Disruptive Behaviour Disorder is a term used to describe a set of externalising negative behaviours that co-occur during childhood. There are three subgroups of externalising behaviours: Oppositional Defiant, Conduct Disorder, and ADHD. Therapy for these disorders at BNC is based on the premise that these behaviours are the result of both metabolic dysfunction and environmental factors. Our therapy for disruptive behaviour disorders is like therapy for ADHD, with an added emphasis on Counselling and Behaviour Modification.
Causes of Disruptive Disorders
Research indicates that there are biological and environmental that contribute to the development of disruptive disorders. A diet high in sugar and refined carbohydrates (in wheat, food colourings, additives, preservatives, and environmental toxins) disrupts healthy brain cell functioning. Additionally, a Western diet lacking in nutrients affects tissue function.
Oppositional Defiant Disorder (ODD)
Oppositional Defiant Disorder (ODD) consists of a pattern of negative, hostile, and defiant behaviours that last at least 6 months, during which four (or more) of the following are present:
- Often loses temper
- Often argues with adults
- Often actively defies or refuses to comply with adult requests or rules
- Often deliberately annoys people
- Often blames others for his or her mistakes or misbehaviour
- Often touchy or easily annoyed by others
- Often angry and resentful
- Often spiteful or vindictive
The above are only considered diagnostic if the behaviour occurs more frequently than is typically observed in children matched in age and developmental level. To meet diagnostic criteria the behaviour must cause clinically significant impairment in social, academic, and/or occupational functioning.
ODD is not diagnosed if the behaviours occur exclusively due to Psychotic or Mood Disorders.
The DSM categorises Conduct Disorder symptoms into four main groups:
- 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
- Serious violations of rules
Conduct Disorder consists of repetitive and persistent patterns of behaviour in which the basic rights of others, or age-appropriate societal norms and/or rules, are violated. Typically, 3 or more of the following have occurred in the past 12 months, with at least 1 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, or forgery)
Serious violations of rules
- Often stays out at night despite parental prohibitions, beginning before age 13
- 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
There are two subtypes of Conduct Disorder outlined in DSM, with diagnosis differing according to the nature of the presenting problems and their course of development.
- The 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 ODD during early childhood. These children usually meet the full criteria for Conduct Disorder before puberty, are more likely to have persistent Conduct Disorder and develop adult antisocial personality disorder than those with the adolescent-onset type.
- The adolescent-onset type is defined by the absence of Conduct Disorder prior to age 10. Compared to individuals with the childhood-onset type, these individuals are less likely to display aggressive behaviours and tend to have more normal peer relationships. Individuals 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 are classified as ‘mild’ if there are few, if any, conduct problems more than 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 effects on others are intermediate between ‘mild’ and ‘severe’. The ‘severe’ classification is justified when many more conduct problems exist than those required for diagnosis, or the conduct problems cause considerable harm to others (e.g., rape, assault, mugging) or property (e.g., breaking, entering).
Co-morbidities and associated disorders
Children with Conduct Disorders are part of a population with higher co-morbidities than other disorders. Research indicates co-morbid relationships between ADHD, ODD, Learning Difficulties, Mood Disorders, Anxiety Disorders, Communication Disorders, and Tourette’s Disorder. In one study of 236 children (age 6-16) n with ADHD, almost 95% had ODD and other related disorders. In an 8-year follow-up study, Barclay and colleagues (1990) find that 80% of the children with ADHD were still hyperactive as adolescents and that 60% of them had developed ODD.
Prevalence of Conduct Disorder
Eight percent of children in the US have Conduct Disorders [REF?]. Its incidence is thought to vary demographically, with more diagnoses in some areas than others. For example, in a New York sample, 12% had moderate Conduct Disorder and 4% had severe Conduct Disorder. Since prevalence estimates are based primarily upon referral rates, and many children and adolescents are never referred for mental health services, the prevalence may be higher.
Course of Conduct Disorders
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. Aggression research in children indicates that externalising problems are relatively stable over time. In one study, Richman and colleagues found that 67% of children who displayed externalising behaviours at age 3 were still aggressive at age 8. Other studies find rates of 50-70%. The true stability rates may be higher since the problems are episodic, situational, and likely to change in presentation.
The onset of ODD is often associated with severe problems later in life, including aggressiveness and antisocial behaviours. However, not all children with Conduct Disorders have poor prognoses. Studies suggest that less than 50% of the severe cases become antisocial as adults. Nevertheless, the fact that this disorder continues into adulthood demonstrates that it is serious and can be life-long.
While not all children with ODD develop Conduct Disorder, and not all children with Conduct Disorder become antisocial adults, there are certain risk factors contributing to the maintenance of the disorder. Risk factors include early onset (preschool years), the spread of antisocial behaviours across settings, the frequency and intensity of antisocial behaviours, the characteristics of the antisocial behaviours, covert behaviours at an early age, and certain parental/familial attributes. However, these risk factors do not fully explain the complex interaction of factors present in any one individual.
