EXTERNALIZING DISORDERS

o Children with ODD are also at risk

INTRODUCTION for other issues, including anxiety
and depressive disorders.
OVERVIEW

Definition: These disorders involve difficulties in BEHAVIORAL CHARACTERISTICS AND

self-control of emotions and behaviors. DIAGNOSIS

Behavioral Manifestation: These issues are

reflected in actions that violate others' rights (e.g., COMMONALITY IN TYPICAL
aggression, destruction of property) or cause DEVELOPMENT:
significant conflict with societal norms or authority o Many behaviors seen in these
figures. disorders can occur in typically
developing individuals.
Underlying Causes: The causes can vary widely o Diagnosis: It’s critical to assess:
across the disorders and even among individuals  The frequency,
within the same category. persistence, and
pervasiveness of the
DISORDERS INCLUDED IN THIS CATEGORY
behavior across
1. Oppositional Defiant Disorder (ODD) situations.
 Whether the behavior is
2. Intermittent Explosive Disorder (IED) typical for the
individual’s age, gender,
3. Conduct Disorder (CD)
and culture.
4. Antisocial Personality Disorder (refer to  If the behavior causes
the “Personality Disorders” chapter) distress to the child or
others, or impacts social
5. Pyromania or academic functioning.

6. Kleptomania EXTERNALIZING SPECTRUM

7. Other Specified and Unspecified

Disruptive, Impulse-Control, and COMMON EXTERNALIZING
Conduct Disorders SPECTRUM:
o These disorders are linked to a
PREVALENCE AND GENDER DIFFERENCES
broader externalizing spectrum
 Male Predominance: These disorders of personality traits, such as:
tend to be more common in males than in  Disinhibition
females, though the degree of male  Negative emotionality
predominance may vary across specific (some facets)
disorders and within different age groups. o These traits are typically
 Onset: Most of these disorders begin in inversely related to traits like
childhood or adolescence, with rare constraint and agreeableness.
onset in adulthood.
CO-OCCURRENCE WITH OTHER
DEVELOPMENTAL RELATIONSHIP BETWEEN DISORDERS
DISORDERS
COMORBIDITY:
ODD AND CD: o High comorbidity between these
o Many cases of conduct disorder disorders and other conditions
(CD) likely had symptoms that like:
met criteria for oppositional  Substance use
defiant disorder (ODD), disorders
especially when CD appears  Antisocial personality
before adolescence. disorder
o However, most children with ODD o The shared personality
do not develop CD. dimensions could explain this
overlap, but the exact nature of
 this common diathesis is still ODD is linked to interpersonal
unknown. difficulties in early adulthood.

PARENTING AND FAMILY IMPACT PROGRESSION:

o Some youths with ODD may
PARENTING CHALLENGES: develop conduct disorder.
o Parenting a child with these o Two main components of ODD:
disorders can be especially  Negative affect (e.g.,
difficult and may lead to: angry, irritable mood).
 Negative parent-child  Defiant and
interactions oppositional behavior.
 Increased family stress o Negative affect predicts future
 Negative feelings about depressive symptoms.
parenting o Oppositional behaviors predict
delinquency and conduct
disorder.
IMPACT OF DIAGNOSIS:
o 50% of individuals with ODD also
o A diagnosis requires a persistent have inattention and
pattern of behavior that is: hyperactivity.
 Atypical for the child’s
culture, gender, age, and DIAGNOSTIC FEATURES
development.
 Severe enough to cause
distress to the child or CORE SYMPTOMS
others, or negatively
ESSENTIAL FEATURES:
impact social or
academic functioning.  A frequent and persistent
pattern of:
OPPOSITIONAL DEFIANT DISORDER o Angry/irritable
mood.
OVERVIEW o Argumentative/defi
ant behavior.
CHARACTERISTICS:
 Vindictiven
o A persistent pattern of angry, ess.
argumentative, or vindictive
behavior lasting at least 6  Mood vs. Behavior:
months. o Individuals may
o Behaviors are directed toward exhibit behavior
authority figures (e.g., parents, typical of ODD
teachers). without negative
o At least four symptoms (e.g., mood symptoms.
short-tempered, resentful, o Angry/irritable
blaming, spiteful, or hostile) must moods are
be present. commonly linked to
o Youth often argue, defy adult behavioral
requests, and blame others, but features.
do not show extreme aggression
or antisocial behavior.
SEVERITY & CONTEXT
SEVERITY  Symptoms may be confined
o Mild ODD: Symptoms occur in to one setting (often home).
one setting (e.g., home).  Severity increases if
o Severe ODD: Symptoms occur in symptoms occur across
three or more settings (e.g., multiple settings (home,
home, school, social settings). school, social).
 Symptoms are more
COURSE AND PROGNOSIS noticeable in interactions
with familiar adults and
o Resolution: Symptoms often peers, rather than during
resolve with intervention, but clinical examination.
DIAGNOSTIC CRITERIA EARLY SIGNS:

