Childhood disruptive disorders

Childhood disruptive disorders are those involving problems with a child’s self-control. They
are characterised by a repetitive & persistent pattern of antisocial, aggressive or defiant
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behaviours. They account for approximately of all child & adolescent psychiatry clinic
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referrals. There are 2 conditions that make up this group of disorders: oppositional defiant
disorder and conduct disorder.

Oppositional defiant disorder

This is an enduring pattern of negative, hostile and defiant behaviour but without serious
violations of societal norms. The disorder may be present in one environment alone (such as
home) and tends to be more evident in interactions with familiar adults & peers. Since it is
normal for most adolescents to demonstrate impulsive & defiant behaviours for some time
in their life, it is widely accepted that converging factors contribute to the persistent
expression this defiant behaviour. The accepted risk factors are:

 Childhood maltreatment, such as physical or sexual abuse.

 Neglect.
 Emotional abuse.
 Overly harsh or punitive parenting.

Most patients with this disorder present at 8 years of age, although patients as young as 3
years of age can be found. It is more common in boys at younger ages; in adolescents the
prevalence ratio is 1:1.

Diagnostic criteria
ODD is defined by the presence of a pattern of angry/irritable mood, argumentative/defiant
behaviour and vindictiveness lasting at least 6 months (criterion A). The diagnosis is
evidenced by at least 4 of the following symptoms:

Angry/irritable mood:

1. Often loses temper.

2. Often touchy or easily annoyed.
3. Often angry & resentful.

Argumentative/defiant behaviour:

4. Often argues with authority figures or adults (for children & adolescents).
5. Often actively defies or refuses to comply with requests from authority figures
and/or rules.
 6. Often deliberately annoys others.
7. Often blames others for his/her mistakes or misbehaviour.

Vindictiveness:

8. Has been spiteful or vindictive at least twice in 6 months.

In children younger than 5 years of age, the behaviour should be seen on most days for at
least 6 months. In children over 5 years, the behaviour should be exhibited at least once a
week for 6 months. The disturbance in behaviour is also associated with distress in the
individual or others in his social circles (criterion B). The behaviours should also not occur
exclusively during the course of a psychotic, substance-induced, depressive or bipolar
disorder (criterion C). Furthermore, the criteria are not met for disruptive dysregulation
mood disorder.

Based on the DSM criteria, ODD is divided into mild, moderate and severe, and the severity
of the disorder is indicated by the pervasiveness of the symptoms:

 Mild ODD is that in which symptoms are only confined to one environment, such as
home or school.
 Moderate ODD is that in which some symptoms are present in 2 environments.
 Severe ODD is that in which some symptoms are present in 3 or more
environments.

The differentials for ODD are:

 ADHD.
 Cognitive disorders.
 Mental retardation.

Management
The treatment methods available are:

 Family intervention. Family intervention involves the use of both direct training of
the parents in child management skills and careful assessment of the family
interactions. The goal of this intervention is to promote pro-social & remove
undesired behaviours at the same time. Parents can pay less attention to the child’s
oppositional behaviour so as to prevent reinforcement of the behaviour.
 Individualised psychotherapy. They can role play & practice more adaptive
responses. The child can learn new strategies to develop a sense of mastery &
success in social situations with peers and family.

Prognosis of the condition is determined by:

 Severity of ODD.
 Age of onset.
  Presence of comorbid psychiatric disorder.
 Family dynamics & psychopathology.

30% of patients will eventually develop conduct disorders.

Conduct disorder (CD)

This is a disorder in which there is repetitive & persistent behaviour of violating rights of
other individuals. It usually involves acts of physical aggression. Children who demonstrate
enduring patterns of aggressive behaviour may continue to demonstrate this same
behaviour later on in life. Longitudinal studies have demonstrated that early patterns of
disruptive behaviour may become a lifelong repertoire culminating in adult antisocial
personality disorder.

Conduct disorder is more common in males, with the male:female ratio being 3-5:1; the
ratio, however, decreases in adolescence. Conduct disorder is more likely to develop in a
child whose parents have antisocial personality disorder and alcohol dependence.

Aetiology
The causes of CD are:

 Genetic factors. Studies have shown that genetic & environmental factors exert
equal influences on the prevalence of the condition.
 Parental factors. Harsh punitive parenting characterised by physical & verbal
aggression. Divorce also predisposes, not as a result of the divorce itself but as a
result of persisting hostility, resentment and bitterness between the divorced
parents. Parental psychopathology & sociopathy also contribute to development of
CD.
 Psychological factors. Poor emotion regulation amongst children is associated with
higher rates of aggression & conduct disorder.
 Sociocultural factors. CD is higher in overcrowded areas, and in amongst low socio-
economic status populations. In addition, the increased exposure & use of
substances in these locations & populations also predisposes to CD.
 Neurologic factors. EEG studies demonstrate that aggressive children have increased
right frontal brain activity. This has been hypothesised to reflect the ability to
regulate emotion. Boys tend to show lower emotional intelligence than girls.
 Neurobiological factors. Children with CD have decreased grey matter in their limbic
brain structures, in the left amygdala and in both insular lobes. There is also a
hypothesis suggesting decreased norepinephrine & serotonin levels in patients with
CD.
 Comorbid factors. CD often co-exists with ADHD. Other conditions that predispose
to this condition are CNS injury, damage or dysfunction.
Diagnostic criteria
Conduct disorder is defined by a repetitive & persistent pattern of behaviour in which the
basic rights of others, major age-appropriate societal norms and rules are violated (criterion
A). This is manifested by 3 of the following symptoms in the past 12 months:

Aggression to people & 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.
4. Has been physically cruel to humans.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim.
7. Has forced someone into sexual activity.

Destruction of property:

8. Has deliberated engaged in fire setting with the deliberate intent of causing damage.
9. Has deliberately destroyed other people’s property.

Deceitfulness or theft:

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

11. Often lies to obtain good or favours or to avoid obligations.
12. Has stolen items of non-trivial value without confronting individuals.

Serious violation of rules:

13. Often stays out at night despite parental prohibitions, beginning before 13 years.
14. Has run away from home overnight at least twice while living with his parents.
15. Is often a truant at school, beginning before 13 years.

The disturbance in behaviour causes clinically significant impairment in social, academic or

occupational functioning (criterion B). In individuals above 18 years, the criteria are not met
for antisocial personality disorder (criterion C).

Management
Management of CD is planned on a case-by-case basis and is likely to require a
multidisciplinary approach.

 Family education. The parents need to be educated on their child’s condition. They
also need to recognise that their actions can reinforce the behaviour the child has.
 Family therapy. The families meet with a therapist with whom they discuss current
problems. They are helped to cooperate in problem-solving.
 Parental management training. NICE criteria recommend that group-based parent
training/educational programmes in children aged 12 years or younger. It trains
parents to reward good behaviour and deal constructively with negative behaviour.
Individual-based programmes are only recommended in situations where there are
particular difficulties engaging with the parents, or a family’s needs are too complex
to be met by group programmes.
 Child interventions. These include anger management, social skills training, problem
solving and confidence building.
 Pharmacologic interventions. Antipsychotics have been proven to work in managing
aggressive behaviour in these children. SSRIs are used clinically to target symptoms
of impulsivity, irritability and mood lability.