Disruptive Behavioral Disorders

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Chapter 27 Disruptive Behavioral Disorders

The disruptive behavior disorders are a group of mental health problems in children and adolescents characterized by out-of-control anger and/or behavior. These disturbances exist on a dimensional spectrum ranging from subsyndromal (i.e., some symptoms are present, but not enough to meet full diagnostic criteria) to syndromal (i.e., full diagnostic criteria are met).

Description

Oppositional defiant disorder is characterized by a persistent pattern of angry outbursts, arguing, vindictiveness, and disobedience, generally directed at authority figures (such as parents and teachers). To meet the diagnosis, ≥4 of these types of behavior must be more frequent and more severe than children of a given developmental stage normally exhibit (especially when tired, hungry, or under stress), must be present at least 6 mo, and must impair the youth’s function at home, at school, or with peers (Table 27-1).

Table 27-1 DSM-IV-TR DIAGNOSTIC CRITERIA FOR OPPOSITIONAL DEFIANT DISORDER

B The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Washington, DC, 2000, American Psychiatric Association.

Conduct disorder is characterized by a persistent pattern of serious rule-violating behavior, including behaviors that harm (or have the potential to harm) others. The patient with conduct disorder typically shows little concern for the rights or needs of others. The symptoms of conduct disorder are divided into 4 major categories: physical aggression to people and animals including bullying, fighting, weapon carrying, cruelty to animals, and sexual aggression; destruction of property, including firesetting and breaking and entering; deceitfulness and theft; and serious rule violations, including running away from home, staying out late at night without permission, and truancy. To meet the diagnosis, ≥3 of these symptoms must be present at least 1 year (1 or more in the past 6 mo) and must impair the youth’s function at home, at school, or with peers (Table 27-2).

Table 27-2 DSM-IV-TR DIAGNOSTIC CRITERIA FOR CONDUCT DISORDER

A A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

Aggression to 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 (e.g., a bat, brick, broken bottle, knife, gun).

4 Has been physically cruel to people.

5 Has been physically cruel to animals.

6 Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

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 others’ property (other than by fire setting).

Deceitfulness or Theft

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

11 Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

12 Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious Violation of Rules

13 Often stays out at night despite parental prohibitions, beginning before age 13 years.

14 Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period).

15 Is often truant from school, beginning before age 13 years.

B The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C If the individual is 18 years or older, criteria are not met for Antisocial Personality Disorder.

Specify Type Based on Age at Onset:

Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years.

Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years.

Specify Severity:

Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only mild harm to others.

Moderate: number of conduct problems and effect on others intermediate between “mild” and “severe.”

Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others.

From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Washington, DC, 2000, American Psychiatric Association.

Disruptive behavior disorder, not otherwise specified (subsyndromal disruptive behavior) is diagnosed when some symptoms of disruptive behavior disorders are present, but not enough to meet full diagnostic criteria for oppositional defiant disorder or conduct disorder.

Epidemiology

Estimates of the prevalence of the disruptive behavior disorders vary according to the methodologic characteristics of the study. Recent surveys using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria suggests a point prevalence of oppositional defiant disorder and conduct disorder together of 5%. The male:female ratio is estimated at 3 : 1 to 5 : 1. Both disorders are believed to be more common in sociodemographically disadvantaged, urban populations.

Differential Diagnosis

Although oppositional defiant disorder and conduct disorder share a number of characteristics, oppositional defiant disorder can be distinguished from conduct disorder by the absence of physical aggression and other severe forms of antisocial behavior. When the youth’s pattern of behavior meets the criteria for both oppositional defiant disorder and conduct disorder, the diagnosis of conduct disorder takes precedence. Other diagnoses to consider in the differential include attention-deficit/hyperactivity disorder (ADHD) (Chapter 30), bipolar disorder (Chapter 24), developmental disorders (Chapter 28), and communication disorders (Chapter 32), in which anger and disruptive behavior can be associated symptoms.

Comorbidity

ADHD, anxiety (Chapter 23), depression and bipolar disorders, post-traumatic stress disorder (Chapter 23), substance abuse (Chapter 108), and impulse control, learning, and communication disorders commonly co-occur with oppositional defiant disorder and conduct disorder. Treating comorbidities when they occur enhances the treatment of the disruptive behavior disorders.