Disruptive Behaviour Disorder is an expression used to describe a set of externalising negative behaviours that co-occur during childhood. There are three subgroups of externalising behaviours; Oppositional Defiant and Conduct Disorder and Attention Deficit/Hyperactivity Disorder. Treatment at the clinic is based on the premise that these behaviours are the result of a combination of a metabolic dysfunction and environmental factors. We approach treatment in a similar way to our treatment of children and adolescents with ADHD. There is however an added emphasis on Counselling and Behaviour Modification techniques.
Causes of Disruptive Disorders
There is evidence from research into causes of conduct disorders that indicates that several biological and environmental factors may contribute to the development of these disorders. Mostly a diet consisting of too much sugar and too many refined carbohydrates from wheat; food colourings, additives and preservatives and environmental toxins that can disrupt the normal functioning of brain cells; and finally the lack of nutrients in our western style diet affecting tissue function.
- Oppositional Defiant disorder (ODD)
- Conduct disorder (CD)
- Attention Deficit Hyperactivity Disorder (ADHD)
Oppositional Defiant Disorder (ODD)
Oppositional Defiant Disorder (ODD) consists of a pattern of negativistic, hostile, and defiant behaviour lasting at least 6 months, during which four (or more) of the following behaviours are present:
- often loses temper
- often argues with adults
- often actively defies or refuses to comply with adults' requests or rules
- often deliberately annoys people
- often blames others for his or her mistakes or misbehaviour
- is often touchy or easily annoyed by others
- is often angry and resentful
- is often spiteful or vindictive
Each of the above is only considered diagnostic if the behaviour occurs more frequently than is typically observed in children of comparable age and developmental level and if the behaviour causes clinically significant impairment in social, academic, or occupational functioning.
Oppositional Defiant disorder is not diagnosed if the behaviours occur exclusively during the course of a Psychotic or Mood Disorder or if Conduct Disorder is diagnosed.
The DSM categorises conduct disorder behaviours into four main groupings:
- aggressive conduct that causes or threatens physical harm to other people or animals,
- non- aggressive conduct that causes property loss or damage,
- deceitfulness or theft, and
- serious violations of rules.
Conduct Disorder consists of a repetitive and persistent pattern of behaviours in which the basic rights of others or major age-appropriate norms or rules of society are violated. Typically there would have been three or more of the following behaviours in the past 12 months, with at least one in the past 6 months:
Aggression to 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, 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, armed robbery)
- has forced someone into sexual activity
Destruction of property
- has deliberately engaged in fire setting with the intention of causing serious damage
- has deliberately destroyed the property of others(other than by fire setting)
Deceitfulness or prone to theft
- has broken into someone else's house, building, or car and
- often lies to obtain goods or favours or to avoid obligations
- has stolen items of nontrivial value without confronting 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 age 13 years
- has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
- is often truant from school, beginning before age 13 years
Subtypes of Conduct Disorder
There are two subtypes of conduct disorder outlined in DSM, and their diagnosis differs primarily according to the nature of the presenting problems and the course of their development.
- The first, childhood-onset type, is defined by the onset of one criterion characteristic of conduct disorder before age 10. Children with childhood-onset conduct disorder are usually male, and frequently display physical aggression; they usually have disturbed peer relationships, and may have had oppositional defiant disorder during early childhood. These children usually meet the full criteria for conduct disorder before puberty, they are more likely to have persistent conduct disorder, and are more likely to develop adult antisocial personality disorder than those with the adolescent-onset type.
- The second, the adolescent-onset type, is defined by the absence of conduct disorder prior to age 10. Compared to individuals with the childhood-onset type, they are less likely to display aggressive behaviours. These individuals tend to have more normal peer relationships, and are less likely to have persistent conduct disorders or to develop adult antisocial personality disorder. The ratio of males to females is also lower than for the childhood-onset type.