The high co-morbidity of Conduct Disorders with ADHD, Tourette’s, and other disorders is due to neurological dysregulation. This suggests that there may be a common factor. Although there are no studies which directly investigate the neurological basis of Conduct Disorders, there is much clinical evidence to indicate that if ADHD is treated with Neurotherapy and nutritional supplementation the symptoms lessen. Neurotherapy may address underlying dysregulation and is thus a good adjunct to cognitive and behavioural interventions. Research is needed to determine whether Neurotherapy is directly responsible for symptom improvement or whether improved attention, reduced hyperactivity, and better self-image are indirectly responsible.
Child Biological Factors
Research indicates the role of child temperament and the tendency to respond to events in predictable ways are predictive of conduct problems. Personality differences such as activity levels, emotional responsiveness, quality of mood and social adaptability also play a part. Longitudinal studies have found that although early patterns of temperament often adjust during adulthood, the longer the time span of symptoms, the weaker this correlation becomes.
An important determinant of persisting behavioural problems is the way parents respond to their child. ‘Difficult’ infants are especially likely to display behavioural problems later in life if their parents are impatient, inconsistent, and demanding. On the other hand, infants with conduct problems whose parents give them the time to adjust to new experiences and learn to master new situations, are at less risk of displaying disruptive behaviour disorders at age 4.
Cognitions also influence the development of Conduct Disorder. Children with Conduct Disorder have been found to misinterpret or distort social cues during interactions with their peers. For example, a neutral situation may be construed as having hostile intent. Furthermore, children who are aggressive seek less information when interpreting the intent of others. Children with Conduct Disorder often have deficits in social problem-solving skills, generating fewer alternate solutions to social problems, seeking less information, viewing problems as hostile in nature, and anticipating fewer consequences than children who do not have a Conduct Disorder.
There is a bidirectional relationship between academic performance and Conduct Disorder. Children with Conduct Disorder often exhibit lower IQ and academic achievement at school. Reading disabilities have been associated with this Conduct Disorder. A study reveals that children with Conduct Disorder are, on average, at a reading level 28 months behind their peers.
In addition, delinquency rates and academic performance are often related to school setting (e.g., the physical attributes of the school, teacher availability, teacher praise, the amount of emphasis placed on individual responsibility and academic work, and the student teacher ratio).
Parent Psychological Factors
A child's risk of developing Conduct Disorder is increased if the parent is also mentally unwell (e.g., depression, alcoholism, antisocial behaviour and/or criminality in either parent).
There is also a high correlation with maternal depression. A possible explanation is that mothers who are depressed misperceive their child’s behaviour as maladjusted or inappropriate. Another explanation considers that maternal depression may change how a mother reacts to their 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. Hence, mothers with depression may unknowingly contribute to behavioural problems in their children through inconsistent limit setting, emotional unavailability, and the reinforcement of inappropriate behaviours through negative attention.
Divorce, Marital Distress, and Violence
Inter-parental conflicts surrounding divorce have been associated with the development of Conduct Disorders. However, it has been noted that although some single parents and their children become depressed and report increased stress levels after separation, others do well. Forgatch [REF] suggests that for some single parents, the events surrounding separation/divorce give rise to a period of increased depression and irritability for families. This, in turn, may give rise to more irritability, ineffective discipline, and poor problem solving in the family home.
Studies into the effects of parental separation and divorce on child behaviour reveal 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 are less likely to have problems than children whose parents remained together but engaged in conflict, or those who continued to have conflict after divorce. Webster notes that 50% of children referred to his clinic with conduct issues were from families with histories of abuse and violence.
In addition to the effects of marital conflict on the child, conflict can influence parenting styles. Marital conflict is associated with inconsistent parenting, higher levels of punishment and a reduction in reasoning and rewards. Parents may adopt a more pessimistic view of their child.
Family Adversity and Insularity
Life stressors such as poverty, unemployment, overcrowding, and ill health have adverse effects on parenting and are related to the development of Conduct Disorder. The presence of major life stressors in the lives of families with children with Conduct Disorder has been found to be 2 to 4 times greater than in other families [REF].
Mothers’ perception of the availability of supports and social contact has been implicated in child Conduct Disorder. Mothers who do not believe supportive social contact is available are termed ‘insular’ are more likely to use punitive consequences when dealing with their children than non-insular mothers [REF?].
Parent Child Interactions
The parents of children with Conduct Disorder frequently lack several important parenting skills. They may use violent and aggressive discipline, are inconsistent, erratic, and permissive, more likely to punish pro-social behaviours and reinforce negative behaviours, and less likely to monitor their children. A child may try and ‘fit’ their parents’ view of them by behaving negatively, leading to more punitive responses which only reinforce the child’s behaviour.
Differences in affect also play a role in Conduct Disordered children. In general, children with Conduct Disorders are less positive, more depressed, and are less reinforcing to their parents.
Other Family Characteristics
Birth order and family size correlate with the development of Conduct Disorder. Middle children and male children from large families are found to be at increased risk of delinquency and antisocial behaviours.
Psychophysiological and Genetic Influences
Neurological abnormalities are sometimes correlated with Conduct Disorder. There is interest in the role of the frontal lobe and limbic system in aggressive children, which may be due to physical abuse in children with Conduct Disorder and related head injuries. Both head injuries and limbic system anomalies can precipitate abnormal externalising behaviours.
