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Salud Mental 2011;34:411-417
Disruptive behavior disorders in children and adolescents
Disruptive behavior disorders in children
and adolescents: diagnosis and treatment
Francisco de la Peña Olvera,1 Lino Palacios Cruz2
Original article
SUMMARY
RESUMEN
Disruptive behavior disorders (DBD) in children and adolescents are
among the most frequent reasons for consultation and counseling.
For oppositional defiant disorder (ODD), psychosocial
management is the therapeutic intervention of choice. Training parents
and caregivers on the behavioral management of the child or early
adolescent (12 to 15 years) is the best intervention approach. Behavioral
perspective must cover all contexts: family, school, and the child him/
herself. The clinician must develop an individualized treatment plan.
Interventions should be based on the methods with the greatest amount
of empirical evidence. The use of medication may be helpful as a
supplement to psychosocial interventions to treat symptoms and
comorbid conditions. Severe and persistent ODD may require prolonged
and intensive treatment. Brief interventions are usually ineffective.
Conduct disorder (CD) is a mixed manifestation that requires
biological, psychological and social therapeutic intervention.
Psychopharmacological treatment alone is never enough. Studies of
medications for the treatment of CD may be grouped according to
the type of drug used: mood stabilizers, antipsychotics and stimulants.
The overall effect size of psychotropic agents in the treatment of
aggression is 0.56. Currently only three psychosocial treatments have
been adequately evaluated: a) Training for parents, b) Cognitive
training on problem-solving skills and c) Multisystemic therapy.
Los Trastornos de la Conducta Disruptiva (TCD) en la infancia y la adolescencia constituyen uno de los motivos más frecuente de consulta.
En el Trastorno Negativista y Desafiante (TND) el tratamiento
psicosocial es la intervención terapéutica de primera elección. Los
programas de intervención desde una perspectiva conductual
abarcan todos los contextos: familiar, escolar y del propio niño o
adolescente. El clínico debe considerar importante cualquier
información obtenida de otros informantes, vgr. maestros, para
realizar un plan de tratamiento individualizado. Las intervenciones
sugeridas a los padres deben basarse en las de mayor evidencia
científica. El uso de medicamentos puede ser útil como tratamiento
adjunto a las intervenciones psicosociales, para el tratamiento
sintomático y el de las comorbilidades. Cuando el TND es intenso y
persistente se pueden requerir tratamientos prolongados e intensivos.
Las intervenciones cortas usualmente son inefectivas.
El Trastorno Disocial (TD) es un fenómeno que por su naturaleza
mixta, biológica, psicológica y social, requiere de una intervención
terapéutica integral. La magnitud del efecto global de los fármacos en
el tratamiento de la agresión es de 0.56. Actualmente sólo tres
tratamientos psicosociales han sido adecuadamente evaluados: a) El
entrenamiento para padres, b) el entrenamiento cognitivo en
habilidades para resolver problemas y c) la terapia multisistémica.
Conclusions
ODD and CD are among the most common and severe mental
disorders among children and adolescents. Treatment of these
conditions must be multimodal or multisystemic, including
pharmacological, psychoeducational and psychotherapeutic
approaches.
Conclusiones
Los padecimientos externalizados como el TND y el TD; constituyen
algunos de los problemas más frecuentes y graves dentro de los
trastornos mentales de inicio en la infancia y la adolescencia. El
tratamiento de estos padecimientos debe tener un enfoque
multimodal o multisistémico que incorpore las aproximaciones
farmacológicas, psicoeducativas y psicoterapéuticas necesarias.
Key words: Disruptive behavior, diagnosis, treatment, children,
adolescent.
INTRODUCTION
Disruptive behavior disorders (DBD) among children and
adolescents constitute one of the most frequent reasons for
seeking psychological, neurological and psychiatric help.1
1
2
Palabras clave: Conducta disruptiva, diagnóstico, tratamiento, niños y adolescentes.
DBDs have also been referred to as «externalized disorders»
or problems.2,3 This «dimension» has included behavioral
problems as well as those caused by the consumption of
drugs and alcohol. The Diagnostic and Statistical Manual
for Mental Disorders (DSM), in its fourth edition,4 includes
Department for Research Support, Ramón de la Fuente Muñiz National Institute of Psychiatry.