Severity of symptoms
Conduct disorder is classified as "mild"; if there are few, if any, conduct problems in excess of those required for diagnosis and if these cause only minor harm to others (e.g., lying, truancy and breaking parental rules). A classification of "moderate"; is applied when the number of conduct problems and effect on others are intermediate between "mild" and "severe". The "severe" classification is justified when many conduct problems exist which are in excess of those required for diagnosis, or the conduct problems cause considerable harm to others or property (e.g., rape, assault, mugging, breaking and entering)
Co-morbidities and associated disorders
Children with conduct disorder are part of a population within which there are higher incidences of a number of disorders than in a normal population. The literature abounds with studies indicating the co-morbid relationships between Attention Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, Learning Difficulties, Mood Disorders, Depressive symptoms, Anxiety Disorders, Communication Disorders, and Tourettes Disorder. In one study, a high level of co-morbidity (almost 95%) was found among 236 ADHD children (aged 6-16 yrs) with conduct disorder, ODD and other related categories. In an 8 year follow-up study, Barclay and colleagues (1990) found that 80% of the children with ADHD were still hyperactive as adolescents and that 60% of them had developed Oppositional Defiant or Conduct Disorder.
Prevalence of Conduct Disorder.
According to research, 8% of children in the United States may have conduct disorder. The incidence of the disorder is thought to vary demographically, with some areas being worse than others. For example, in a New York sample, 12% had moderate level conduct disorder and 4% had severe conduct disorder. Since prevalence estimates are based primarily upon referral rates, and since many children and adolescents are never referred for mental health services, the actual incidences may well be higher.
Course of Conduct Disorder
The onset of conduct disorder may occur as early as age 5 or 6, but more usually occurs in late childhood or early adolescence; onset after the age of 16 years is rare. The results of research into childhood aggression have indicated that externalising problems are relatively stable over time. In one study, Richman and colleagues found that 67% of children who displayed externalising problems at age 3 were still aggressive at age 8. Other studies have found stability rates of 50-70%. However, these stability rates may be higher due to the belief that the problems are episodic, situational, and likely to change in character.
Age of onset of ODD seems to be associated with the development of severe problems later in life, including aggressiveness and antisocial behaviour. However, not all conduct disordered children have a poor prognosis. Studies suggest that less than 50% of the most severe cases become antisocial as adults. Nevertheless, the fact that this disorder continues into adulthood for many people conveys that it is a serious and life-long dysfunction
While not all ODD children develop conduct disorder, and not all conduct disorder children become antisocial adults there are certain risk factors that have been shown to contribute to the continuation of the disorder. The risk factors identified include; an early age of onset (preschool years), the spread of antisocial behaviours across settings, the frequency and intensity of antisocial behaviours, the forms that the antisocial behaviours take, having covert behaviours at an early age and also particular parent and family characteristics. However, these risk factors do not fully explain the complex interaction of variables involved in understanding the continuation of Conduct Disorder in any one individual.
The high co-morbidity rate of Conduct Disorder with ADHD, Tourettes syndrome and other disorders known to be due to neurological dysregulation suggests that Conduct Disorder may be a co-manifestation of the same underlying dysregulation. Although there are no studies to our knowledge, which have directly investigated the neurological basis for conduct disorder, there is ample clinical evidence indicating that when treating ADHD with Neurotherapy, and Nutrient supplementation, Conduct Disorder abates. It appears that Neurotherapy may address the underlying dysregulation and facilitate clinical treatment using cognitive and behavioural interventions. More research is needed in this area to determine whether Neurotherapy is directly responsible for this abatement or whether the resultant improvement in attention, and reduction in hyperactivity promotes better self image which in turn improves behaviour.
Child Biological Factors
Considerable research has been carried out into the role of child temperament, the tendency to respond in predictable ways to events, as a predictor of conduct problems. Aspects of the personality such as activity levels displayed by a child, emotional responsiveness, quality of mood and social adaptability are part of his or her temperament. Longitudinal studies have found that although there is a relationship between early patterns of temperament, and adjustment during adulthood, the longer the time span the weaker this relationship becomes.
