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i

Understanding Conduct Disorder

and Oppositional-​D efiant Disorder

This vital guide takes a new approach to conduct and

oppositional defiant disorders (CD and ODD), present-
ing the science in an accessible way to empower both par-
ents and practitioners. Vanzin and Mauri cover a range of
key topics, including distinguishing between typical and
atypical behavioral development, how to choose the best
course of treatment for a child and how parental behavior
can help or hinder progress, providing a comprehensive
overview of these two disorders.
In six clearly labeled chapters, the authors explain
the ­science behind popular treatments, providing prac-
tical advice and clear, step-​by-​step instructions on how
to approach challenging behavior. Written in concise
and straightforward language, each chapter concludes
with “important points” summarizing key information,
designed to help those living or working with children
suffering from behavioral disorders to both understand
the nature of the disorders and achieve the best outcome
for the child. The final chapter of the book presents an
in-​depth case study of a child with behavioral disorders,
thoroughly detailing symptoms, treatment and outcome,
providing a demonstration of best practice and affirming
that challenging behavior can be effectively managed.
ii

Illustrated with clinical vignettes of the experiences of chil-

dren living with CD and ODD, Understanding Conduct
Disorder and Oppositional-​Defiant Disorder is essential
reading for parents and caregivers, as well as practitioners
in clinical and educational psychology, counseling, mental
health, nursing, child welfare, public healthcare and those
in education.

Laura Vanzin is a psychologist and psychotherapist at the

Child Psychopathology Unit, Scientific Institute, IRCCS
Eugenio Medea in Bosisio Parini, Lecco, Italy, and a lec-
turer at the Catholic University of Milan.

Valentina Mauri is a psychologist and psychotherapist at

the Child Psychopathology Unit, Scientific Institute, IRCCS
Eugenio Medea in Bosisio Parini, Lecco, Italy.
iii

Understanding Atypical Development

Series editor: Alessandro Antonietti,
Università Cattolica del Sacro Cuore, Italy

This volume is one of a rapidly developing series in

Understanding Atypical Development, published by
Routledge. This book series is a set of basic, concise guides on
various developmental disorders or issues of atypical devel-
opment. The books are aimed at parents, but also profession-
als in health, education, social care and related fields, and are
focused on providing insights into the aspects of the condi-
tion that can be troubling to children, and what can be done
about it. Each volume is grounded in scientific theory but
with an accessible writing style, making them ideal for a wide
variety of audiences.
Each volume in the series is published in hard-
back, paperback and e-​ book formats. More informa-
tion about the series is available on the official website at:  ​
www.routledge.com/​Understanding-​Atypical-​Development/​
book-​ series/​
UATYPDEV, including details of all the titles
published to date.

Published titles

Understanding Tourette Syndrome

Carlotta Zanaboni Dina and Mauro Porta

Understanding Rett Syndrome

Rosa Angela Fabio, Tindara Caprì and Gabriella Martino

Understanding Conduct Disorder and Oppositional-​

Defiant
Disorder
Laura Vanzin and Valentina Mauri
iv
v

U nd e rst a n di n g
C ond uc t D i so rd e r a nd
O p p os i t i o n a l -​D ef ia nt
D i s ord e r

A G ui de t o S ymp t om s,
Manageme n t an d Tre at m e n t

Laura Vanzin &

Valentina Mauri
vi

First published 2020
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
52 Vanderbilt Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2020 Laura Vanzin & Valentina Mauri
The right of Laura Vanzin & Valentina Mauri to be identified as authors of this work
has been asserted by them in accordance with sections 77 and 78 of
the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised
in any form or by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without
intent to infringe.
British Library Cataloguing-​in-​Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-​in-​Publication Data
A catalog record has been requested for this book
ISBN: 978-​0-​367-​23229-​0  (hbk)
ISBN: 978-​0-​367-​23231-​3  (pbk)
ISBN: 978-​0-​429-​32814-​5  (ebk)
Typeset in Sabon
by Newgen Publishing UK
vii

Contents

1 Conduct disorder and oppositional-​defiant

disorder: signs and symptoms  1
2 Treatments  27
3 Treatment with children and adolescents  39
4 Treatment with parents or caregivers  59
5 Educative strategies in the school context  95
6 Paul against the world  105

Bibliography  137
Index  149
viii
1

Chapter 1

Conduct disorder and

oppositional-​d efiant disorder
Signs and symptoms

All children can be crabby, fickle and refuse to follow the

rules enforced by adults, thus coming into conflict. What
can vary is the pervasiveness of such behaviors, which can
be of an extent such that they compromise children’s func-
tioning in those life contexts where they are integrated.
In general, when we talk about “behavioral problems,” we
are referring to those difficulties pertaining to the sphere of
externalizing disorders or “acting out,” meaning those cases
in which a person’s discomfort reflects on the outside, causing
a troubling situation in the surrounding context.
Not all behavioral issues, however, become true behav-
ioral disorders; indeed, the intensity, pervasiveness and
chronicity with which those issues exhibit themselves vary,
and therefore their consequences for the child and the sur-
rounding social context also vary.
In the fifth version of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-​5), published by the
American Psychiatry Association (APA, 2013), behavioral
disorders of the child and adolescent became inserted into
the diagnostic category “Disruptive, Impulse-​Control, and
Conduct Disorders,” which comprises:

•​ Oppositional-​Defiant Disorder;
•​ Intermittent Explosive Disorder;
2

2  Signs and symptoms

•​ Conduct Disorder;
•​ Antisocial Personality Disorder;
•​ Pyromania;
•​ Kleptomania;
•​ Other Specified or Unspecified Disruptive, Impulse-​
Control, and Conduct Disorder.