 Four or more symptoms present for at  Symptoms typically

least 6 months, and behavior should begin in preschool
exceed what is normative for the years.
individual's age, gender, and culture.  Rarely develop after
o Example: A preschool child early adolescence.
having temper outbursts daily for
6 months may qualify, especially PROGRESSION
if it leads to impairment (e.g.,
o ODD often precedes conduct
destruction of property, exclusion
disorder, especially in children
from school).
with the childhood-onset type.
 Temper loss can also be shown as angry
o However, many children and
facial expressions, verbal expressions of
adolescents with ODD do not
anger, or subjective feelings of anger, not
develop conduct disorder.
just tantrums.

RISK OF OTHER DISORDERS:

PATTERN OF INTERACTIONS
o Increases risk for anxiety
o Often part of a problematic
disorders and major depressive
interaction pattern:
disorder, even without conduct
 Individuals with ODD
disorder.
typically justify their
o The defiant, argumentative
behavior as a response to
symptoms are more linked to
unreasonable demands.
conduct disorder.
 It can be difficult to
o Angry/irritable mood symptoms
determine if the child's
are more linked to mood and
behavior led to hostile
anxiety disorders.
responses from parents
or vice versa.
 Family environment ADULTHOOD OUTCOMES
(e.g., hostile parenting, o Individuals with ODD are at
neglect) can contribute increased risk for:
to or exacerbate  Functional
symptoms. impairments in
relationships (family,
ASSOCIATED FEATURES peers, romantic
partners).
 Lower educational
CO-OCCURRING CONDITIONS:
attainment.
o ADHD and conduct disorder are  Workplace stress.
common.  Persistence of ODD
o ODD is also associated with an symptoms.
increased risk of suicide  Other
attempts, even when controlling psychopathology:
for comorbid disorders. antisocial behavior,
impulse-control issues,
PREVALENCE substance abuse,
anxiety, and depression.
GLOBAL PREVALENCE:
RISK AND PROGNOSTIC FACTORS
o Ranges from 1% to 11%, with an
average of 3.3%.
o Higher prevalence in boys than TEMPERAMENTAL FACTORS
girls (1.59:1) before adolescence. o Emotional regulation issues
o Male predominance is not (e.g., high emotional reactivity,
consistent in adolescence or poor frustration tolerance) are
adulthood. predictive of ODD.

DEVELOPMENT AND COURSE

ENVIRONMENTAL FACTORS

AGE OF ONSET
 o Harsh, inconsistent, or neglectful o In non-Western cultures, the
parenting is associated with prevalence of ODD is more
increased symptoms. gender-equal compared to
o Environmental influence: Western cultures.
Children with ODD can influence  Migrants and refugees
their surroundings, creating a may have a lower risk of
cycle of worsening behaviors. developing ODD, despite
o Bullying: Children with ODD are adverse experiences.
at greater risk of bullying peers
and being bullied by peers. COMORBIDITY

