, brandishing or using a weapon, committing acts of physical cruelty, or forcing someone into sexual activity, all with little or no feelings of remorse. In some cases their aggression and cruelty is directed at animals. These children or adolescents may engage in destruction of property, deceit, and theft. They tolerate frustration poorly and are commonly reckless, violating rules and parental prohibitions (eg, by running away from home, being frequently truant from school). Aberrant behaviors differ between the sexes: Boys tend to fight, steal, and vandalize; girls are likely to lie, run away, and engage in prostitution. Both genders are likely to use and abuse illicit drugs and have difficulties in school. Suicidal ideation is common, and suicide attempts must be taken seriously.
CD is diagnosed if the child or adolescent has demonstrated ≥ 3 of the above findings in the previous 12 mo, and at least 1 in the previous 6 mo. The symptoms or behaviors must be significant enough to impair functioning in relationships, at school, or at work.
Prognosis
and Treatment
Most youth with CD cease their disruptive behaviors in early adulthood, but about 1⁄3 of cases persist. Of these, many meet criteria for antisocial personality disorder. Early onset is associated with a poorer prognosis. Some develop subsequent mood or anxiety disorders, somatoform and substance-related disorders, and early adult-onset psychotic disorders. Children and adolescents with CD tend to have higher rates of physical and other mental disorders.
Treating comorbid disorders with drug therapy and psychotherapy may improve the patient's self-esteem and self-control and ultimately improve control of CD. Moralization and dire admonitions are ineffective and should be avoided. Individual psychotherapy, including cognitive therapy and behavior modification, may help. Often, only separation from a damaging environment and external discipline and consistent behavioral management systems offer hope of success.
Last full review/revision November 2005
Content last modified November 2005
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