Here below, we will describe briefly the typical develop-

ment trajectories, with a focus on the ability of children to
acquire adequate tolerance of frustration and good man-
agement of aggression. We will also outline briefly the clas-
sification of behavior disorders in a descriptive fashion,
with particular attention to Oppositional-​Defiant Disorder
and Conduct Disorder, which are widespread in the devel-
opmental age populations.

Typical developmental trajectories

Aggressive behavior
Studies on infant development show that the newborn cry
is among the first forms of communication. Developmental
age psychologists have indeed demonstrated that babies
communicate very much before they can talk (Bates, 1976;
Bates et al., 1977) and, such as with crying, they exert a
remarkable influence over adults, to the point of leading
them into coming close and providing care.
Aggression has been considered as a primordial form
of communication as well. Aggression, meant as the abil-
ity of self-​defense against physical and verbal attacks, is
a “physiological” behavior since it contributes to survival
and to the development of adaptation abilities. It is com-
mon among preschool toddlers, but it constantly dimin-
ishes with age, to become quite absent by the onset of
adolescence (Bongers et al., 2004).
3

Signs and symptoms  3

Anger is among the first emotions to appear in infancy.

Between 2 and 6  months of age, children engage in rec-
ognizable manifestations of anger through crying, and by
7  months of age, clear facial expressions related to this
emotion can be detected (Stenberg et al., 1983). Aggressive
behaviors like biting, pushing, hitting, punching, spitting
and grasping hair are common throughout infancy.
Brownlee and Bakeman (1981) observed how, for instance,
the act of a child hitting another with an open hand induces a
rapid ceasing of interactions with the aggressor, just as if the
meaning of the act is “leave me alone.” From the age of three,
however, children resort more to verbal language and less to
aggression in order to influence peers. In this way, a more
refined communication method (verbal language) progres-
sively substitutes for the primordial communication method
(aggression). The literature on typical child development
shows how, when individuals acquire novel modes of achiev-
ing their goals through the use of language, they tend to lose
the more primordial modes (crying, shouting, aggression) of
achieving these goals.
Some children encounter hardships and delays in the
process of acquiring verbal language. Stevenson and
Richman (1978) demonstrated a strong association
between behavior disorders and impairments in expressive
language, and several following studies demonstrated that
children whose communication development is limited
have a greater probability of being described as disobedi-
ent, aggressive and oppositional. This does not rule out,
however, that persons with an excellent verbal language
may resort to aggressive behavior when, for instance, they
want to escape from an unpleasant situation.
Growing up, most children thus tend to become social and
to inhibit aggressive behaviors. Interactions with adults play
an important role in modeling the behavioral repertoire of
children toward more appropriate modes of expressing their
4

4  Signs and symptoms

desires and defending their rights. Caregivers tend to answer

expressions of anger and aggression from children by ignoring
them or reacting negatively (Malatesta et al., 1986; Huebner
& Izard, 1988). In time, children learn what is socially accept-
able and their anger manifestations diminish.
However, it must be noted that cultures may differently
condemn or uphold aggression and that each kind of child-
hood education reflects such values. For instance, among
peoples like the Esquimese, who value harmony in social
relations and do not tolerate any violent behavior, chil-
dren tend to show little aggression, whereas among ethnic
groups from New Eastern Guinea, where cannibalism is
still practiced, children are encouraged to be independent
and aggressive. Among Western cultures, there is general
agreement on the importance of maintain control over
aggression and on the fact that a fundamental task of par-
ents and teachers is to ensure that the baby learns to con-
trol hostile urges as soon as possible.
Aggression can take many forms:  verbal or physical;
enacted in a group or individually; accompanied by strong
emotions or cold-​hearted; and directed or indiscriminate.
A distinction based on personal intention leads to three
categories of aggressive acts:

(1) Hostile aggression: motivated by the intention to inflict

pain, damage or suffering to the other person;
(2)
Instrumental aggression:  use of force to obtain
something;
(3) Retaliation: hostile act in response to a similar act done
by others toward oneself.

These kinds of aggression show different development

trends across growth.
In typically developing children, physical aggression
peaks around the age of two and then tends to decline with
5