A more important determinant of whether or not temperamental qualities persist has been shown to be the manner in which parents respond to their children. "Difficult" infants have been shown to be especially likely to display behaviour problems later in life if their parents are impatient, inconsistent, and demanding. On the other hand "difficult" infants, whose parents give them time to adjust to new experiences, learn to master new situations effectively. In a favourable family context a "difficult" infant is not at risk of displaying disruptive behaviour disorder at 4 years old.
Cognitions may also influence the development of conduct disorder. Children with conduct disorder have been found to misinterpret or distort social cues during interactions with peers. For example, a neutral situation may be construed as having hostile intent. Further, children who are aggressive have been shown to seek fewer cues or facts when interpreting the intent of others. Children with conduct disorder experience deficits in social problem solving skills. As a result they generate fewer alternate solutions to social problems, seek less information, see problems as having a hostile basis, and anticipate fewer consequences than children who do not have a conduct disorder.
A bidirectional relationship exists between academic performance and conduct disorder. Frequently children with conduct disorder exhibit low intellectual functioning and low academic achievement from the outset of their school years. In particular, reading disabilities have been associated with this disorder, with one study finding that children with conduct disorder were at a reading level 28 months behind normal peers.
In addition, delinquency rates and academic performance have been shown to be related to characteristics of the school setting itself. Such factors as physical attributes of the school, teacher availability, teacher use of praise, the amount of emphasis placed on individual responsibility, emphasis on academic work, and the student teacher ratio have been implicated.
Parent Psychological Factors
It is known that a child's risk of developing conduct disorder is increased in the event of parent psychopathology. Maternal depression, paternal alcoholism and/or criminality and antisocial behaviour in either parent have been specifically linked to the disorder.
There are two views as to why maternal depression has this effect. The first considers that mothers who are depressed misperceive their child's behaviour as maladjusted or inappropriate. The second considers the influence depression can have on the way a parent reacts towards a child's misbehaviour. Depressed mothers have been shown to direct a higher number of commands and criticisms towards their children, who in turn respond with increased noncompliance and deviant child behaviours. Hence, depressed and irritable mothers may indirectly cause behaviour problems in their children through inconsistent limit setting, emotional unavailability, and reinforcement of inappropriate behaviours through negative attention.
Divorce, Marital Distress, and Violence
The inter-parental conflicts surrounding divorce have been associated with the development of conduct disorder. However, it has been noted that although some single parents and their children become chronically depressed and report increased stress levels after separation, others do relatively well. Forgatch suggested that for some single parents, the events surrounding separation and divorce set off a period of increased depression and irritability which leads to loss of support and friendship, setting in place the risk of more irritability, ineffective discipline, and poor problem solving outcomes. The ineffective problem solving can result in more depression, while the increase in irritable behaviour may simultaneously lead the child to become antisocial.
More detailed studies into the effects of parental separation and divorce on child behaviour have revealed that the intensity of conflict and discord between the parents, rather than divorce itself, is the significant factor. Children of divorced parents whose homes are free from conflict have been found to be less likely to have problems than children whose parents remained together but engaged in a great deal of conflict, or those who continued to have conflict after divorce. Webster noted that half of all those children referred to their clinic with conduct problems were from families with a history of marital spouse abuse and violence.
In addition to the effect of marital conflict on the child, conflict can also influence parenting behaviours. Marital conflict has been associated with inconsistent parenting, higher levels of punishment with a concurrent reduction in reasoning and rewards, as well as with parents taking a negative perception of their child's adjustment.
Family Adversity and Insularity
Life stressors such as poverty, unemployment, overcrowding, and ill health are known to have an adverse effect on parenting and to be therefore related to the development of conduct disorder. The presence of major life stressors in the lives of families with conduct disordered children has been found to be two to four times greater than in other families.
Mothers' perception of the availability of supportive and social contact has also been implicated in child contact disorder. Mothers who do not believe supportive social contact is available are termed "insular" and have been found to use more aversive consequences with their children than non-insular mothers.
