DISRUPTIVE BEHAVIORS IN

CHILDREN
PRESENTED BY – DR. RIYA SINGH
JUNIOR RESIDENT
PSYCHIATRY
DEFINITION

■ Consists of 2 disorders :
1. OPPOSITIONAL DEFIANT DISORDER (ODD)
2. CONDUCT DISORDER (CD)

■ These conditions involve individual problems in emotional and/or behavioral regulation

that either bring the individual into significant conflict with authority figures (ODD and
CD) or violate the rights of others and/or societal norms (CD).
OPPOSITIONAL DEFIANT DISORDER

■ Oppositional defiant disorder describes enduring patterns of negativistic, disobedient,

and hostile behavior toward authority figures, as well as an inability to take
responsibility for mistakes, leading to placing blame on others.

■ Child’s temper outbursts, active refusal to comply with rules, and annoying behaviors
exceed expectations for these behaviors for children of the same age.
DIAGNOSTIC CRITERIA
DSM -5 ICD -10
Diagnostic name Oppositional Defiant Disorder Oppositional Defiant Disorder

Duration ≥6 month
For age < 5 : occurs more days
than not
For age ≥ 5 : occurs at least 1/week

Symptoms • Losing temper Defined as a conduct disorder in

• Sensitive/easily annoyed younger children
• Angry/resentful Predominant symptoms:
• Arguing with authority figures • Disobedience
• Refusing request from • Defiance
authorities or rules • Disruptive behavior
• Deliberately annoys
others
• Blames others for
mistakes/behaviors
• Spiteful/Vindictiveness
(at least 2× in 6 month)
Required number of ≥4 symptoms
symptoms

Marked distress and/or

Psychosocial consequences impairment
of symptoms

Substance use No delinquent, severely

Exclusions (not result of): Another mental illness aggressive or dissocial
behavior

Severity specifiers Mild: symptoms in 1 setting

Moderate: symptoms in 2
settings
Severe: symptoms in ≥3
settings
EPIDEMIOLOGY

■ Oppositional and negativistic behavior is found in 16 to 22 percent of school-age

children
■ Can begin as early as 3 years typically noted till 8 years and not later than early
adolescence
■ Boys > girls before puberty ; equal sex ratio after puberty
■ Prevalence diminishes in youth older than 12 years of age.
ETIOLOGY

■ No one cause in identified.

■ Biological factors which increase risk:

• parents with a history of ADHD, ODD, CD, or mood disorders

• parents with substance abuse problems
• brain-chemical imbalance
• toxin exposure
• poor nutrition
■ Psychological factors which increase risk :

• Poor relationship with parent(s)

• Neglectful/absent parent(s)
• Difficulty forming social
relationships or identifying
social cues.
• Coercion theory
■ Social factors :

• Poverty
• Child abuse
• Lack of supervision
• Family instability
TYPES OF ODD

■ 3 Types ( as per DSM V )

1. Angry/ Irritable Children

2. Argumentative/ Defiant Children
3. Vindictive type
COURSE AND PROGNOSIS

■ Depends on the severity of the symptoms

■ Persistent ODD pose increased risk of additional disorders such as mood disorders,
conduct disorders and substance use disorders.
■ Positive outcome - more likely in stable families without any history of parental
psychopathology.
■ Children with long history of aggression and ODD (angry/ irritable type and vindictive
type) are more prone to develop conduct disorder.
■ Prognosis depends on family functioning and the development of comorbid
psychopathology.
CHILDHOOD ODD TO ADOLESCENT
CD
DIFFERENTIAL DIAGNOSIS

1. Adjustment Disorder
2. ADHD
3. Cognitive disorders
4. Mental retardation
TREATMENT

1. Main stay of treatment is family intervention :

– Direct training of parents in child management skills
– Assessment of family interactions.
■ Goals of this intervention :
– Reinforce more prosocial behaviors
– Diminish undesired behavior.

2. Cognitive Behavior Therapy

3. Parent Child Interaction Therapy
4. Individual Psychotherapy of Children
CONDUCT DISORDER

■ Conduct disorder is an enduring set of behaviors in a child or adolescent that evolves,

usually characterized by aggression and violation of the rights of others.