Signs and symptoms  5

growth, reaching the lowest point during late adolescence

(Stanger et al., 1997; Nagin & Tremblay, 1999; Keiley et al.,
2000; Bongers et al., 2003, 2004). From 24 months of age,
children are indeed capable of controlling their expres-
sions of anger and are more prone to showing sadness, an
emotion that is more often reinforced by caregivers (Buss
& Kiel, 2004). Studies on infant development show that
between 2 and 4 years of age physical aggression tends to
be substituted for verbal expressions of hostility. During
early infancy, children thus learn appropriate ways of man-
aging and expressing their anger, also thanks to the acqui-
sition of an increasingly wide emotional repertoire and to
improved comprehension of causes and consequences of
feelings (Ridgeway et al., 1985; Denham, 1998).
When they reach the age of attending primary school,
children have usually developed good awareness of what
is adequate and functional regarding emotion expres-
sion. Concerning anger, school-​age children believe that
the most appropriate way to express this feeling is ver-
bal, while frowning, crying and aggression are thought to
be less adequate (Shipman et al., 2003). Toward 6–​7 years
of age, there is a global reduction of aggression manifes-
tations because children are less willing, as compared to
those of preschool age, to resort to instrumental aggres-
sion. This positive trends is, however, associated with an
increase of hostile aggression and retaliation.
As age increases, there is a differentiation in the percep-
tion of others’ intentions: some children limit retaliation to
cases in which the hostility of others is clear, while others
instead tend to interpret neutral or positive signals from
their peers as hostile and react consequently with stances
that convey aggression. In this second case, the likelihood
of triggering a growing spiral of negativity in personal
relationships increases, which may lead to the social rejec-
tion that aggressive children often face (Dodge, 1980).
6

6  Signs and symptoms

Since it has been documented that, once established

during development, the tendency to react aggressively
becomes a stable personality trait, these children are con-
sidered as subjects who are at risk even when inappropri-
ate acts are still of a modest capacity (Caprara, 1992).

Oppositional behavior
Clashes, whims and refusals to comply with rules are behav-
iors that any child may manifest throughout develop­ment.
During early infancy, the oppositional behavior, which has
its peak at around 18–​24  months of age when toddlers
reach good ambulatory mastery, is an expression of the
toddler’s will to become autonomous:  the desire to dis-
cover the world and experiment is why children display
signs of rebellion every time someone tries to impede them.
When this phase is over, the toddler acquires a form of self-​
regulation that allows for the establishment of less com-
bative relationships.
Children indeed begin to understand the consequences
of their own behavior between 6 and 9 months of age, a
time frame during which they may also begin to recognize
the meaning of the word “no.” Starting from the age of
2, the ability to follow simple instructions also starts to
develop, thanks to the development of physical, cognitive,
social and linguistic competence (Matthys et  al., 2017).
However, little compliance with parental requests is very
common for children between 2 and 3 years of age, prob-
ably because of parents’ expectations (about the “terrible
twos”) and due to an insufficient capacity of parents to
teach their children to be compliant (Brumfield & Roberts,
1998). Developmental trajectories predict that rule-​
following increases with age, and improvement in respect-
ing maternal requests becomes evident between 18 and
30 months of age (Vaughn et al., 1984). When they reach
7

Signs and symptoms  7

school age, children are expected to follow the requests of

adults most of the time: the rates of compliance to requests
is indeed around 80 percent for children showing typical
development (McMahon & Forehand, 2003).
During adolescence, rule-​ breaking behaviors often
increase again:  changes in cognition and social abilities,
together with the need for independence and definition of
self-​identity, can bring about an increase in conflicts with par-
ents that is maximal during early adolescence and gradually
declines until the late adolescence (Laursen et al., 1998).

Offense in adolescence
Adolescence is a period when the relationship with rules is
maximally under question. An increase of impulsiveness,
connected with pubertal development, leads to the enact-
ment of behaviors considered to be transgressions of rules
imposed by parents and by social context. It is indeed fre-
quent for adolescents to be involved in offensive behaviors
like drinking alcohol, running away from home and steal-
ing from shops. These actions are often performed in small
groups.
These behaviors come from the drive to grow and put
oneself to the test, thus they do not necessarily represent the
manifestation of a problem. It is important to distinguish
behaviors that characterize adolescence (those common to
most adolescents) from those that really are expressions of
a minority. Psychosocial investigations have observed how
adolescents and adults tend to judge as acceptable and
unrelated to a behavioral disorder behaviors like drink-
ing alcohol, playing truant and not paying for bus tickets.
Other behaviors, like doing drugs, vandalism and sexual
offenses, are judged sternly by adolescents as well as by
adults, and they are considered to be deviations from nor-
mal developmental trajectories.
8

8  Signs and symptoms

Antisocial adolescents
Offensive behavior can sometimes be the manifestation
of a deeper issue demanding clinical attention. Antisocial
adolescents are those who tend to enact severe offensive
behaviors repeatedly, who barely accept socially shared
rules and rarely succeed in participating in a social context
and so developing an adult identity.
Antisocial behavior can develop in distinct ways (Loeber
et al., 1998):

•​ Some offending adolescents, those who often also

develop violent behaviors, already manifested difficul-
ties in complying with rules at the preschool age, par-
ticularly with regard to hyperactive behavior.
•​ Some start to manifest antisocial behaviors during late
infancy or at the beginning of adolescence, enacting
less severe offenses in group.
•​ Others, starting from mid-​adolescence, use and abuse
substances without any other rule-​breaking.

