Heather J. Walter, David R. DeMaso
The disruptive, impulse-control, and conduct disorders are interrelated sets of psychiatric symptoms characterized by a core deficit in self-regulation of anger, aggression, defiance, and antisocial behaviors. The disruptive, impulse-control, and conduct disorders include oppositional defiant, intermittent explosive, conduct, other specified/unspecified disruptive/impulse control/conduct, and antisocial personality disorders, as well as pyromania and kleptomania.
Oppositional defiant disorder (ODD) is characterized by a pattern lasting at least 6 mo of angry, irritable mood, argumentative/defiant behavior, or vindictiveness exhibited during interaction with at least 1 individual who is not a sibling (Table 42.1 ). For preschool children, the behavior must occur on most days, whereas in school-age children, the behavior must occur at least once a week. The severity of the disorder is considered mild if symptoms are confined to only 1 setting (e.g., at home, at school, at work, with peers), moderate if symptoms are present in at least 2 settings, and severe if symptoms are present in ≥4 settings.
Intermittent explosive disorder (IED) is characterized by recurrent verbal or physical aggression that is grossly disproportionate to the provocation or to any precipitating psychosocial stressors (Table 42.2 ). The outbursts, which are impulsive and/or anger-based rather than premeditated and/or instrumental, typically last <30 min and frequently occur in response to a minor provocation by a close intimate.
Conduct disorder (CD) is characterized by a repetitive and persistent pattern over at least 12 mo of serious rule-violating behavior in which the basic rights of others or major societal norms or rules are violated (Table 42.3 ). The symptoms of CD are divided into 4 major categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violations (e.g., truancy, running away). Three subtypes of CD (which have different prognostic significance) are based on the age of onset: childhood-onset type, adolescent-onset type, and unspecified. A small proportion of individuals with CD exhibit characteristics (lack of remorse/guilt, callous/lack of empathy, unconcerned about performance, shallow/deficient affect) that qualify for the “with limited prosocial emotions” specifier. CD is classified as mild when few if any symptoms over those required for the diagnosis are present, and the symptoms cause relatively minor harm to others. CD is classified as severe if many symptoms over those required for the diagnosis are present, and the symptoms cause considerable harm to others. Moderate severity is intermediate between mild and severe.
Other specified/unspecified disruptive/impulse-control/CD (subsyndromal disorder) applies to presentations in which symptoms characteristic of the disorders in this class are present and cause clinically significant distress or functional impairment, but do not meet full diagnostic criteria for any of the disorders in this class.
The prevalence of ODD is approximately 3%, and in preadolescents is more common in males than females (1.4 : 1). One-year prevalence rates for IED and CD approximate 3% and 5%, respectively. For CD, prevalence rates rise from childhood to adolescence and are higher among males than females. The prevalence of these disorders has been shown to be higher in lower socioeconomic classes. This class of disorders constitutes the most frequent referral problem for youth, accounting for one third to one half of all cases seen in mental health clinics. Racial/ethnic minority youth with these disorders utilize specialty mental health services at lower rates than their white peers.
Oppositional behavior can occur in all children and adolescents at times, particularly during the toddler and early teenage periods when establishing autonomy and independence are normative developmental tasks. Oppositional behavior becomes a concern when it is intense, persistent, and pervasive and when it affects the child's social, family, and academic life.
Some of the earliest manifestations of oppositionality are stubbornness (3 yr), defiance and temper tantrums (4-5 yr), and argumentativeness (6 yr). Approximately 65% of children with ODD exit from the diagnosis after a 3 yr follow-up; earlier age at onset of oppositional symptoms conveys a poorer prognosis. ODD often precedes the development of CD (approximately 30% higher likelihood with comorbid attention-deficit/hyperactivity disorder [ADHD]), but also increases the risk for the development of depressive and anxiety disorders. The defiant and vindictive symptoms carry most of the risk for CD, whereas the angry, irritable mood symptoms carry most of the risk for anxiety and depression.
IED usually begins in late childhood or adolescence and appears to follow a chronic and persistent course over many years.
The onset of CD may occur as early as the preschool years, but the first significant symptoms usually emerge during the period from middle childhood through middle adolescence; onset is rare after age 16 yr. Symptoms of CD vary with age as the individual develops increased physical strength, cognitive abilities, and sexual maturity. Symptoms that emerge first tend to be less serious (e.g., lying), while those emerging later tend to be more severe (e.g., sexual or physical assault). Severe behaviors emerging at an early age convey a poor prognosis. In the majority of individuals, the disorder remits by adulthood; in a substantial fraction, antisocial personality disorder develops. Individuals with CD also are at risk for the later development of mood, anxiety, posttraumatic stress, impulse control, psychotic, somatic symptom, and substance-related disorders.