Parent Child Interactions
Research has suggested that parents of children with conduct disorder frequently lack several important parenting skills. Parents have been reported to be more violent and critical in their use of discipline, more inconsistent, erratic, and permissive, less likely to monitor their children, as well as more likely to punish pro-social behaviours and to reinforce negative behaviours. A coercive process is set in motion during which a child escapes or avoids being criticised by his or her parents through producing an increased number of negative behaviours. These behaviours lead to increasingly aversive parental reactions which serve to reinforce the negative behaviours.
Differences in affect have also been noted in conduct disordered children. In general their affect is less positive, they appear to be depressed, and are less reinforcing to their parents. These attributes can set the scene for the cycle of aversive interactions between parents and children.
Other Family Characteristics
Birth order and size of the family have both been implicated in the development of conduct disorder. Middle children and male children from large families have been found to be at an increased risk of delinquency and antisocial behaviours.
Psychophysiological and Genetic Influences
Studies have found that neurological abnormalities are sometimes correlated with conduct disorder. While there has been interest in the implication of the frontal lobe - limbic system partnership in the deficits of aggressive children, these problems may be the consequence of the increased likelihood for children with conduct disorder to experience abuse and subsequent head injuries. Both head injuries and limbic system anomalies can precipitate abnormal externalising behaviours. QEEG imaging can throw a light on these aetiologies.
While twin studies have found greater concordance of antisocial behaviour among monozygotic rather than dizygotic twins, and adoption studies have shown that criminality in the biological parent increases the likelihood of antisocial behaviour in the child, genetic factors alone do not account for all of the developmental disorders, and hence environmental factors also play a significant part in behavioural disorders. Research indicates that a Western-style diet" of refined carbohydrates and sugars from highly processed cereal grains, low nutrients in the diet, food additives and preservatives are all to blame for the rise in these disorders.
Final Word on Aetiology
While the risk factors outlined have been shown to be implicated in the development of conduct disorder, it is important to note that not all children exposed to these factors develop a conduct disorder. Rather, the evidence suggests that in those children who do develop conduct disorders have an aetiology comprised of a combination of these factors. There is strong evidence that 75% of ADHD children with hyperactivity develop behavioural problems including 50% conduct disorder and 21% antisocial behaviour (Klein & Mannuzza, 1991).
A number of interventions have been identified which are useful in reducing the prevalence and incidence of conduct disorder. Interventions consist of prevention and treatment, although these should not be considered as separate entities. Prevention addresses the onset of the disorder, although the child has not manifested the disorder, and treatment addresses reduction of the severity of the disorder. In mainstream Psychology, prevention and treatment for Conduct Disorder primarily focuses on skill development, not only for the child but for others involved with the child, including the family and the school environments.
As previously discussed there may be clinical advantages in applying a Mediterranean-like diet of fresh foods including fruit, vegetables, legumes, fish and unprocessed meat. Dietary changes, Nutritional supplementation and Neurotherapy where appropriate can work wonders with children with Disruptive Behaviour Disorders, in conjunction with cognitive and behavioural intervention. The following paragraphs considers three interventions, that assist in preventing and treating conduct disorder; child training, family training, and school and community interactions.
Child training involves the teaching of new skills to facilitate the child's growth, development and adaptive functioning. Research indicates that as a means of preventing child conduct disorder there is a need for skill development in the area of child competence. Competence refers to the ability for the child to negotiate the course of development including effective interactions with others, successful completion of developmental tasks and contacts with the environment, and use of approaches that increase adaptive functioning. It has been found that facilitating the development of competence in children is useful as a preventative measure for children prior to manifestation of the disorder rather than as a treatment.
Additionally, treatment interventions have been developed to focus on altering the child's cognitive processes. This includes teaching the child problem solving skills, self control facilitated by self statements and developing prosocial rather than antisocial behaviours. Prosocial skills are developed through the teaching of appropriate play skills, development of friendships and conversational skills. The social development of children provides them with the necessary skills to interact positively in their environment. A child's development of cognitive skills provides a sound basis from which to proceed. However, cognitive development should not be considered in isolation, but as part of a system, which highlights the need to include the family in the training process.