From the point of view of prognosis, the age of onset of

behavioral problems is of particular concern. The earlier
the first signs of discomfort, conflict and scant social rela-
tionships show up, the greater the possibility that be­haviors
and problems that are hard to manage will emerge during
adolescence, and these may lead to an overt psychiatric
disorder.
Risk factors leading to the onset of more frequent and
more severe antisocial behaviors are thus the presence of
hyperactive, disruptive, oppositional behavior and of dif-
ficulty in getting along with peers in infancy. These chil-
dren often also show learning issues and tend to have
mood disorders. When they become adolescents, they tend
to be especially impulsive and seek novel and exciting
9

Signs and symptoms  9

experiences. These characteristics, when persisting through

late adolescence, often lead to trouble with work, family
and friendships.
Antisocial adolescents may thus become adults who
answer life frustrations with violence and who tend to be
indebted and to gamble (Rutter et al., 1998).

Oppositional-​d efiant disorder (ODD)

In the case of ODD, the hostile/​ oppositional behavior
that, as we saw, can be a normal feature of some develop-
mental stages persists through time and causes significant
impairment to the quality of life of an individual regarding
their relationships and their family and social environment
(Despinoy, 2001).
Children with ODD indeed show a recursive behavior
mode that is negative, hostile and challenging. They are
children who refuse to follow the rules, to obey orders and
to comply with requests and, in general, to do what others
would expect from them. They express anger more often
than other children, they do not want adult authority and
overtly rise up against it. Their aggression is not just react-
ive; rather, they enjoy provoking and challenging others
and disturbing others intentionally, although not being
violent (Mastroeni, 1997).
Oppositionality may also include the constant pushing
of limits by ignoring orders, quarrelling and not tolerating
rebukes or by acting to deliberately annoy others.
Hostility can be directed toward adults or peers and is
expressed mostly verbally. These children, in addition, ref-
use to take responsibility for their own actions perceived
as normal reactions to a frustrating or hostile context.
They do not judge themselves as guilty and blame others
for their own bad behaviors. Subjects with this disorder
often justify their behavior as the answer to unreasonable
10

10  Signs and symptoms

requests or conditions. However, a great variety of behav-

iors can exist within those that can be considered as oppos-
itional and defiant, ranging from mere withdrawal from
tasks and requests to physical clashing. Some children may,
in fact, act more passively, being whiny, while others may
confront, scream at and physically clash with adults.
What they have in common is the regularity, frequency
and severity of behaviors that, as stated above, cause sig-
nificant issues to children in their main life contexts involv-
ing family, school and peer groups.
Symptoms of ODD may indeed be exhibited, especially
in the early stages, only within the family context, with
strenuous fights over the achievement of everything (going
to bed, brushing teeth, getting dressed, leaving the house
and so on). Subsequently, they also begin to involve exter-
nal contexts, starting with people whom the child knows
best, such as play friends. Eventually, it is probable that
these aggressive behaviors will be directed indiscriminately
against anyone who might try to establish a relationship
with these children.
The earliest manifestations of the disorder emerge
before 5 years of age (APA, 2013) and become more overt
after attending school. Children with this disorder indeed
demonstrate an inability to adapt to school rules and dis-
play relevant issues with peer relationships, especially in
recreational activities and teamwork. Examples of school
behavior can be: refusing to carry out any activity; mock-
ing teachers; ignoring all kinds of reprimands; or even
responding aggressively (Colvin, Ainge & Nelson, 1997).
With peers, during play, they do not take turns and they
are not cooperative; rather, they want to command and they
impose their will at any cost, even with insults and threats.
In the DSM-​5 (APA, 2013), ODD is described as a pat-
tern of anger/​irritable mood, argumentative/​defiant behav-
ior or vindictiveness lasting at least 6 months as evidenced
11

Signs and symptoms  11

by at least four symptoms from any of the following cat-

egories, and exhibited during interaction with at least one
individual who is not a sibling.

Anger/​irritable  mood
• Often loses temper.
• Is often touchy or easily annoyed.
• Is often angry and resentful.

Argumentative/​defiant behavior
• Often argues with authority figures or, for children and
adolescents, with adults.
• Often actively defies or refuses to comply with requests
from authority figures or with rules.
• Often deliberately annoys others.
• Often blames others for his or her mistakes or misbehavior.

Vindictiveness
• Has been spiteful or vindictive at least twice within the
past 6 months.

The DSM-​5 also stresses the importance of considering

persistence, intensity and frequency as criteria to distin-
guish a behavior that is within the boundaries of normality
as opposed to what configures a symptom. Specifically, for
children under 5  years of age, the pathological behavior
should be present almost every day for a period of at least
6 months; for children aged 5 or more, at least once per
week for at least 6 months. In addition, the intensity must
be of such a nature that this behavior creates discomfort to
the child or to people in the nearest social context, or has
a negative impact on functioning in the social, educational
or work context or in other relevant contexts.
12

12  Signs and symptoms

The prevalence of this disorder varies between 1 and

11  percent, with an estimated mean of around 3.3  per-
cent. Its incidence can vary regarding the age and sex of
the child. Among age categories before adolescence, the
disorder seems to be exhibited more frequently by males
rather than by females (1.4:1). This predominance is not,
however, always found in the adolescent and adult age cat-
egories (APA, 2013).
Among males, the disorder is associated with ill temper
(highly reactive, barely soothable) or intense motor activity
since preschool age. The disorder is more frequent among
males than females before puberty, but after puberty the sex
prevalence becomes even. Symptoms are similar between
sexes, but in males they are more persistent.
During school age, low self-​esteem, mood swings and
intolerance of frustration may set in. Oppositional symp-
toms tend to increase with age.
The onset of the first symptoms most often occurs in
preschool age, rarely after early adolescence; onset after
16  years of age is extremely rare among both sexes
(Kazdin, 1997).
The disorder usually presents itself in comorbidity with
attention deficit hyperactivity disorder (ADHD) and is
associated with an increased risk of developing anxiety or
depressive disorders. Moreover, ODD is considered a pre-
cursor and a predisposing factor for the onset of a conduct
disorder.