 ADHD is highly comorbid with ODD, likely

GENETIC AND PHYSIOLOGICAL due to shared temperamental risk
FACTORS factors.
o Neurobiological markers  ODD often precedes conduct disorder,
associated with ODD: especially in childhood-onset types.
 Lower heart rate and  ODD increases the risk of:
skin conductance o Anxiety disorders.
reactivity. o Major depressive disorder
 Reduced basal cortisol (especially in those with
reactivity. angry/irritable mood).
 Prefrontal cortex and  High comorbidity with disruptive mood
amygdala dysregulation disorder (DMDD):
abnormalities. o Many individuals with DMDD
o Genetic links between show symptoms of ODD.
irritability/anger symptoms in o If ODD and DMDD symptoms
ODD and depression or anxiety overlap, only DMDD is diagnosed.
disorders.  Higher rates of substance use disorders
in adolescents and adults with ODD,
CULTURAL AND DIAGNOSTIC ISSUES though this may overlap with conduct
disorder.

CULTURAL VARIATIONS:
o Prevalence rates may vary
across different cultures.
o Social norms can influence the
diagnosis, as some behaviors
may not be considered
problematic in all cultures.

DIAGNOSITIC CRITERIA FOR OPPOSITIONAL DEFIANT DISORDER

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at
least 6 months, as evidenced by at least four symptoms from any of the following categories, and
exhibited during interaction with at least one individual who is not a sibling.
1. Angry/Irritable Mood
 a. Often loses temper.
 b. Is often touchy or easily annoyed.
 c. Is often angry and resentful.
2. Argumentative/Defiant Behavior
 a. Often argues with authority figures or, for children and adolescents, with adults.
 b. Often actively defies or refuses to comply with requests from authority figures or with rules.
 c. Often deliberately annoys others.
 d. Often blames others for his or her mistakes or misbehavior.
3. Vindictiveness
 a. Has been spiteful or vindictive at least twice within the past 6 months.
Note: The persistence and frequency of these behaviors should be used to distinguish behavior that is
within normal limits from behavior that is symptomatic.
 For children younger than 5 years, the behavior should occur on most days for a period of at
least 6 months unless otherwise noted (Criterion A8).
 For individuals 5 years or older, the behavior should occur at least once per week for at least 6
months, unless otherwise noted (Criterion A8).
While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other
factors should also be considered, such as whether the frequency and intensity of the behaviors are
outside a range that is normative for the individual’s developmental level, gender, and culture.
B. Distress or Negative Impact
The disturbance in behavior is associated with distress in the individual or others in their immediate social
context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational,
occupational, or other important areas of functioning.
C. Exclusion Criteria
The behaviors do not occur exclusively during the course of any of the following:
 Psychotic disorder
 Substance use disorder
 Depressive disorder
 Bipolar disorder
Also, the criteria are not met for disruptive mood dysregulation disorder.
Specify Current Severity
 Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
 Moderate: Some symptoms are present in at least two settings.
 Severe: Some symptoms are present in three or more settings.
INTERMITTENT EXPLOSIVE DISORDER year), involving damage or
destruction of an object or
OVERVIEW causing physical injury to
animals or others.

PREVALENCE, PERSISTENCE, AND

IMPAIRMENT: CORE FEATURES OF IED:

o IED is prevalent, persistent, and o Failure to control impulsive

seriously impairing. aggressive behavior in response
o Underdiagnosed and to subjectively experienced
undertreated (McLaughlin et al., provocation.
2012). o Provocation typically wouldn't
result in aggressive outbursts.
o Outbursts are impulsive or
DIAGNOSTIC CRITERIA:
anger-based, not premeditated
o (a) High-frequency/lower- or instrumental.
intensity aggressive outbursts o Results in distress or
(approximately twice weekly for impairment in occupational or
at least 3 months). interpersonal functioning, or
o (b) Low-frequency/high- financial/legal consequences.
intensity outbursts (three
occurrences within 1 year) EXCLUSIONS FOR DIAGNOSIS:
involving damage or injury to
people, animals, or property o Individuals under 6 years old (or
(Coccaro, Lee, & McCloskey, equivalent developmental level).
2014). o Aggressive outbursts better
explained by another mental
disorder.
OUTBURST CHARACTERISTICS:
o Should not be diagnosed with
o Occur suddenly in response to disruptive mood dysregulation
minor provocation. disorder or if outbursts are
o Not premeditated; exaggerated, caused by a medical condition or
angry, or impulsive reactions the physiological effects of a
causing distress or impairing substance.
interpersonal functioning. o Children ages 6–18 years should
o Unlike DMDD, the child’s mood is not be diagnosed if outbursts
normal between outbursts. occur in the context of an
o Diagnosis can only be made when adjustment disorder.
the child is at least 6 years old,
presumed to have learned to ASSOCIATED FEATURES
control aggressive impulses (APA,
2013).
COMORBIDITIES:

DIAGNOSTIC FEATURES o Commonly associated with

depressive disorders, anxiety
 Rapid onset of impulsive (anger-based) disorders, and substance use
aggressive outbursts: disorders.
o Typically little or no prodromal o Onset of these comorbid
period. disorders typically occurs later
o Last for less than 30 minutes. than IED.
 Commonly occur in
response to a minor
NEUROBIOLOGICAL FINDINGS:
provocation from a
close person. o Serotonergic abnormalities
 Frequency and severity: globally and specifically in areas
o Criterion A1: Frequent like the limbic system (e.g.,
aggressive outbursts (twice anterior cingulate) and
weekly for 3 months), such as orbitofrontal cortex.
temper tantrums, verbal o Amygdala responses to anger
arguments, or fights, without stimuli are greater in individuals
damage or injury. with IED compared to healthy
o Criterion A2: Infrequent individuals.
aggressive outbursts (three in a
 o Reduced volume of gray matter RISK AND PROGNOSTIC FACTORS
in frontolimbic regions,
correlating with measures of
aggression. ENVIRONMENTAL FACTORS:
o Brain differences are not always o Increased risk for individuals with
present. a history of physical and
emotional trauma during the first
PREVALENCE 20 years of life.
o Displacement from home and
 1-year prevalence in the United States:
separation from family are risk
2.6%.
factors, particularly in some
 Lifetime prevalence: 4.0%.
refugee populations.
 Higher 1-year prevalences in:
o 3.9% among African American
adolescents. GENETIC AND PHYSIOLOGICAL
o 6.9% among Caribbean Black FACTORS:
adolescents, especially in males. o First-degree relatives of
 Cultural factors: individuals with IED are at
o Higher psychiatric disorder rates increased risk.
among immigrant Caribbean o Twin studies suggest a
Black men and their offspring, substantial genetic influence
possibly related to downward for impulsive aggression.
social mobility and the effects of
racism. CULTURE-RELATED DIAGNOSTIC ISSUES
o Prevalence may be affected by
misdiagnosis or overdiagnosis
LOWER PREVALENCE IN SOME
among some cultural
REGIONS:
backgrounds.
 Age-related prevalence: o Countries/regions like Asia,
o More prevalent in individuals Middle East, and Romania have
younger than 35–40 years. lower reported prevalence of IED.
o Less prevalent in individuals over o This could be due to cultural
50 years and those with higher factors, where recurrent
educational attainment. impulsive aggressive behaviors
 Sex and gender differences: are either not elicited during
o Some studies find a higher questioning or less likely to be
prevalence in men and boys. present.
o Other studies find no sex or
gender differences. COMORBIDITY