The disorders in this diagnostic class share a number of characteristics with each other as well as with disorders from other classes, and as such must be carefully differentiated. ODD can be distinguished from CD by the absence of physical aggression and destructiveness and by the presence of angry, irritable mood. ODD can be distinguished from IED by the lack of serious aggression (physical assault). IED can be distinguished from CD by the lack of predatory aggression and other, nonaggressive symptoms of CD.
The oppositionality seen in ODD must be distinguished from that seen in ADHD, depressive and bipolar disorders (including disruptive mood dysregulation disorder), language disorders, intellectual disability, and social anxiety disorder. ODD should not be diagnosed if the behaviors occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder, or if criteria are met for disruptive mood dysregulation disorder. IED should not be diagnosed if the behavior can be better explained by a depressive, bipolar, disruptive mood dysregulation, psychotic, antisocial personality, or borderline personality disorder. The aggression seen in CD must be distinguished from that seen in ADHD and intermittent explosive, depressive, bipolar, and adjustment disorders.
Rates of ODD are much higher in children with ADHD, which suggests shared temperamental risk factors. Depressive, anxiety, and substance use disorders are most often comorbid with IED. ADHD and ODD are both common in individuals with CD, and this comorbid presentation predicts worse outcomes. CD also may occur with anxiety, depressive, bipolar, learning, language, and substance-related disorders.
The disruptive, impulse-control, and conduct disorders are associated with a wide range of psychiatric disorders in adulthood and with many other adverse outcomes, such as suicidal behavior, physical injury, delinquency and criminality, legal problems, substance use, unplanned pregnancy, social instability, marital failure, and academic and occupational underachievement.
At the individual level, a number of neurobiologic markers (lower heart rate and skin conductance reactivity, reduced basal cortisol reactivity, abnormalities in the prefrontal cortex and amygdala, serotonergic abnormalities) have been variously associated with aggressive behavior disorders. Other biologic risk factors include pre-, peri-, and postnatal insults; cognitive and linguistic impairment, particularly language-based learning deficits; difficult temperamental characteristics, particularly negative affectivity, poor frustration tolerance, and impulsivity; certain personality characteristics (novelty seeking, reduced harm avoidance, and reward dependence); and certain cognitive characteristics (cognitive rigidity, hostile attributions for ambiguous social cues).
At the family level, a consistently demonstrated risk factor is ineffective parenting . Parents of behaviorally disordered children are more inconsistent in their use of rules; issue more and unclear commands; are more likely to respond to their child based on their own mood rather than the child's behavior; are less likely to monitor their children's whereabouts; and are relatively unresponsive to their children's prosocial behavior. Complicating this association is the consistent finding that temperamentally difficult children are more likely to elicit negative parenting responses, including physical punishment, which can exacerbate anger and oppositionality in the child. Other important family-level influences include impaired parent–child attachment, child maltreatment (physical and sexual abuse), exposure to marital conflict and domestic violence, family poverty and crime, and family genetic liability (family history of the disorders in this class along with substance use, depressive, bipolar, schizophrenic, somatization, and personality disorders, as well as ADHD, have all been shown to be associated with the development of behavior disorders).
Peer-level influence on the development of behavior problems include peer rejection in childhood and antisocial peer groups. Neighborhood influences include social processes such as collective efficacy and social control.
A useful conduct problem prevention program is the Fast Track (http://fasttrackproject.org ), a multicomponent school-based intervention comprising a classroom curriculum targeted at conflict resolution and interpersonal skills, parent training, and interventions targeted at the school environment. Implemented in 1st through 10th grade, former program participants at age 25 had a lower prevalence of any externalizing, internalizing, or substance abuse problem than program nonparticipants. Program participants also had lower violent and drug crime conviction scores, lower risky sexual behavior scores, and higher well-being scores. Another useful prevention program, the Seattle Social Development Project (http://ssdp-tip.org/SSDP/index.html ), is also a multicomponent school-based intervention of teacher, parent, and student components targeting classroom management, interpersonal problem-solving, child behavior management, and academic support skills. Implemented in 1st through 6th grades, outcomes at age 19 yr demonstrated that the intervention decreased lifetime drug use and delinquency for participant males compared with males in comparator communities, but had no significant effects on females.
The parents of children presenting in the primary care setting should be queried about angry mood or aggressive, defiant, or antisocial behavior as part of the routine clinical interview. A typical screening question would be, “Does [name] have a lot of trouble controlling [his/her] anger or behavior?” A number of standardized broad-band screening instruments widely used in the primary care setting (Pediatric Symptom Checklist , Strengths and Difficulties Questionnaire , Vanderbilt ADHD Diagnostic Rating Scales) have items specific to angry mood and aggressive behavior, and as such can be used to focus the interview.
