Disruptive, Impulse-Control, and Conduct Disorders

Question 1

Disruptive, Impulse-Control, and Conduct Disorders

Answer 1

The disorders in this category involve “problems in the self-control of emotions and behaviors” (American Psychiatric Association, 2013, p. 461) and include oppositional defiant disorder, conduct disorder, and intermittent explosive disorder.

Oppositional Defiant Disorder: The diagnosis of oppositional defiant disorder (ODD) requires a recurrent pattern of an angry/irritable mood, argumentative/defiant behavior, and/or vindictiveness as evidenced by four or more characteristic symptoms that occur during interactions with at least one person who is not a sibling – e.g., often loses temper, is angry and resentful, often deliberately annoys others, often blames others for his/her mistakes or misbehavior. Symptoms have lasted for at least six months and have caused distress for the individual or others in the individual’s immediate social context or have a negative impact on the individual’s functioning. In young children, ODD is more common in boys than girls but, in older children and adolescents, it occurs about equally often in boys and girls. About 30% of children who have a diagnosis of ODD eventually receive a diagnosis of conduct disorder, with an early age of onset of symptoms being associated with a higher risk for conduct disorder (Connor, 2002).

There is no single optimal treatment for individuals with ODD, and the most effective treatment is multimodal and tailored to the age, symptoms, and comorbidities of the child or adolescent. Evidence-based psychosocial interventions are first-line treatments and are the same as those for other disruptive behavior disorders. These interventions are described in the section on treatments for conduct disorder.

Conduct Disorder: The diagnosis of conduct disorder (CD) requires a persistent pattern of behavior that violates the basic rights of others and/or age-appropriate social norms or rules as evidenced by the presence of at least three characteristic symptoms during the past 12 months and at least one symptom in the past six months. Symptoms represent four categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violation of rules. Symptoms must have caused significant impairment in functioning. The diagnosis cannot be assigned to individuals over age 18 who meet the criteria for antisocial personality disorder. This disorder is more common in males than females and, although symptoms may occur during early childhood, they more often emerge between middle childhood and middle adolescence.

The DSM-5 provides specifiers for three subtypes: childhood-onset type for individuals who have at least one symptom before age 10; adolescent-onset type for individuals who exhibit no symptoms before age 10; and unspecified onset when the onset is unknown. The childhood-onset type is associated with a higher degree of aggressiveness and a greater risk for a future diagnosis of antisocial personality disorder and/or a substance-related disorder. It also provides specifiers for severity of the disorder (mild, moderate, and severe) that are based on the number of conduct problems and their consequences.

1. Etiology of Conduct Disorder: Conduct disorder has been linked to multiple biological and environmental factors including heredity, abnormalities in brain structure and functioning, neurotransmitter and neuroendocrine abnormalities, prenatal exposure to opiates or alcohol, and negative parenting practices (e.g., harsh and inconsistent punishment). With regard to neurotransmitter and neuroendocrine abnormalities, studies suggest that reduced serotonin and dopamine contribute to increased aggression, reduced sensitivity to punishment, and increased risk-taking behaviors (Efferson & Glenn, 2018). In addition, Fairchild and colleagues (2008) compared male adolescents with childhood- or adolescence-onset CD to adolescents without a psychiatric disorder and found that baseline cortisol levels were similar for adolescents with and without CD during the morning hours but differed significantly in the evening, with adolescents in both CD groups having higher levels than adolescents without a psychiatric disorder. They also found that adolescents with CD did not experience the typical increase in cortisol level and cardiovascular response to a stressful procedure even though adolescents with and without CD reported similar increases in negative affect during the procedure. According to Fairchild et al., the discrepancy for youth with CD “between subjective and physiologic changes suggests poorer coordination between emotional and physiologic arousal” (p. 609).

Moffitt (1993) distinguishes between two types of antisocial behavior that correspond to DSM-5’s childhood-onset and adolescent-onset CD, and she attributes the two types to different factors: Her life-course-persistent type involves a pattern of increasingly serious antisocial behaviors that begins in early childhood, continues into adulthood, and is consistent across situations. Moffitt describes this type as being due to a combination of neuropsychological deficits that affect the individual’s temperament, cognitive abilities, and other characteristics and an adverse child-rearing environment. In contrast, her adolescence-limited type is a temporary and situational type of antisocial behavior that’s due to a “maturity gap” between an adolescent’s biological and sexual maturity and his/her social maturity. For individuals with this type, antisocial behaviors are a way to attain mature status.

Moffitt’s description of the outcomes of life-course persistent and adolescent-limited types of conduct disorder are consistent with the DSM-5’s description of the course of the disorder. According to the DSM-5, for most individuals, conduct disorder remits by adulthood, and this is especially true for those whose symptoms have an onset in adolescence. In contrast, individuals whose symptoms begin in childhood have a worse prognosis and “an increased risk of criminal behavior, conduct disorder, and substance-related disorders in adulthood” (APA, 2013, p. 473).