Department of Clinical Research, Ramón de la Fuente Muñiz National Institute of Psychiatry.
Correspondence: Dr. Francisco de la Peña. Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Calz. México-Xochimilco 101, San Lorenzo
Huipulco, 14370, México, D.F., Mexico. E-mail: [email protected]
Vol. 34, No. 5, September-October 2011
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De la Peña Olvera and Palacios Cruz
attention deficit hyperactivity disorders (ADHD), ODD,
dyssocial disorder, as well as substance use disorders
(SUDs) and intermittent explosive disorder (IED). IED
forms part of the impulse control disorders, which is
frequently comorbid with externalized disorders.
Considering that ODD and dyssocial disorder constitute
the key conditions of DBDs within the DSM-IV, while
corresponding to the categories of behavioral disorders
(F.90)5 of the WHO International Classification of Diseases
(ICD), in its tenth edition, in particular to sets F91.0, F91.1
and F91.2 of behavioral disorders and F91.3 corresponding
to oppositional defiant disorder, clinical and therapeutic
descriptions will focus on these two disorders.
Oppositional defiant disorder is characterized by the
manifestation of a pattern of hostile behavior (argumentative,
disobedient, etc.), primarily against authority figures. It
begins during childhood and results in deterioration of
functioning in at least two of these three areas: school, home,
and friends.4
Dyssocial disorder is characterized by a persistent and
repetitive pattern of violating rules and norms established
for respective age groups (lying, stealing, hurting, etc.). It
begins during childhood and results in deterioration of
functioning in at least two of these three areas: school, home,
and friends.4
In 2007, the American Academy of Child and Adolescent
Psychiatry (AACAP) released the practical parameters for
diagnosis and treatment of ADD.6 Likewise, in Mexico, the
Juan N. Navarro Children’s Psychiatric Hospital published
its Clinical Guidelines in 2010. The Second Clinical
Guidelines correspond to behavioral disorders.7 The RFM
National Institute of Psychiatry, through its Adolescent
Clinic, published Clinical Guidelines for ODD8 and for DD.9
These publications constitute an important element for the
preparation of this article, and we recommend they be used
as a reference when seeking more extensive parameters and
guidelines. The main objective of this review is to present
the most important information for diagnosis and treatment
of DBD.
OPPOSITIONAL DEFIANT DISORDER
Clinical Definition and Characteristics
ODD is defined by a recurrent pattern, which causes
clinically significant deterioration, of oppositional, defiant,
disobedient and hostile behavior directed toward authority
figures, which must present more or less constantly, and
which include some of the following behaviors: shouting
and temper tantrums, arguing with adults, actively defying
adults or refusing to meet their demands, deliberately
annoying others, accusing others for one’s own mistakes
or bad behavior, being easily bothered by others, anger and
412
resentment, spiteful and vindictive actions. While ODD is
of significant clinical relevance, relatively little is known
about it, possibly due to the false belief that this disorder is
a variation or manifestation of DD.4 Diagnosis of ODD is
clinical, and no laboratory or desk studies are required.
Etiology
It has been difficult to differentiate between the etiological
factors of ODD, given that research is generally geared
towards DD. However, we can identify at least three types
of factors: biological, psychological, and social.