Youth (and/or their parents) presenting in the primary care setting who self-report or respond affirmatively to queries about difficulties managing angry mood or aggressive or antisocial behavior should be afforded the opportunity to talk about the situation with the pediatric practitioner (separately with the older youth as indicated). By engaging in active listening (e.g., “I hear how you have been feeling. Tell me more about what happened to make you feel that way”), the pediatric practitioner can establish a therapeutic rapport and begin to assess the onset, duration, context, and severity of the symptoms, and associated dangerousness, distress, and functional impairment. In the absence of acute dangerousness (e.g., homicidality, assaultiveness, psychosis, substance abuse) and significant distress or functional impairment, the pediatric practitioner can schedule a follow-up appointment within 1-2 wk to conduct a behavior assessment. At this follow-up visit, to assist with decision-making about appropriate level of care, a behavior screening instrument can be administered (Table 42.4 ) and additional risk factors explored (see Etiology and Risk Factors earlier).
Table 42.4
Anger/Aggression-Specific Screening Instruments
| NAME OF INSTRUMENT | INFORMANT(S) | AGE RANGE | NUMBER OF ITEMS |
|---|---|---|---|
| Children's Aggression Scale | Parent, Teacher | 5-18 yr | 33 (P), 23 (T) |
| Eyberg Child Behavior Inventory | Parent | 2-16 yr | 36 |
| Outburst Monitoring Scale | Parent | 12-17 yr | 20 |
| Sutter-Eyberg Student Behavior Inventory–Revised | Teacher | 2-16 yr | 38 |
| Vanderbilt ADHD Diagnostic Rating Scales | Parent, Teacher | 6-12 yr | 55 (P), 43 (T) |
For mild symptoms (manageable by the parent and not functionally impairing) and in the absence of major risk factors (homicidality, assaultiveness, psychosis, substance use, child maltreatment, parental psychopathology, or severe family dysfunction), guided self-help (anticipatory guidance) with watchful waiting and scheduled follow-up may suffice. Guided self-help can include provision of educational materials (pamphlets, books, videos, workbooks, internet sites) that provide information to the youth about dealing with anger-provoking situations, and advice to parents about strengthening the parent–child relationship, effective parenting strategies, and the effects of adverse environmental exposures on the development of behavior problems. In a Cochrane review, media-based parenting interventions had a moderate positive effect on child behavior problems, either alone or as an adjunct to medication. An example of a self-help program for parents is the Positive Parenting Program (Triple P; www.triplep.net ), online version, in which parents can purchase 4 modules of instruction addressing techniques for positive parenting and strategies for encouraging good behavior, teaching new emotional and behavioral skills, and managing misbehavior (see Chapter 19 ).
If the problematic behavior is occurring predominantly at school, the parent can be advised about the role of a special education evaluation in the assessment and management of the child's misbehavior, including the development of a behavioral intervention plan to prevent disciplinary actions that is formalized in an individualized educational plan (IEP) or 504 plan.
If a mental health clinician has been co-located or integrated into the primary care setting, all parents of young children (universal prevention), as well as the parents of youth with mild behavior problems (indicated prevention), can be provided with a brief version of parent training . Programs targeted at toddlers through 12 yr olds have been found to be effective in improving parenting skills, parental mental health, and child emotional and behavior problems. For example, Incredible Years (http://www.incredibleyears.com ) has a 6-8 session universal prevention version to help parents promote their 2-6 yr old children's emotional regulation, social competence, problem solving, and reading readiness. A 12-20 session version is designed to strengthen parent–child interactions, reduce harsh discipline, and foster parents' ability to promote children's social, emotional, and language development in their toddler to school-age children. A randomized trial in pediatric practices found that Incredible Years significantly improved parenting practices and 2-4 yr olds' disruptive behaviors compared to a wait-list control. Similarly, for children with behavior problems, the Triple P program has seminar (three 90 min sessions), brief (15-30 min consultations), and primary care (four 20-30 min consultations) versions for the parents of youth from birth to the teenage years, specifically designed for implementation in the primary care setting. The Triple P interventions, supported by an extensive evidence base, focus on strengthening the parent–child relationship, identifying and monitoring the frequency of a problem behavior, and implementing and reviewing the effects of a targeted behavior plan.
For youth who continue to have mild to moderate behavior problems after several weeks of guided self-help or a brief course of parent training, or who from the outset exhibit moderate to severe or comorbid aggression, homicidality, assaultiveness, psychosis, or substance use, or who have a history of child maltreatment or severe family dysfunction or psychopathology, assessment and treatment in the specialty mental health setting by a child-trained mental health clinician should be provided.