2. Treatment of Conduct Disorder: Evidence-based psychosocial interventions are the first-line treatments for CD and other disruptive behavior disorders and can be categorized as child-focused, parent-focused, family-focused, or multimodal (Gatti, Grattagliano, & Rocca, 2019):

(a) Child-Focused Intervention: Problem-solving skills training (PSST; Kazdin, 2003) is for children and adolescents who have CD or another disruptive behavior disorder. It focuses on the cognitive processes that underlie children’s problematic behaviors and helps them accurately perceive the feelings of others, understand the consequences of their actions, and identify prosocial ways to resolve interpersonal problems and conflicts.

(b) Parent-Focused Interventions: Parent management training – Oregon model (PMTO; Patterson, Reid, & Dishion, 1992) is for parents of children 2 to 18 years old. It is based on the assumption that children’s aggressive, antisocial, and other externalizing behaviors are the result of an escalating cycle of coercive interactions between children and their parents. PMTO helps parents replace coercive parenting practices with positive parenting that includes positive reinforcement, non-coercive discipline, setting limits, and monitoring children’s behaviors. Kazdin’s parent management training (PMT; Kazdin, 2003) is for parents of children 2 to 17 years old with oppositional, aggressive, and/or antisocial behavior. Training is based on the principles of operant conditioning and focuses on replacing antecedents and consequences that are maintaining problematic behaviors with antecedents and consequences that foster desirable behaviors. Research has confirmed that PMT has positive effects on child symptoms, parent symptoms, and family relationships and suggests that combining PMT with PSST is even more effective than either treatment alone for improving child and parent functioning (Kazdin, Siegel, & Bass, 1992; Kazdin & Wassell, 2000). Parent-child interaction therapy (PCIT; Eyberg & Calzada, 1998) is for parents of children 2 to 7 years old who have severe behavioral problems and is also an evidence-based intervention for children who have experienced or are at risk for experiencing maltreatment. PCIT focuses on altering negative parent-child interactions and consists of a child-directed interaction phase that focuses on enhancing the parent-child relationship and a parent-directed interaction phase that focuses on teaching parents effective disciplinary practices.

(c) Family-Focused Interventions: Functional family therapy (FFT; Alexander, Pugh, Parsons, & Sexton, 2000) is an intervention for families that include a child 11 to 18 years old who has an externalizing behavior disorder and/or substance use problem or is at high risk for delinquency. It is based on the assumption that problematic behaviors within a family help regulate relational connections by fostering interdependence or independence and regulate relational hierarchies by creating power structures. The primary goal of therapy is to replace problematic behaviors with non-problematic behaviors that serve the same functions. Multidimensional family therapy (MDFT; Liddle, 2009) is for families that include a member 11 to 21 years old who has a substance use disorder and comorbid internalizing or externalizing symptoms and/or delinquency. It incorporates elements of family systems theory, ecological theory, and developmental psychology. Its primary goals are to reduce or eliminate the adolescent’s substance use, aggression, and other symptoms and improve adolescent and family functioning by facilitating change in four interdependent domains: adolescent, parents, family interactions, and extrafamilial sources of influence.

(d) Multimodal Interventions: Multisystemic therapy (MST; Schoenwald & Henggeler, 2005) is an intensive family and community-based intervention for adolescents 12 to 18 years of age who are at imminent risk for out-of-home placement due to antisocial behaviors, substance use problems, and/or serious psychiatric problems. It is based on Bronfenbrenner’s ecological theory and assumes that problematic behaviors are the result of multiple risk factors at individual, family, peer, school, and community levels and that interventions must be provided at all levels. MST-CAN is a version of MST for families of abused and neglected children who are 6 to 17 years of age. Multidimensional treatment foster care (MTFC; Chamberlain, 2003) is an alternative to residential care for children and adolescents who need intensive support due to child maltreatment, severe emotional disturbance, and/or juvenile delinquency. It involves developing a behavioral management plan that is tailored to the child and administered by a treatment team in the child’s home, school, and community. Children reside with highly trained and supervised foster parents while their biological parents receive the training and support they need for positive reunification.

Note that research investigating the effectiveness of Scared Straight programs as a prevention or intervention for conduct disorder have found that they tend to have harmful effects, with participation in these programs increasing the likelihood that juvenile offenders and at-risk juveniles will engage in criminal behaviors in the future. The studies have also found that confrontational “rap sessions” and nonconfrontational (educational) approaches have similar negative effects and that these programs may have even worse outcomes for seriously delinquent juveniles (Petrosino, Turpin-Petrosino, Hollis-Peel, & Lavenberg, 2014).

Intermittent Explosive Disorder: This disorder is diagnosed when the individual has had recurrent behavioral outbursts that are due to a failure to control aggressive impulses as manifested by one of the following: (a) verbal or physical aggression that occurs, on average, twice weekly for at least three months, with physical aggression not resulting in damage or destruction to property or physical injury to other people or animals. (b) three behavioral outbursts in a 12-month period that resulted in damage or destruction of property and/or physical injury to other people or animals. The diagnosis also requires that the level of aggressiveness must not be proportional to provocation or any precipitating social stressor and that outbursts must not be premeditated or committed to achieve a tangible outcome and must cause significant distress to the individual, impaired occupational or interpersonal functioning, or negative financial or legal consequences. In addition, the individual must be at least six years old or at the equivalent developmental level. The onset of this disorder is usually in childhood or adolescence.