QEEG imaging throws light on these aetiologies.
Twin studies find greater prevalence of antisocial behaviour in monozygotic rather than dizygotic twins. Adoption studies also show that criminality on the part of biological parents increases the likelihood of antisocial behaviour children. Genetic factors may be part of the puzzle, but environmental factors also play a significant role. A Western-style diet (low in nutrients and high in refined carbohydrates and sugars) are all factors that can contribute.
Final Word on Aetiology
While there are many risk factors implicated in Conduct Disorder, it is important to note that not all children exposed to these factors develop Conduct Disorder. Rather, the evidence suggests that in those children who do develop Conduct Disorders their aetiology is a combination of these risk factors. There is evidence that 75% of children with ADHD develop behavioural problems (50% have Conduct Disorder and 21% have antisocial behaviour: Klein & Mannuzza, 1991). [REF]
Interventions for Conduct Disorder consist of prevention and therapy, although these should not be considered as separate entities. Prevention addresses the onset of the disorder, whereas therapy aims to reduce symptom severity. Prevention and therapy primarily focus on skill development, not only for the child but all involved (parents, teachers, carers etc.)
There are advantages in following a loosely Mediterranean diet of fresh foods including fruit, vegetables, legumes, fish, and unprocessed meat. Dietary changes, nutritional supplementation and Neurotherapy have proven benefits for children with Disruptive Behaviour Disorders. Dietary changes should co-occur with cognitive and behavioural interventions. Child, parents and school and community training are all recommended.
Child training involves teaching new skills to facilitate the child’s growth, development, and adaptive functioning. Research indicates that to prevent child Conduct Disorder there is a need for skill development in child competence [REF]. Competence refers to the ability of the child to negotiate their own development including effective interactions with others, successful completion of tasks, contact with their environment, and the use of adaptive skills. Fostering competence is useful as a preventative measure for children.
Additionally, therapeutic interventions that focus on altering the child's cognitive processes are found to be helpful. These interventions include teaching the child problem-solving skills and self-control (self-statements and prosocial behaviours). Prosocial skills refer to appropriate play skills, friendliness, and conversation. Once these skills are acquired, the child can interact with their environment in a more positive manner. However, the child’s cognitive training is only one part of the puzzle since there is a need for the family to be onboard with the learning process.
A child’s family has a key role in prevention and therapy for Conduct Disorder. The child is part of a network, rather than as a single entity. Often parents of children with Conduct Disorder can improve their parenting skills. Good parenting techniques are a primary mechanism for positive changes (i.e., a reduction of Conduct Disorder severity, frequency, and duration).
Training programs have been developed to increase parenting skills. Such training programs have positive results, with significant positive changes in both child adjustment and parental behaviours. Research suggests that parents who have participated in parental training programs are more successful in reducing their child’s aggression by 20—60%. [REF]
Various training programs have been developed which focus on increasing parent skills in managing their child's behaviours and facilitating new social skills. Parents learn appropriate reinforcement and disciplinary techniques, problem solving, negotiation strategies, and how to communicate effectively with their child.
Behavioural management is also vital and involves simple and effective strategies for behavioural contracting, contingency management, facilitating generalisation, and maintaining skills acquired. These techniques promote healthy family relationships. Various components of the family system can impact a parent’s ability to cope. Family characteristics (e.g., depression, anxiety, stress) are associated with fewer treatment gains in parental training programs. Thus, many programs now teach cognitive, psychological, and social adjustment strategies to parents. If the parents’ issues are addressed, it can promote positive interactions with their child.
School and Community Education
A child's environment plays an active role in Conduct Disorder and can be a preventative measure. Interventions have been developed for schools and the communities that focus on problem solving, anger management, social and communication skills.
School based programs
There are various school-based preventative programs that enable cognitive skill development. Several programs focus on encouraging decision-making and cognition. Many school-based programs involve teaching the child interpersonal problem-solving skills, strategies for increasing physiological awareness, and learning self-talk and self-control to address problems.
Several school-based therapy interventions also exist Conduct Disorder. These programs focus on further skill development, including anger management and rewarding appropriate classroom behaviour. Children learn to understand their feelings, problem solve, be friendly, talk to their peers, and succeed academically. School-based programs are often designed to prevent adjustment problems by rewarding appropriate classroom behaviour, punctuality, and a reduction in disciplinary action.
Many community-based programs have been developed which focus on involving youth in activity programs and training. Youth are rewarded for their attendance and participation.
The above therapies are helpful in reducing the prevalence and symptoms of Conduct Disorder. It remains also important to adopt an integrated multidisciplinary approach with also includes appropriate diet changes, Neurotherapy and behavioural training (if relevant).
Conduct disorder is very common among children and adolescents and affects not only the individual, but their family and environment. Conduct disorder appears in various forms, and a combination of factors appear to contribute to its development. Many interventions exist that target Conduct Disorder. The ideal method appears to be an integrated approach that considers the child and their family in a variety of contexts throughout their lives.