The youth's problem behavior may predominantly occur at home, at school, with peers, or in the community, or it may be pervasive. If possible, interventions need to address each context specifically, rather than assuming generalizability of treatment. Thus, for behaviors mostly manifested in the home setting, parent training would be the treatment of choice, whereas for behaviors manifested mostly at school, consultation with the teacher and recommendation of a special education evaluation for service eligibility can be useful. When there are pervasive problems, including aggression toward peers, cognitive-behavioral therapy with the child/teen can be employed in addition to the other interventions.
Parent training has been extensively studied for the treatment of youth problem behavior. These programs, typically 10-15 wk in duration, focus on some combination of the following components: understanding social learning principles, developing a warm supportive relationship with the child, encouraging child-directed interaction and play, providing a predictable structured household environment, setting clear simple household rules, consistently praising and materially rewarding positive behavior, consistently ignoring annoying behavior (followed by praise when the annoying behavior ceases), and consistently giving consequences (e.g., time-out, loss of privileges) for dangerous or destructive behavior. Other important targets for parenting training include understanding developmentally appropriate moods and behavior, managing difficult temperamental characteristics, fostering the child's social and emotional development, and protecting the child from traumatic exposures. Specific parent training programs include Parent–Child Interaction Therapy , Triple P , Helping the Noncompliant Child, Incredible Years, and Parent Management Training Oregon. Predictors of nonresponse to these interventions have included greater initial symptom severity as well as involvement of the parent with child protection services.
Adherence to the complete treatment regimen has limited the effectiveness of parent training programs. Estimates of premature termination are as high as 50–60%, and termination within 5 treatment sessions is not uncommon. Predictors of premature termination of parent training programs have included single-parent status, low family income, low parental education levels, young maternal age, minority group status, and life stresses.
Cognitive behavioral therapy (CBT) for youth with disruptive behavior also has been extensively studied. Common CBT techniques for disruptive behavior include identifying the antecedents and consequences of disruptive or aggressive behavior, learning strategies for recognizing and regulating anger expression, problem-solving and cognitive restructuring (perspective-taking) techniques, and modeling and rehearsing social appropriate behaviors that could replace angry or aggressive reactions. Programs typically are delivered in 16-20 weekly sessions.
Multicomponent treatments for serious behavior disorders such as CD target the broader social context. Multidimensional Treatment Foster Care , delivered in a foster care setting for 6-9 mo, typically includes foster parent training and support; family therapy for biologic parents; youth anger management, social skills, and problem-solving training; school-based behavioral interventions and academic support; and psychiatric consultation and medication management, when needed. Multisystemic Therapy , typically lasting 3-5 mo, generally includes social competence training, parent and family skills training, medications, academic engagement and skills building, school interventions and peer mediation, mentoring and after-school programs, and involvement of child-serving agencies. These multicomponent programs have been designated “probably efficacious” because of the limited rigorous supporting evidence. Predictors of nonresponse to multicomponent treatments have included higher frequency of rule-breaking behavior and predatory aggression, higher psychopathy scores, and comorbid mood disorders.
Two classes of medication, stimulants and atypical antipsychotics , have strong evidence for the management of impulsive, anger-driven aggressive behavior, although neither is approved by the U.S. Food and Drug Administration (FDA) for this indication. Resource limitations may necessitate provision of pharmacotherapy in the primary care setting; the safety and efficacy of this practice can be enhanced by regular consultation with a child and adolescent psychiatrist. Several studies have shown favorable effects of stimulants on oppositional behavior and aggression in youths with ADHD. The doses of stimulants used for aggression are similar to those used for ADHD (average dose for methylphenidate, approximately 1 mg/kg/day). There is evidence for efficacy of risperidone in reducing aggression and conduct problems in children age 5-18 yr. The suggested usual daily dose of risperidone for severe aggression is 1.5-2 mg for children and 2-4 mg for adolescents. The initial starting doses are 0.25 mg for children and 0.5 mg for adolescents, titrating upward to the usual daily dose, as indicated and tolerated.
Medication trials should be systematic, and the duration of trials should be sufficient (generally 6-8 wk for atypical antipsychotics) to determine the agent's effectiveness. The short-term goal of treatment is to achieve at least a 50% reduction in aggressive symptoms, as assessed by a standardized rating scale (see Table 42.4 ); the ultimate goal is to achieve symptom remission (below clinical cutpoint on rating scale). A 2nd medication of the same class can be considered if there is insufficient evidence of response to the maximal tolerated dose by 8 weeks. Care should be taken to avoid unnecessary polypharmacy, in part by discontinuing agents that have not demonstrated significant benefit. Discontinuation of the medication should be considered after a symptom-free interval.
Most children and adolescents with a behavior disorder can be safely and effectively treated in the outpatient setting. Youths with intractable CD may benefit from residential or specialized foster care treatment, where more intensive treatments can be provided.