 Common comorbidities in community

DEVELOPMENT AND COURSE
samples:
o Depressive disorders.
ONSET: o Anxiety disorders.
o Most common in late childhood o Posttraumatic stress disorder.
or adolescence. o Bulimia nervosa and binge-
o Rare onset after age 40. eating disorder.
o Substance use disorders.
 Increased risk for comorbidity with:
COURSE:
o Antisocial personality disorder.
o Episodic, with recurrent periods o Borderline personality disorder.
of impulsive aggressive o Disruptive behavior disorders
outbursts. (e.g., ADHD, conduct disorder,
o Chronic and persistent course oppositional defiant disorder).
over many years.
o Common, regardless of the
presence of ADHD or other
disruptive, impulse-control, and
conduct disorders.
 DIAGNOSTIC CRITERIA OF INTERMITTENT EXPLOSIVE DISORDER
A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested
by either of the following:
1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical
aggression toward property, animals, or other individuals, occurring twice weekly, on average,
for a period of 3 months. The physical aggression does not result in damage or destruction of
property and does not result in physical injury to animals or other individuals.
2. Three behavioral outbursts involving damage or destruction of property and/or physical
assault involving physical injury against animals or other individuals occurring within a 12-
month period.
B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion
to the provocation or to any precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based)
and are not committed to achieve some tangible objective (e.g., money, power, intimidation).
D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in
occupational or interpersonal functioning, or are associated with financial or legal consequences.
E. Chronological age is at least 6 years (or equivalent developmental level).
F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major
depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder,
antisocial personality disorder, borderline personality disorder) and are not attributable to another medical
condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects of a substance (e.g., a
drug of abuse, a medication). For children ages 6–18 years, aggressive behavior that occurs as part of an
adjustment disorder should not be considered for this diagnosis.
Note: This diagnosis can be made in addition to the diagnosis of attention-deficit/hyperactivity disorder,
conduct disorder, oppositional defiant disorder, or autism spectrum disorder when recurrent impulsive
aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical
attention.
CONDUCT DISORDER  Callous, unemotional traits:
o Cruelty, aggression, and a lack
OVERVIEW of remorse are common.
o Youth with these traits are
 Conduct disorder (CD) is characterized unconcerned about victim
by a persistent pattern of antisocial suffering or punishment (Pardini
behavior that: & Byrd, 2012).
o Reflects dysfunction within the o They show limited neural
individual (not a pattern accepted responsiveness in brain regions
in the person’s subculture). associated with empathy when
o Includes serious violations of presented with images of people
rules and social norms and in pain (Lockwood et al., 2013).
disregard for the rights of others. o Adolescents with CD and callous
 Diagnosis of CD requires at least three traits demonstrated pleasure in
different behaviors involving: watching videos of people in pain
o Deliberate aggression: (Decety, Michalska, Akitsuki, &
 Bullying, physical Lahey, 2009).
fights, use of weapons,  Risk:
cruelty to people or o Youth with these traits are at high
animals, aggressive risk for continuing criminal
theft, forced sexual behavior and may be diagnosed
contact. with antisocial personality
o Destruction of property, disorder in adulthood (Kahn,
including fire-setting. Byrd, & Pardini, 2013; Lubit,
o Theft or deceit: 2012).
 Stealing, forgery, home  The behaviors associated with CD are a
or car invasion, significant concern to the public.
“conning others”. o Some youth advocates
o Serious violation of rules: recommend widespread
 Staying out at night, screening for CD in young
truancy, running away. children, as early intervention
 Behavior patterns often start in early can help modify the course of the
childhood and can persist through the disorder (Hektner, August,
school years (Rolon-Arroyo, Arnold, & Bloomquist, Lee, & Klimes-
Harvey, 2014). Dougan, 2014).
 Disorderly behavior may increase or
become more serious with age. DIAGNOSTIC FEATURES:
 Boys with CD: Often involved in
confrontational aggression (e.g.,  The essential feature of CD is a repetitive
fighting, aggressive theft). and persistent pattern of behavior where
 Girls with CD: More likely to display the basic rights of others or major age-
truancy, substance abuse, or chronic appropriate societal norms or rules are
lying. violated (Criterion A).
 Four main groupings of behaviors:
o Aggressive conduct causing or
PREVALENCE:
threatening physical harm to
o Approximately 2–9 percent of people or animals (Criteria A1–
youth meet the diagnostic criteria A7).
for CD. o Nonaggressive conduct that
o About half of those with CD also causes property damage or loss
display inattention and (Criteria A8–A9).
hyperactivity (APA, 2013). o Deceitfulness or theft (Criteria
 According to DSM-5, some youth with CD A10–A12).
have “limited prosocial emotions”: o Serious violations of rules
o Display minimal guilt or remorse. (Criteria A13–A15).
o Unconcerned about their  Three or more characteristic behaviors
wrongdoing or the feelings of must have occurred during the past 12
others. months, with at least one behavior