■ Children with conduct disorder usually have behaviors characterized by aggression to

persons or animals, destruction of property, deceitfulness or theft, and multiple
violations of rules, such as truancy from school.
DIAGNOSTIC CRITERIA
DSM - 5 ICD - 10
Diagnostic Name Conduct Disorder Conduct Disorder
Duration ≥1 criteria for ≥6 month ≥6 month
Other symptoms occur over
≥12 month
Symptoms • Bullying others Repeated and pervasive pattern
• Initiating physical fights of antisocial behavior
• Using weapon to inflict • Aggression
serious harm • Defiance
• Physical cruelty to May be
• others • Angry
• Physical cruelty to • Cruel
• Animals • Bullying
• Confronting and robbing • Destructive
• Someone • Lying
• Forcing sex • Truant/running away
• Fire setting from home

Required number of symptoms
Exclusions (not result of):
Symptom specifiers
• Property damage
• Breaking into properties
• Lying for personal gain
• Stealing valuable items
• Staying out late against
parent’s will < age 13
• Running away from home
≥2 times (or once with
prolonged absence)
• Frequent truancy <age 13
≥3
Age-appropriate behavior
With limited prosocial • Conduct disorder confined to
emotions: demonstrating at the family context (within
least two of the following over nuclear family)
12 month in multiple contexts: • Unsocialized conduct
• Lack of remorse or guilt disorder (predominant
• Callous-–lack of empathy aggression, often toward
• Unconcerned about other children)
performance • Socialized conduct
• Shallow or deficient affect disorder (despite aggression,
there is good integration into
their peer group)
Course specifiers Childhood onset type: < age 10

Adolescent onset type: ≥ age

10

Unspecified onset
Severity specifiers Mild: minimal symptoms,
minor harm/consequences

Moderate: intermediate
symptoms and consequences

Severe: many symptoms,

considerable harm caused
EPIDEMIOLOGY

■ ranges from 6 to 16 percent for males

■ 2 to 9 percent for females
■ ratio of conduct disorder in males compared to females ranges from 4:1 to as much as
12:1
■ occurs with higher frequency in the children of parents with antisocial personality
disorder and alcohol use disorder
ETIOLOGY
■ Parental factors :
 Harsh, punitive parenting
 Chaotic home conditions
 Parental psychopathology
 Child abuse and negligence

■ Sociocultural factors :
 Unemployed parents
 Lack of a supportive social network
 Lack of positive participation in community activities
 Exposure and prevalence of substance use ( more prevalent in urban areas )
■ Violent Video Games and Violent Behavior :
 Related to aggressive effect, Physiologic arousal , and aggressive behavior.

■ Psychological factors :
 Poor emotion regulation associated with higher levels of aggression

■ Neurobiological factors :
 Studies have shown decreased gray matter in limbic brain structures, bilateral
anterior insula and left amygdala in children with CD.
 Low levels of plasma dopamine β-hydroxylase
 high plasma serotonin levels in the blood of conduct-disordered juvenile
offenders

■ Child Abuse and Maltreatment : Increased risk in

 Children chronically exposed to violence
 Physical or sexual abuse
 Neglect
COURSE AND PROGNOSIS

■ Negative prognostic signs :

– Young age
– High number of symptoms
– Severe symptoms
Children with severe CD are more vulnerable to comorbid disorders later in life such as
mood disorders and substance use disorders.
■ Positive prognostic signs :
– Mild symptoms
– No coexisting psychopathology
– Normal intellectual functioning
DIFFERENTIAL DIAGNOSIS

1. ADHD
2. ODD
3. Disruptive mood dysregulation disorder
4. Major depression
5. Bipolar disorder
6. Specific learning disorders
7. Psychotic disorders
TREATMENT

■ Psychosocial Interventions

 Early sustained preventive interventions (e.g., at a kindergarten age) can significantly

alter the course and prognosis of aggressive behavior.
Example : The Fast Track Preventive Intervention
CBT TREATMENT INTERVENTIONS

1. Kazdin’s Problem-Solving Skills Training (PSST)

– 12 week sequential program
– Helps children develop problem solving solutions when faced with conflictual
situations.
– can also be accompanied by Parent Management Training

2. Incredible Years (IY)

– Targets children from 3-8 years
– Administered over 22 weeks
– Delivers sessions to child and has a parent training component and a teacher training
3. Anger Coping Program
– 18 session intervention
– School age children in grade 4 to 6
– Focuses on child’s increased development of emotion recognition and regulation, and
managing anger

4. School Based Prevention Programs

– Focus on increasing social behavior and social competence and reducing aggressive
behavior
– Use behavioral techniques to promote socially acceptable behavior towards peer

5. Multi-Systemic Treatment (MST) and Multidimensional Treatment Foster Care (MTFC)

– Developed to treat older children and adolescents with established antisocial and
aggressive behavior
– Used as an alternative placements to incarceration or psychiatric hospitalization
PHARMACOLOGIC INTERVENTIONS

■ Generally palliative and not curative

■ Used for treatment of associated symptoms such as impulsivity , explosive aggression,
irritability , negative emotions, etc.
■ CD is also associated with high rate of comorbidity with other psychiatric disorders
such as ADHD and affective disorder.

■ Atypical antipsychotics – Risperidone, Olanzapine , Quetiapine , Aripiprazole

■ Mood Stabilizers – Sodium Valproate , Lithium
■ Alpha 2 agonist – clonidine , guanfacine
THANK YOU