A child's family system, has an important role in the prevention and treatment of conduct disorder. The child needs to be considered as a component of a system, rather than as a single entity. Research supports the notion that parents of conduct disordered children have underlying deficits in certain fundamental parenting skills. The development of effective parenting skills has been considered as the primary mechanism for change in child conduct disorder, through the reduction of the severity, duration and manifestation of the disorder.
A number of parent training programs have been developed to increase parenting skills. Research indicates that the parent training programs have been positive, indicating significant changes in parents' and children's behaviours and parental perception of child adjustment. Research suggests that parents who have participated in parent training programs are more successful in reducing their child's level of aggression, frequently by 20 - 60 %.
Various training programs have been developed, which focus on increasing parents' skills in managing their child's behaviour and facilitating social skills development. The skills focused on, include parents learning to assist in administration of appropriate reinforcement and disciplinary techniques, effective communication with the child and problem solving and negotiation strategies.
A further component of parental training incorporates behavioural management. This involves providing the family with simple and effective strategies including behavioural contracting, contingency management, and the ability to facilitate generalisation and maintenance of their new skills, thus encouraging parents' positive interaction with their child.
However, although these interventions assist parents in developing effective parenting skills, a number of families require additional support. There are various characteristics within the family system that can have an impact on parents' ability to cope. This includes depression, life stress and marital distress. Research suggests that family characteristics are associated with fewer treatment gains in parent training programs. Several programs have expanded upon the standard parent training treatment. These programs have incorporated parents' cognitive, psychological, and marital or social adjustment. Through addressing the parent's own issues it assists their ability to manage and interact positively with the child.
School and Community Education
A child's environment plays an active role in the treatment of conduct disorder and as a preventative measure. A number of interventions have been developed for schools and the community in relation to conduct disorder. The various programs outlined in this paper have a primary focus involving the skill development for the child in the areas of problem solving, anger management, social skills, and communication skills.
School based programs
There are various preventative programs devised which focus on specific cognitive skill development of a child. A number of programs developed focus on encouraging the child's development in decision making and cognitive process. In addition school based programs have involved teaching the child interpersonal problem solving skills, strategies for increasing physiological awareness, and learning to use self talk and self control during problem situations.
In addition to prevention programs, a number of treatment interventions have been developed for children where conduct disorder has manifested. The treatment programs focus on further skill development, including anger management and rewarding appropriate classroom behaviour, skill development of the child including the understanding of their feelings, problem solving, how to be friendly, how to talk to friends, and how to succeed in school. As Webster and colleagues describe, one school based program has been designed to prevent further adjustment problems, by rewarding appropriate classroom behaviour, punctuality, and a reduction in the amount of disciplinary action. In addition, the program provided parents and teachers with the opportunity to focus on specific problems of a child and for these to be addressed.
Community based interventions have also addressed both treatment and prevention. A number of programs have been developed, and focus on involving the youths in activity programs and providing training for those activities. The children are rewarded for attendance and participation in the programs.
The treatments discussed are helpful in reducing the prevalence and incidence of conduct disorder. In their application it is important to provide an integrated multidisciplinary approach to treatment in multiple settings and by providing relevant nutritional supplements, Neurotherapy and behaviour training as appropriate.
Conduct disorder is very common among children and adolescents in our society. This disorder not only affects the individual, but his or her family and surrounding environment. Conduct disorder appears in various forms, and a combination of factors appear to contribute to its development and maintenance. A variety of interventions have been put forward to reduce the prevalence and incidence of conduct disorder. The optimum method appears to be an integrated approach that considers both the child and the family, within a variety of contexts throughout the developmental stages of the child and family's life.
However, we cannot stress enough the importance of a Mediterranean style diet and nutrient supplements to make up for the deficits in our diet of foods grown in impoverished soils using chemical fertilisers, combined with Neurotherapy and counselling as appropriate.