Clinical vignette
Maurice, 6 years of age, is a child with good cognitive
abilities but significant language issues on the expres-
sive side. He does not come from a socially disadvan-
taged environment.
13

Signs and symptoms  13

Since the beginning of primary school, his teachers

noticed several behaviors that increased in frequency
after the very first weeks, starting in October.
His teachers immediately noticed Maurice could not
easily manage frustrations with daily living, such as
waiting for his turn to speak, waiting in line or sharing
a teacher’s attention during conversation and games.
When Maurice does not succeed at being the best or
at obtaining what he desires, he complains, refuses to
continue with assigned tasks and sometimes becomes
aggressive both verbally and physically. Other times,
he cries and hides under the bench or flees down the
corridor.
As soon as he arrives in the morning, troublesome
situations occur in which Maurice shows issues with
peer relationships. When the children are lined up to
move around in school, several times a day, Maurice
reports being annoyed by one or more schoolmates.
If he judges someone to be too close to him, this is
enough for him to bounce into them, say unpleas-
ant things or make annoying noises, or to react by
screaming, “Get away,” “Don’t annoy me,” or curs-
ing, pushing, kicking and punching.
Oftentimes, Maurice feels provoked by peers:  he
refers to be pushed around, insulted and excluded from
activities. In some cases, he cannot stand being looked
at or to have someone smile or laugh in his direction,
since he interprets this as a challenge or mockery by
schoolmates. Sometimes, a look or a laugh are enough
to trigger his reaction: Maurice screams at other chil-
dren in order to intimidate them into stopping, and
he insults and threatens them. He gets up from his
chair and pretend to hit them, or even actually does
hit them. He has spat on a schoolmate a couple times.
14

14  Signs and symptoms

Classes are severely hampered by his behavior:

every day he refuses to work and keeps on disturbing
schoolmates and the teacher with yells, rude noises,
insults, throwing objects and erasing writing from the
chalkboard.
During moments of free play, Maurice wants to
impose his rules and leadership. If others refuse to do
as he says, he reacts with verbal and physical aggres-
sion or by disrupting the games of others.
The abrupt angry outbursts of Maurice are not
only directed toward peers, but also at adults, and if
a teacher tries to soothe him or stop him when he is
at his angriest and attacking other children, Maurice
reacts by screaming, thrashing around, punching,
kicking, scratching, spitting and biting.

Conduct disorder (CD)
As for oppositional behaviors, anger and aggression are
also common among toddlers. Some children, however,
frequently display aggressive and rule-​ breaking behav-
iors. Children with aggression problems demonstrate lim-
ited capability for analyzing social events, they develop
a twisted and impoverished mode of deciphering others’
intentions and they tend to evaluate social signs predomi-
nantly in a hostile way and to react aggressively (Lochman
& Dodge, 1994). These children indeed display issues
with interpersonal problem-​solving:  rarely finding adap-
tive solutions to problems, they consider aggression as the
most effective strategy for regulating interpersonal rela-
tionships (Lochman & Lenhart, 1993; Lochman & Wells,
2003). A  tendency can indeed be observed toward being
aggressive and bullying, and their willingness to intimidate
15

Signs and symptoms  15

others gives rise to quarrels and clashes. They are children

who, in general, lie often and tend to circumvent others to
gain an advantage.
The main feature of the CD is indeed the systematic and
persistent infringement of others’ rights and of social rules,
with severe consequences for their academic and social
functioning. The manifestation of CD is mainly character-
ized by the presence of aggression on several levels: these
children/​adolescents can demonstrate bullying, threaten-
ing or intimidating behavior, intentionally trigger clashes,
steal from their victim and coerce others into sexual abuse.
These behaviors arise in different contexts of life, at
home, in school and in the community. Children who
have these disorders continuously break school and family
rules. Adolescents with these characteristics tend to mini-
mize their issues and adults may find it hard to recognize
their difficulties.
Their behavior is bullying or intimidating, and they fre-
quently start clashes. They may have scarce empathy and
attention for others’ feelings and well-​being. They often
react with aggression that they believe to be appropriate,
misinterpreting others’ intentions as hostile and threatening.
Scarce tolerance of frustration and irritability are fre-
quently associated features, together with a low self-​esteem
in spite of their overt behavior.
These children often display a precocious onset of sexual
activity, drinking, smoking and substance abuse, together
with risky and daring behaviors.
In the beginning, less severe behaviors arise, such as lying
and stealing at home, but later on, more severe behaviors
take place.
CD has a prevalence rate ranging from 2 to 10  per-
cent (APA, 2013), with a clear predominance among
males. Males more frequently display physical aggression,
16

16  Signs and symptoms

vandalism, robbery and school discipline issues; females

are more likely to play truant, abuse substances, lie and
have precocious sexual behaviors.
In DSM-​5, CD is described as 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 3 of the follow-
ing 15 criteria in the past 12 months from any of the cat-
egories below, with at least 1 criterion present in the past
6 months:

Aggression toward people and animals

• Often bullies, threatens or intimidates others.
• Often initiates physical fights.
• Has used a weapon that can cause serious physical
harm to others (e.g., a bat, brick, broken bottle, knife
or gun).
• Has been physically cruel to people.
• Has been physically cruel to animals.
• Has stolen while confronting a victim (e.g., mugging,
purse-​snatching, extortion or armed robbery).
• Has forced someone into sexual activity.