Biological Factors: There are associated family patterns
of psychopathology such as ADHD, SUD and affective
disorders.10 In addition, factors have been identified relating
to bad temper in children that later develop ODD.11
Psychological Factors: ODD has been associated with
insecure attachment as well as deficient parental care.12 In
addition, aggressive children demonstrate a failure to
recognize certain social cues, wrongly attribute the behavior
of peers as being aggressive, resulting in few solutions for
problems, and the expectation of being rewarded for their
aggressive responses.13
Social Factors: Poverty, lack of social structure, and
violence in the community contribute to diagnosis of ODD.14
It must be taken into account that there is a high level of
comorbidity between ODD, ADHD and DD, and as such,
these children and adolescents experience multiple intraindividual and contextual risk factors, beginning in childhood, which can result in adverse formation of personality
as the last manifestation of the overall risk of externalized
psychopathology.15
Epidemiology
In the general population, ODD is estimated to occur in
approximately 1 to 16% of individuals.16 Around 75% of
subjects with ADHD present at least one comorbid disorder,
and ODD is the most common such disorder. ODD increases
the risk of suffering from DD during adolescence and an
antisocial personality disorder (APD) during adulthood. The
co-occurrence of ODD and DD with ADHD occurs in a
bidirectional way, that is, in children and adolescents with
ADHD, presence of ODD or DD has been estimated at
between 15 and 60%. Likewise, between 70 to 80% of children
and adolescents with BD or ODD meet the criteria for ADHD.6
Treatment
The eleven general principles recommended by the practical
parameters of the AACAP6 for ODD are included in Table 1.
Once diagnosis is confirmed of ODD, psychosocial
management is the therapeutic option of choice. A recommendation that will help in considering psychosocial
Vol. 34, No. 5, September-October 2011
Disruptive behavior disorders in children and adolescents
Table 1. Practice Parameters for Oppositional Defiant Disorder from
the American Academy of Child and Adolescent Psychiatry
1. Optimal evaluation and treatment of ODD require a sufficient
therapeutic partnership with the child or adolescent and his/
her parents.
2. Cultural aspects must be taken into consideration in diagnosis
and treatment.
3. Evaluation of ODD must include information obtained directly
from the child or adolescent as well as his/her parents in the
areas of basic symptoms, age of onset, duration of symptoms
and level of functional deterioration.
4. Psychiatric comorbidity must be considered.
5. The clinician must give importance to any other information
obtained from other informants, such as teachers.
6. The use of instruments or interviews in the evaluation and
follow-up is recommended.
7. The clinician must perform an individualized treatment plan.
8. Interventions suggested for parents must be based on the
interventions with the most empirical evidence.
9. The use of medications may be useful as an adjunct to
psychosocial interventions, for symptomatic treatment and for
comorbid conditions.
10. When ODD is severe and persistent, prolonged and intensive
treatments may be required.
11. Interventions in which the child or adolescent is exposed to
frightening scenarios or situations meant to induce him/her to
desist from his/her behaviors should be avoided. Shorter
interventions are typically ineffective.
intervention and for the specific treatment indications for
children and early adolescents is to consider the presence of
ODD with or without the presence of a DD. Among the
interventions with greatest evidence is the training of parents
and caregivers on behavioral management of the child or
early adolescent (12 to 15 years of age).17 These interventions
are based on the supposition that bad behavior is the result
of inadequate, inconsistent and non-contingent parenting.
For this reason, the child has learned that oppositional
behavior is an effective way to manipulate adults so that
they bend to his/her will. Intervention programs from a
behavioral perspective cover all contexts: family, school, and
that of the child him/herself. Most behavioral intervention
models are based on behavioral analysis through an
approach called ABC (antecedents, behavior, consequences).
One of the most widely used programs for ODD
treatment is the Russell Barkley Program. The Barkley
program consists of eight steps which seek to improve
behavior, social relationships and general adaptation at home
of the child or early adolescent. These steps are: learn to
provide the child with positive attention, use the power of
their attention to make him/her behave, give effective orders,
teach him/her not to interrupt activities, establish a reward
system at home, learn to punish bad behavior in a
constructive way, spend more time out of the house, and
learn to control the child in public places. 18 A study
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comparing training of parents provided by nurses and
psychologists and self-instruction using bibliographic
materials indicated that both instruction by a professional
and self-instruction were effective in reducing oppositional
and defiant behaviors in children.19 Interventions in older
adolescents (16 to 17 years of age) must include family
psychoeducational interventions or family therapy.
Pharmacological treatment of ODD is aimed primarily
at comorbidity with ADHD, DD, or the suspicion of an
affective disorder and/or sub-syndromic anxiety disorder,
and must be conducted by a physician specialized in mental
health.