o Manipulative and may appear present in the past 6 months.
superficially polite and friendly  The disturbance causes significant
when something is to gain (APA, impairment in social, academic, or
2013). occupational functioning (Criterion B).
  The behavior pattern is usually present responding with aggression that they
across various settings: home, school, believe is justified.
community.  Personality Features:
 Additional informants are often needed o Negative emotionality, poor
as individuals with CD may minimize their self-control, including:
conduct problems.  Frustration tolerance,
irritability, temper
EXAMPLES OF BEHAVIORS: outbursts.
 Suspiciousness,
AGGRESSIVE BEHAVIOR: insensitivity to
punishment,
 Bullying, threatening, or
recklessness.
intimidating behavior,
 Thrill seeking.
including via web-based
 Substance misuse: Common,
social media (Criterion A1).
particularly in adolescent girls.
 Frequent physical fights
(Criterion A2). PREVALENCE:
 Use of weapons (e.g., bat,
knife, gun) (Criterion A3).  One-year prevalence estimates in the
 Physical cruelty to people United States and other high-income
(Criterion A4) or animals countries range from 2% to 10%, with a
(Criterion A5). median of 4%.
 Stealing while confronting a  Lifetime prevalence:
victim (Criterion A6). o 12.0% in men.
 Forced sexual activity o 7.1% in women.
(Criterion A7).  Prevalence appears consistent across
Western countries.
DESTRUCTION OF PROPERTY:  Prevalence rises from childhood to
adolescence.
 Fire-setting intended to
 Adolescent-onset CD often linked to
cause serious damage
psychosocial stressors such as
(Criterion A8).
discrimination.
o Vandalism,
 Few children with impairing CD receive
smashing car
treatment.
windows, or
destroying other DEVELOPMENT AND COURSE:
people's property
(Criterion A9).  Onset: May start as early as the preschool
years, though symptoms usually emerge
DECEIT OR THEFT: from middle childhood to middle
adolescence.
 Breaking into homes, cars, or
 Oppositional defiant disorder is a
buildings (Criterion A10).
common precursor for childhood-onset
 Lying or breaking promises
CD.
for personal gain (Criterion
 Aggressive symptoms are more common
A11).
in childhood, while nonaggressive
 Shoplifting, forgery, or fraud
symptoms increase in adolescence.
(Criterion A12).
 Adult Diagnosis: CD is rarely diagnosed
after age 16.
RULE VIOLATIONS:
 Course: Variable:
 Staying out late despite o Many individuals with
parental prohibitions adolescent-onset or milder
(Criterion A13). symptoms show adequate
 Running away from home social and occupational
(Criterion A14). adjustment as adults.
 Truancy from school o Childhood-onset predicts worse
(Criterion A15). prognosis, with higher risk of
criminal behavior and
ASSOCIATED FEATURES substance disorders in
adulthood.
 Aggressive individuals with CD often
 Symptoms evolve as individuals age, with
misperceive ambiguous situations as
less severe behaviors appearing first (e.g.,
more hostile and threatening,
 lying, shoplifting), and more severe YOUTH FROM UNDERSERVED
behaviors (e.g., rape, theft involving ETHNIC AND RACIALIZED GROUPS:
confrontation) appearing later.
o Reactions to racism may involve
anger and resistance-based
RISK AND PROGNOSTIC FACTORS
coping, which could be
misdiagnosed as conduct
TEMPERAMENTAL RISK FACTORS: disorder.
o Difficult infant temperament o This association is suggested in
and lower-than-average adolescent-onset conduct
intelligence, especially verbal disorder in these groups.
IQ.
SEX- AND GENDER-RELATED DIAGNOSTIC
ISSUES
ENVIRONMENTAL RISK FACTORS:
 Boys and men with conduct disorder:
FAMILY-LEVEL: o Frequently exhibit:
 Parental rejection, neglect,  Fighting.
harsh discipline, physical or  Stealing.
sexual abuse.  Vandalism.
 Lack of supervision,  School discipline
frequent caregiver changes, problems.
parental criminality.  Girls and women with conduct disorder:
o More likely to exhibit:
COMMUNITY-LEVEL:  Lying.
 Truancy.
 Peer rejection, delinquent  Running away.
peers, neighborhood  Prostitution.
disadvantage, exposure to  Relational aggression:
violence.
o Boys and men: Exhibit physical
aggression and relational
GENETIC AND PHYSIOLOGICAL aggression.
RISK FACTORS: o Girls and women: Exhibit
o Genetic risk, especially for relational aggression, but less
aggressive symptoms. physical aggression than boys
o Family history of conduct and men.
disorder, alcohol use disorder,
depressive and bipolar COMORBIDITY
disorders, schizophrenia, or
ADHD. COMMON COMORBIDITIES:
o Slower resting heart rate and
o ADHD.
reduced autonomic fear
o Oppositional defiant disorder.
conditioning in individuals with
o This comorbid presentation
CD.
predicts worse outcomes.
o Brain differences in areas
associated with affect regulation
(e.g., prefrontal cortex, ANTISOCIAL PERSONALITY
amygdala). DISORDER:
o Individuals showing personality
CULTURE-RELATED DIAGNOSTIC ISSUES features associated with
antisocial personality disorder
MISAPPLICATION OF DIAGNOSIS: may violate others’ basic rights or
major age-appropriate societal
o Conduct disorder may be norms, meeting criteria for
misapplied in settings where conduct disorder.
disruptive behavior is viewed as
near-normative (e.g., in high-
OTHER POSSIBLE COMORBIDITIES:
crime areas or war zones).
o The context of behavior should o Specific learning disorder.
be considered when diagnosing. o Anxiety disorders.
o Depressive or bipolar disorders.
o Substance-related disorders.
 ACADEMIC ACHIEVEMENT: levels based on age and
intelligence.
o Particularly in reading and verbal
o May justify the diagnosis of
skills, is often below expected
specific learning disorder or a
communication disorder.