Destruction of property
• Has deliberately engaged in fire-​setting with the inten-
tion of causing serious damage.
• Has deliberately destroyed others’ property (other than
by fire-​setting).

Deceitfulness or theft
• Has broken into someone else’s house, building or car.
• Often lies to obtain goods or favors or to avoid obliga-
tions (i.e., “cons” others).
17

Signs and symptoms  17

• Has stolen items of nontrivial value without confront-

ing a victim (e.g., shoplifting, but without breaking and
entering; forgery).

Serious violations of rules

• Often stays out at night despite parental prohibitions,
beginning before 13 years of age.
• 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.
• Is often truant from school, beginning before 13 years
of age.

The DSM-​5 suggests specifying whether the onset is in

childhood (at least 1 symptom before 10 years of age) or
in adolescence (after 10 years of age). A CD may indeed
have a precocious onset or become manifest only later on,
during adolescence, but very rarely does its onset occur
after 16 years of age (APA, 2013).
A CD usually has its precursor in an ODD:  by early
infancy, children can appear irritable, barely cooperative,
oppositional and easily frustrated. With development,
these traits increase and actions that are more overtly
aggressive begin to show up, such as beating peers and
adults or breaking others’ toys. These aggressive behav-
iors can become established:  oppositional behaviors and
difficult interactions with parents remain, and lies and
attempts at deceiving others increase with age. Children
tend to perceive others as accusing and hostile, experience
isolation since they are cast away by peers and thus team
up in groups with other aggressive children. Disobedience
with respect to parents increases, together with vandalism,
substance abuse (involving alcohol, cannabis and other
illicit drugs), frequent truancy and episodes of running
18

18  Signs and symptoms

away from home. In adolescence, conduct issues can

become real criminal acts, also involving sexual aspects.
When these children reach adulthood, their symptoms of
aggression, property destruction, deceit and rule-​breaking,
involving violence committed against colleagues, partners
and offspring, can show themselves on the workplace or at
home. In these cases, a diagnosis of antisocial personality
disorder can be taken in consideration.

Clinical vignette
Matthew is a 13-​year-​old boy. Even before school he
was evidently irritable, experiencing significant diffi-
culty in regulating his emotional life and showing fre-
quent fits of rage, during which he screamed, cursed,
hit and threw objects, slammed doors and assaulted
people.
When Matthew is frustrated by any request, he
screams, punches drawers in his room and then shows
his red knuckles to parents, saying, “Do you see this?
You said no and I did this.”
Evident as well is the tendency to resist requests
and to break rules set at home and in school. Matthew
tends to deliberately provoke adult caregivers, dis-
respecting their authority. He lies and steals small
amounts of money at home and schoolmates’ belong-
ings in class, denying his deeds until the end.
Over the years, his relationships with peers have
been gradually worsening. Since primary school, rela-
tionships with classmates have indeed been very dif-
ficult, in spite of attempts by other children to include
him and contain his angry outbursts. Matthew told
many lies, denying, for instance, that he hid or took
his mates’ belongings, even when faced with proof of
19

Signs and symptoms  19

his deeds. When he went downstairs in a group, he

pushed and kicked those who were standing in his
way. In the cafeteria, he played with his food, making
balls to throw at classmates, or he took food from
their dishes with his hands, just to bite it and put it in
different dishes, smiling when anybody complained.
Threats were also frequent: “I’ll kill you,” he said,
mimicking such scenes with objects, such as stabbing
bread or sticking pencils in erasers.
Requests from teachers were also ignored and,
when he occasionally accepted a task, he would not
carry it out, or would do it so as to bother somebody.
For instance, when carrying papers around, he inten-
tionally stumbled into other children.
Today, these issues are still evident; moreover, they
are followed by a propensity to retaliation. If Matthew
believes he has been wronged, he retaliates aggres-
sively, even after some time has passed. Matthew fre-
quently gets into fights with other boys, often without
any clear reason.
In light of his behavior, Matthew can hardly main-
tain friendships and currently is friends with only one
boy, who is judged to be a “disreputable companion.”
Matthew has been recently charged with hav-
ing tied up a boy and filmed the act, and vandalism
against others is frequent: Matthew was caught mark-
ing the wall of an underpass with offensive words and
drawings.