DYSSOCIAL DISORDER
Clinical Definition and Characteristics
DD is the most serious of externalized disorders, and is
characterized by a repetitive and persistent pattern of
behavior that includes the violation of the basic rights of
others, social norms, or laws. DD is one of the psychiatric
disorders most common in clinical and community samples
of the adolescent population.9
DD is characterized by four areas of manifestation:
aggression toward people and animals, destruction of
property, fraudulence/theft, and serious violation of social
norms. This category includes a series of very heterogeneous
manifestations that have been described as including:
bragging; threats or intimidation toward others; physical
fights; use of weapons that can cause serious physical harm
to others (sticks, bottles, knives, guns); manifestation of
physical cruelty toward people or animals; theft; forcing
someone to perform a sexual act; deliberately causing fires
with the intention of causing serious damage; deliberate
destruction of other people’s property; forced entry into other
people’s homes or cars; lying to obtain benefits, favors, or
avoid obligations; theft of items of nontrivial value without
confronting the victim; staying out at night despite parental
demands; beginning these behaviors before 13 years of age;
sneaking out of the house at night on at least two occasions;
and «cutting class.»4 The DSM specifies the type, be it
childhood- or adolescence-onset, and intensity, as light,
moderate, or serious, based on the number of symptoms
present. Diagnosis of DD is clinical and does not require
laboratory tests or desk studies.
In terms of the development of DD, it can have four
trajectories: the first includes the group of individuals with
light but sustained behavioral manifestations through
development; the second concerns subjects that experience
onset during childhood and whose behavioral problems are
limited to this life stage; a third group includes subjects that
experience onset during childhood and whose behavioral
problems persist throughout development.20 The trajectory
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De la Peña Olvera and Palacios Cruz
of the DD presented by each patient must be considered in
order to adjust and customize treatment options.
Individual differences in aggressiveness (predatory vs.
non-predatory, open vs. concealed) are as stable as the
individual differences in intelligence, and several studies
have shown that the presence of youth aggression and
violence are predictors of future delinquency. The best
predictor of the continuity of aggressive behaviors is
whether such behaviors began prior to 10 years of age.21
A review was recently published on the proposed
modifications for DD in the DSM-5, indicating that diagnostic
protocol for this disorder include: evaluation of a subtype
restricted to childhood, family psychiatric history,
characteristics of «emotional callus,» specific criteria for
females and pre-school age children, early use of substances,
and psychological, genetic and brain imaging biomarkers.22
Epidemiology
The reported prevalence of this disorder in community
samples varies from 1.5 to 3.4%. This disorder is four times
more common in males than in females. Clinical samples
show high comorbidity with both externalized and
internalized disorders.21
Treatment
DD is a phenomenon that due to its biological, psychological and social nature, requires comprehensive therapeutic intervention, referred to as multimodal treatment.23
The guidelines for evaluation and treatment of severe DD
and indications for pharmacological treatment are shown
in Table 2.21
Pharmacological Treatment
Pharmacological treatment alone will never suffice and must
be combined with management of aggressive behaviors and
comorbid conditions. Studies on medications for treatment
of DD can be categorized according to the type of drug used:
mood stabilizers, antipsychotics, and stimulants. Lithium is
the medication with most documentation of successful
treatment in controlled studies (range of dosage from 0.5 to
2.1 g/day). There are three controlled studies with typical
antipsychotic drugs (haloperidol at 1 to 6 mg/day) and two
with atypical antipsychotic drugs in which symptoms were
decreased. The use of atypical antipsychotic drugs is
recommended, such as risperidone (1.5 to 40 mg/day) or
aripiprazole (5 to 15 mg/day). The side effects of lithium
and antipsychotic drugs (both typical and atypical) must be
taken into account. In particular, the metabolic changes
associated with prolonged use of atypical antipsychotic
drugs must be considered. In the case of stimulants,
methylphenidate (0.6 to 1 mg/kg/day) has been seen to
414
decrease symptoms of DD even without diagnosis of ADHD.
Some other pharmacological agents such as antidepressants
(bupropion) or alpha-adrenergic agonists (clonidine) have
been used to decrease aggressive symptoms.24
Very recently, an open study was published of preschool age children with no intellectual disability but with
behavioral problems. The study included 10 subjects, 8 boys
and two girls. Average daily dosage of risperidone during a
period of eight weeks was 0.78 mg/day, with a maximum
of 1.5 mg/day. The clinical global impression scale was used
(CGI) to assess improvements. Risperidone was associated
with a reduction of 78% in the severity score of the CGI.