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 at least three of the
following 15 criteria in the past 12 months from any of the categories below, 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 Violations 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 the 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 age 18 years or older, criteria are not met for antisocial personality disorder.
Specify whether:
 F91.1 Childhood-onset type: Individuals show at least one symptom characteristic of conduct
disorder prior to age 10 years.
 F91.2 Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder
prior to age 10 years.
 F91.9 Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not
enough information.
ETIOLOGY externalizing disorders (Parens &
Johnston, 2010).
EXTERNALIZING DISORDERS AND  A child’s early environment appears to
ETIOLOGY: moderate the relationship between
individual vulnerability and the age at
 Externalizing disorders often begin in which antisocial behavior emerges.
early childhood.  Parents and teachers are able to exert
 The etiology of these disorders involves more influence on the behavior of children
an interaction between biological, with antisocial tendencies during
psychological, social, and sociocultural childhood compared to adolescence, a
factors. period when peer influences
 Among the externalizing disorders, predominate (Fairchild, van Goozen,
biological factors appear to exert the Calder, & Goodyer, 2013).
greatest influence on the development of
CD, the disorder which is the focus in this PARENTING AND DISCIPLINE:
etiological discussion.
 In some cases, disruptive and aggressive
BIOLOGICAL FACTORS AND BRAIN behaviors are associated with harsh or
ABNORMALITIES: inconsistent discipline (Pederson & Fite,
2014).
 Antisocial behavior has been linked to  Disruptive behavior may develop when
brain abnormalities associated with parents behave in a punitive,
deficits in social information processing, inconsistent, or impatient manner in
as well as reduced activity in the response to typical childhood
amygdala in situations associated with misbehaviors.
fear (Sterzer, 2010).  Parent–child conflict and power
 These deficits appear to decrease the struggles can further intensify
ability to learn from rewards and inappropriate behaviors.
punishments (Byrd, Loeber, & Pardini,  Patterson (1986) formulated a classic
2014). psychological-behavioral model of
disruptive behavior based on the following
GENETIC FACTORS AND RISK:
pattern of parental reaction to
 Risk of CD is increased when carriers of misbehavior:
the genotype "low-activity MAOA" (an
1. The parent addresses
allele associated with fear-regulating
misbehavior or makes an
circuitry in the amygdala) are subjected
unpopular request.
to childhood maltreatment (Fergusson,
Boden, Horwood, Miller, & Kennedy, 2. The child responds by arguing or
2012). counterattacking.
 Reduced activity of the autonomic
nervous system and an associated 3. The parent withdraws from the
increased need for stimulation to achieve conflict or gives in to the child’s
optimal arousal is also associated with demands.
CD in males; this may account for the risk-
taking behaviors associated with the  If this pattern develops, the child does not
disorder (El-Sheikh, Keiley, & Hinnant, learn to respect rules or authority.
2009).  An alternate pattern that sometimes
occurs involves a vicious cycle of harsh,
HORMONAL FACTORS: punitive parental responses to
misbehavior, resulting in defiance and
 Elevated stress hormones (cortisol) disrespect on the part of the child and
have been associated with symptoms of further coercive parental behaviors
impulsive aggression, whereas low (Tynan, 2008).
cortisol levels occur in youth with
callous and unemotional traits and PARENTING PRACTICES AND DISRUPTIVE
predatory aggression (Barzman, Patel, BEHAVIOR:
Sonnier, & Strawn, 2010).
 Limited parental supervision,
FAMILY AND SOCIAL CONTEXT: permissive parenting, and avoidance of
conflict, excessive attention for negative
 Both family and social context play a behavior, inconsistent disciplinary
large role in the development of practices, and failure to teach prosocial
 skills or use positive management
techniques can further exacerbate
disruptive behavior (Bernstein, 2012).