Risk factors
Because not all oppositional children become antisocial
(children who tend to persevere with antisocial and
20

20  Signs and symptoms

offending behavior are estimated to be around 6 percent

of the general population; Maggiolini, 2002), it is import-
ant to know which risk factors may transform the ten-
dency toward offending behaviors into a real antisocial
disorder. Rutter (1998) found as main risk factors the age
of onset and the presence of an ADHD (characterized by
restlessness, impulsiveness and inattention, which ends up
interfering with social and academic functioning, since it
prevents the child from following the most simple behav-
ioral rules).
Adolescents who tend to persist with offending behavior
show ill-​tempered characteristics by between 3 and 5 years
of age and they often come from families with more issues
(e.g., socially disadvantaged environments). At 18  years
of age, they have few constructive relationships and tend
to feel suspicious and socially withdrawn. They are more
often aggressive and impulsive.
Adolescents who persist with offending acts also often
have emotional, social and behavioral issues in adult-
hood:  the offenses committed may change, yet the anti-
social conduct persists.
Hyperactivity is associated with all kinds of antisocial
behavior, and the correlation is stronger with the frequency
of offenses rather than with their severity: hyperactive chil-
dren and adolescents are indeed very transgressive, but
usually not violent.
Sex (i.e., being male) is also an important risk factor
for criminality. The difference between males and females
varies only slightly as a function of ethnic group (there is
a less clear prevalence among black people as compared
to white people, and this is clearly greater among Asians).
Male prevalence is higher between 18 and 20 years of age
as compared with during adolescence, and it is more evi-
dent for offenses connected with the use of force. Females
in general are less habitual offenders (Rutter et al., 1998).
21

Signs and symptoms  21

Finally, the influence of violent TV on offending behav-

iors seems to be limited: the role of mass media is not to
induce the imitation of violent behaviors, but rather to make
violent behaviors more acceptable (Varin et al., 1997).

Cross-​c ultural influences

Specialists resort to norms and guidelines that are useful
for describing the problems they observe, which take into
due consideration the possible influences of sex, age, eth-
nicity, culture and context. In order to formulate a spe-
cific psychopathological diagnosis, the DSM-​ 5 provides
the necessary criteria for classifying symptoms while also
considering variables such as the age or culture of sub-
jects. This allows us to give a name to the issue and consti-
tutes a first step toward access to treatment and necessary
interventions. Recognizing symptoms promptly, thanks
to instruments shared by the scientific community, allows
us to conduct timely and precise interventions in order
to avoid or reduce the risk of further complications. An
internationally shared diagnostic system also allows us to
determine prevalence indices and to study risk factors and
the outcomes of different therapeutic interventions.
Cross-​cultural differences that may influence the preva-
lence and manifestation of symptoms show up early. They
concern, for instance, the interpretation and value given
to the expression of emotions, as well as what is consid-
ered as dysfunctional and less socially tolerated. We may
observe cultural differences by early infancy: cultures like
Asian ones and some African ones are, for instance, char-
acterized by a high value given to obedience and by sig-
nificant respect for the elderly. In these contexts, aggressive
and angry behaviors are little tolerated and it is less prob-
able that children will overtly manifest negative emotions.
Parents from such cultures may manifest a lower tolerance
22

22  Signs and symptoms

of externalizing behaviors and tend to discourage them.

In other cultures, like the European or North American
ones, self-​expression of children is supported with regard
to the manifestation of a state of discomfort. These early
influences may be read as congruous with the prevalence
of emotional and behavioral disorders during develop-
ment:  a study conducted in sixteen nations reports that
among Asian peoples there is a greater prevalence of inter-
nalizing disorders compared to Western peoples (Crijnen
et  al., 1999). The environment in which the family lives
and the social context with which it interacts thus have
crucial influences on the reinforcement or dissuasion of
specific behavioral manifestation and, therefore, on shap-
ing a child’s behavior. A different issue concerns belonging
to different ethnic groups within the same society: much
research has demonstrated that ethnicity has no specific
influence on the prevalence of behavioral disorders. Rather
than ethnicity, psychosocial adversity seem to be what
constitutes a risk factor for the onset of emotional and
behavioral issues during development (Leung et al., 2008).
Genetic predisposition may influence a child’s responses
to environmental stimuli, including stressors. Every indi-
vidual thus has an innate predisposition regarding the
manifestation of emotions, although this predisposition
interacts with and is shaped by the environment. Children
who live in socially disadvantaged environments have an
increased chance of experiencing such risk factors as poor
prenatal healthcare, bad nutrition, exposure to toxic sub-
stances or infections. Children who live in disadvantaged
environments may have to face, in their early life, situations
on the fringes of the law, poverty and abuse. However, it
must be stressed that a family environment characterized
by positive attachment, by adequate supervision and by
careful monitoring constitutes a protective factor and is
associated with a lower prevalence of conduct disorders,
23

Signs and symptoms  23

even in the context of disadvantaged social environments

(Bird et al., 2006).