Tolerability was good and no serious side effects were
observed. Statistically significant increases were detected in
levels of prolactin (p<0.05), but there was no manifestation
of clinical symptoms associated with prolactinemia.25
Prior to writing a prescription, it is recommended that
the clinician review the «practical parameters» for use of psychotropic medications in pediatric populations, published
by the American Academy of Child and Adolescent Psychiatry.26
In recent years a review was published on the efficacy
and effect size (ES) of different medications on aggressive
behavior. The overall ES of the psychotropic agents studied
on treatment for aggression was 0.56. Despite the variability
in the psychiatric diagnoses, the different selected agents
showed a moderate to large ES for aggression. Most of the
studies focused on younger children (average age = 10.4
Table 2. Guidelines for evaluation and treatment of severe behavioral
disorder and indications for pharmacological treatment
1. Crisis Management, as needed
• Hospitalization and crisis therapy.
• Antipsychotics, if aggressive behavior persists.
2. Evaluate the psychopathology of the adolescent and his/her context
• Psychiatric vulnerabilities.
• Family environment and social context.
• Academic performance.
• Cognitive abnormalities.
• History of prior treatments.
3. Choose the appropriate interventions for each individual case
according to prior evaluation
• Family therapy, cognitive behavioral therapy, multisystemic
therapy, etc.
4. Consider pharmacotherapy when:
• The behavioral disorder persists.
• Associated psychiatric morbidity exists.
5. After prescription, evaluate:
• Acceptance of treatment by the adolescent and his/her family.
• Quantify and monitor symptoms.
6. Select the medication according to points 4 and 5
• ADHD: stimulants.
• Emotional lability: mood stabilizers.
• Aggressiveness: mood stabilizers or antipsychotics.
• Anxiety: antidepressants.
7. Always use psychosocial intervention and family support
Vol. 34, No. 5, September-October 2011
Disruptive behavior disorders in children and adolescents
years), and were of shorter duration (7 to 70 days). Greater
effects were found with methylphenidate for the treatment
of aggression when comorbid with ADHD (average ES =
0.9) and for risperidone in young people with disruptive
behavior disorder and intellectual quotient below average
(average ES = 0.9).27
by their sexual behaviors, delinquency, the use of substances,
externalized symptoms, and problems outside of their
home.28 It has also demonstrated greater cost effectiveness
as compared to individual therapy in young people with
violent/aggressive behavior.29
Psychosocial Treatment
«EMOTIONAL CALLUS» AND PSYCHOPATHY
Currently, only three psychosocial treatments have been
properly assessed: 1. training of parents, which is aimed at
changing the parent-child relational pattern at home; 2.
training of the child or adolescent on problem-solving skills,
which focuses on the cognitive processes associated with
social behaviors and acknowledging the consequences of
their behaviors; 3. MST, which focuses on the individualfamily-environmental systems as a means to reduce
symptoms and encourage socially adapted behaviors.23
Parent training has been described as part of ODD
treatment. Training on problem-solving skills and
acknowledging the consequences of behaviors offers the
opportunity to modify aggressive behaviors.