CHILD TEMPERAMENT AND PEER

REJECTION:

 Difficult child temperament (e.g.,

irritable, resistant, or impulsive
tendencies) contributes to behavioral
conflict and increases the need for
parents to learn and consistently apply
appropriate behavior management
skills.
 These temperamental tendencies can
lead to rejection by peers and a blaming,
negative worldview, sometimes
accompanied by aggressive behavior.

EMOTIONAL ISSUES AND LONG-TERM

OUTCOMES:

 Underlying emotional issues are

common in CD and other disruptive
behavior disorders.
 In fact, childhood externalizing behavior
disorders are associated with the
development of depressive disorders in
adulthood (Loth, Drabick, Leibenluft, &
Hulvershorn, 2014).
TREATMENT INCARCERATION:

INTERVENTIONS ADDRESSING FAMILY AND  Incarceration within juvenile or adult

SOCIAL CONTEXT: facilities is one of the most frequent
interventions for youth with CD.
 Interventions that address the family and  Unfortunately, this practice often
social context of behaviors, as well as produces additional behavioral or
deficits in psychosocial skills, can psychological difficulties rather than
significantly improve externalizing rehabilitation, especially when
behaviors (Parens & Johnston, 2010). incarceration occurs in adult facilities
(Lambie & Randell, 2013).
COGNITIVE-BEHAVIORAL PARENT
EDUCATION:

 A well-established intervention for

externalizing disorders is cognitive-
behavioral parent education.
 These programs teach parents to:
o Regulate their own emotions.
o Increase positive interactions
with their children.
o Establish appropriate rules.
o Consistently implement
consequences for inappropriate
behavior.
 Parent-focused interventions can
improve both child behavior and parent
mental health (Furlong et al., 2013).

PSYCHOSOCIAL INTERVENTIONS FOR

CHILDREN:

 Psychosocial interventions that focus on

teaching youngsters:
o Assertiveness.
o Anger management techniques.
o Building skills in empathy,
communication, social
relationships, and problem-
solving.
 These interventions can produce marked
and durable changes in disruptive
behaviors (Eyberg et al., 2008).

ADULT MENTORSHIP:

 Mobilizing adult mentors who

demonstrate:
o Empathy.
o Warmth.
o Acceptance.
 This intervention has been shown to be
effective (Kazdin, Whitley, & Marciano,
2006).

CONDUCT DISORDER TREATMENT:

 Conduct Disorder (CD) is particularly

difficult to treat.
 Success is increased when treatment
begins before patterns of antisocial
behavior are firmly established (Lubit,
2012).