Theories on etiology
A link exists between the temper that can be observed
during the first stages of life and the following develop-
ment of oppositional behavior (Hagekull, 1994; Thomas
& Chess, 1986). Negative emotion, which is the tendency
of the newborn to poorly adapt to the environment and
to biological rhythms and to display irritability and high
reactivity to environmental stimuli, is often displayed by
children who subsequently present with behavior prob-
lems. These temper characteristics are most significantly
influenced by genetic factors. When investigating the influ-
ence of such variables, the presence of a high correlation
between CD and ODD emerged, although there is no com-
plete overlap between them. In particular, some genes may
represent a potentially global risk factor (e.g., influencing
temper, personality or uninhibited behavior), thus increas-
ing the risk of developing a disorder of the externalizing
kind, whereas other genes can contribute to specific ODD
or CD symptoms (Dick et al., 2005). The impact of genetic
factors influences the precocious expression of ODD,
whereas subsequently, in infancy and adolescence, envi-
ronmental variables would impact more on the manifesta-
tion of CD (Breaux & Lugo-​Candelas, 2016). While the
analysis of the association between symptoms of CD and
ODD stresses the existence of genetic influences shared
at least in part, the effects of environmental influences
seem to be distinct regarding the two disorders (Knopik
et al., 2014). Common environmental factors described in
families where a child or adolescent presents with CD or
ODD are: maternal depression; dysfunctional family rela-
tionships and high intra-​ familiar hostility; sociocultural
24

24  Signs and symptoms

disadvantage; and parental addiction to drugs and alco-

hol. Environmental factors that associate more frequently
with CD than ODD are:  parental psychopathology and
antisocial paternal behavior; inadequate parental supervi-
sion; and stern discipline. Excessively invasive and hyper-​
protective parenting associates with CD only in girls, not
in boys (Rowe et al., 2002). Hanging out with inappropri-
ate peers is associated with a delayed onset of CD, which
typically shows a better prognosis as compared to early-​
onset cases (below 10 years of age).
Reflecting on the interaction of a biological vulnerabil-
ity with the influence of environmental variables, it is clear
that these factors influence child behavior starting from
the earliest life phases, and this, in turn, generates expec-
tations, behaviors and emotional reactions in caregivers.
Indeed, from a bi-​ directional perspective, children who
have difficulties at adapting or have a “difficult” temper
generate in parents high levels of fatigue and stress and
this, in turn, impacts negatively on their relationship.
Interactions with the environment shape habits, reactions
and relationships within the various contexts of life. The
child is influenced by relationships with surrounding per-
sons, which in turn influence the behavior of others. When
facing increased stress levels, it is frequent to observe
the use of educative styles oscillating between stern and
authoritative, and permissive and accommodating. In add-
ition, the more behavioral disorders that develop over the
years, the more parenting styles seem to worsen. Recent
research demonstrates that parenting style is not predictive
of the onset of CD; rather, the disturbed behaviors of chil-
dren would themselves lead to a scarcity of discipline and
to an inefficacious parenting style. Children and adoles-
cents with ODD indeed more frequently have parents who
display an educative style that is characterized by scant
discipline: parents, in fear of their children’s reactions to
25

Signs and symptoms  25

imposed limits, tend to reduce attempts at regulating their

behavior.
Therefore, following the hypothesis of the bi-​directional
influence, it does not seem likely that a poorly efficacious
educative style would be responsible for increasing the
risk of children exhibiting behavior problems. Rather,
the opposite relationship is supported:  children who,
due to an innate temper dysregulation, exhibit behav-
ioral issues from the earliest stages of life may promote
scarcely coherent educative choices and an inefficacious
parenting style. This inefficacious parenting style, in time,
becomes not only a maintenance factor for pre-​existing
issues, but also favors the manifestation of novel prob-
lems with managing and relating to the child. It is indeed
proven that interventions focused on modifying paren-
tal styles are efficacious at reducing problem behaviors
(Burke et al., 2008).
During more advanced developmental stages, the school
context also plays a relevant role in the manifestation of
behavioral issues. School workers’ scarce knowledge of the
aspects of behavior management may facilitate educative
strategies that are not only inefficacious, but also create
negative loops in which the child takes on a negative role
in the school context and becomes gradually confirmed in
that role.

Important points
• Aggression and oppositional behavior are “physio-
logical” behaviors. They are common among pre-
school toddlers and they usually diminish with a year.
Interactions with adults play an important role in
modeling the behavioral repertoire of the child regard-
ing more appropriate modes of expressing their own
desires and defending their rights.
26

26  Signs and symptoms

• It is important to distinguish behaviors typical of most

adolescents from those that may suggest a deeper dis-
comfort that is worthy of clinical investigation.
• Antisocial adolescents manifest the tendency to per-
form more severely offensive behaviors repeatedly.
They show problems with accepting socially shared
rules, at inserting themselves into the social context
and at developing an adult identity.
• Everyone has an innate predisposition regarding the
manifestation of emotions; however this predisposition
interacts with and is shaped by the environment.
• The impact of genetic factors influences the early
expression of ODD, while subsequently, in infancy and
adolescence, environmental factors seem to more sig-
nificantly influence the manifestation of the disorder.
• It has been proven that interventions focused on modi-
fying parental style are efficacious at reducing behav-
ioral problems.
• ODD refers to a pattern of irritable mood and quar-
relsome/​defiant or retaliatory behavior, often associ-
ated with a poor capability of analyzing social events,
a distorted and deficient mode of decoding the inten-
tions of others and a tendency to evaluate social signals
predominantly in a hostile key and to react to those
aggressively.
• CD refers to a pattern of behavior in which the sys-
tematic and persistent violation of others’ rights and
of social norms can be observed, with severe conse-
quences for academic and social functioning. The
manifestation of the disorder is mainly characterized
by the presence of aggression of several types: children
may show bullying, threatening or intimidating behav-
ior, intentionally start fights, steal from their victim
and/​or coerce others into sexual abuse.
27

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