The principles of multisystemic therapy (MST) are based
on the general systems theory and Bronfenbrenner’s socioecological theory. This type of therapy considers the
individual and the environment that surrounds him/her as
systems in permanent connection with reciprocal and
dynamic influences. The objective is to identify the current
problems of the adolescent and his/her family within the
community environment, to analyze the problems identified
based on the dynamic interaction of the subsystems involved,
and lastly, to design interventions according to each
particular case. These interventions must be conducted within the natural environment in which the child/adolescent
lives. The principles upon which MST is based include:
1. understanding the way in which the problems identified
interact; 2. the therapist favors positive aspects of intervention
in order to motivate parents and the child/adolescent to participate; 3. interventions are designed to promote responsible
behaviors among family members; 4. interventions are
focused on the present and aimed at taking action for specific
and well-defined problems; 5. interventions are aimed
sequentially toward different systems that maintain the
problem; 6. interventions are designed taking into consideration the developmental level of the child/adolescent; 7. interventions require active and permanent participation on the
part of the family; 8. permanent evaluations are conducted
on the effectiveness of the interventions; 9. interventions are
planned to promote the generalization of the treatment and
to maintain changes over the long term. MST has a duration
of between three and five months, with the possibility of
increasing said period depending on the results obtained.23
MST has proven its efficacy in young people with
sexually aggressive behaviors, reducing the problems caused
«Emotional Callus»
Vol. 34, No. 5, September-October 2011
In current literature, there is increasing evidence with
regard to the presence of so-called «emotional callus» (EC)
as a distinctive element for DD subtypes. This characteristic
involves the lack of guilt or remorse, absence of empathy
for others, lack of concern for poor personal performance
at work or in school, and a deficient expression of
affectation or kindness. 30 This characteristic has been
identified as a violent, stable and serious form of aggressive
and antisocial behavior. In addition, different cognitive
patterns have been identified in children with EC, including
lack of sensitivity to punishment, expectations of a favorable
outcome from aggressive behavior, and lack of empathy.31
Etiological factors have been identified related to EC,
as shown in family studies. Hereditability of APD has been
estimated at 81% when there is also a significant
manifestation of EC. In contrast, the hereditability of APD
alone has been reported at 30% when few signs of EC are
present. Studies with twins have shown that there is a
hereditability shared between EC and DD.32 The association
between EC and DD has been studied in community
samples of children and adolescents; 46.1% of subjects with
DD showed significant signs of EC and 2.5% of subjects
without DD showed significant signs of EC; children and
adolescents with DD and significant signs of EC showed
more intense symptoms of DBD and a higher risk of
continuing with DD in a three-year follow-up evaluation.33
The DSM-III included the signs of EC in the lowsocialization subtype of DD, including among others,
changes in interpersonal relations as a result of a lack of
empathy and guilt. It is likely that the DSM-5 and the ICD11 will contain descriptors for identification of EC.22
Psychopathy
The construct of psychopathy associated with personality
has been a focus of clinical research in recent decades. It is
one of the most studied dimensions, given its relevance as
a predictor of severity and recurrence of dyssocial behavior.
Studies that evaluate psychopathy have reported three
fundamental factors that make up this construct: EC,
narcissism, and impulsivity. Most of these studies have
focused on the adult population, or on small samples of
the pediatric population (predominantly males) referred
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De la Peña Olvera and Palacios Cruz
to clinical treatment, which limits the generalization of
findings. The evaluation of psychopathic behavior has been
studied using the Psychopathy Screening Device (PSD),
which has been adapted for the pediatric population. It
consists of 20 items with a parent/guardian version and a
teacher version. Factor analysis of this instrument in the
overall population has identified two factors: Narcissistic
traits/impulsivity and «callus»/emotional numbness.34
There is no rational therapeutic option designed
specifically to treat specifiers of EC and psychopathy.
Current options focus on the DD and APD without detailing
concrete actions for these specifiers.
CONCLUSIONS
Externalized disorders include ODD and DD as primary
categories. They correspond to the most common and severe
problems within mental disorders with childhood- and
adolescence- onset. Manifestations with which DD is
currently diagnosed are very heterogeneous, given that they
include extremely aggressive behaviors (for example, assault
with a firearm, physical and sexual violence) and other less
aggressive behaviors (for example, lying, or «cutting class»).
There is significant continuity with subjects with DD who
experience early onset toward manifestations of APD in adult
life. The etiology of DBDs incorporates both biological and
psychosocial components. Treatment of these disorders must
implement a multimodal or multisystemic approach that
incorporates the necessary pharmacological, psychoeducational and psycho-therapeutic approaches. Despite all the
aforementioned therapeutic options, there is little specificity
due to the variability of behavioral manifestations. Some
subjects with DD and «emotional callus» develop a psychopathy, which constitutes a specifier related to more intense
and severe disruptive behaviors of DBDs.
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Article without competing interests
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