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).

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

Destruction of Property

Deceitfulness or Theft

Serious Violation of Rules

Specify Type Based on Age at Onset:

Specify Severity:

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.

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.

Clinical Course

Oppositional behavior can occur in all children and adolescents from time to time, particularly during the toddler and early teenage periods when autonomy and independence are developmental tasks (see 27.1). Oppositional behavior becomes a concern when it is intense, persistent, and pervasive and when it affects the child’s social, family, and academic life.

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