131 Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD)

Antisocial and aggressive behavior

Antisocial behavior (ASB) in children and adolescents can fall into two primary categories in the DSM-IV-TR, which are Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). Official rates of antisocial behavior have fallen since the 1990’s, but still are much higher in the United States than in any other industrialized nation.

Defining the problem

From a legal perspective, delinquency involve children, while criminal acts involve adults. It refers to one act and not a series of acts. Also, it is official if they are caught for the act and self-reported if they only admit to doing it.
From an empirical, psychological perspective, externalizing behaviors are acting out while internalizing behaviors are acting in. Antisocial behaviors would be an externalizing, disruptive, acting out behavior. This does not refer to ADHD-type behaviors though. Aggression and antisocial behaviors frequently co-occur but are very different.
From the diagnostic perspective, ODD and CD are disruptive behavior disorders in children and adolescents and antisocial personality disorder (ASPD) is a disorder found in adults. There is a backwards trend-children with ODD or CD will not necessarily have ASPD when they get older. Many children drop out of their disorders. There is not a forward trend to this though.
From the developmental perspective, they examine development of callous, unemotional traits in childhood, and how it relates to traits of psychopathy in adults. The callous/unemotional trait may be a downward extension of the affective/interpersonal factor of psychopathy (Mash & Barkley, 2003).

Subtypes of aggression and antisocial behavior

There is verbal versus physical. Physical emerges earlier with a peak during preschool years, verbal shows later onset. There are high levels of physical during middle childhood that may warrant clinical attention, as may early emergence of verbal aggression. Physical aggression may become violent in later development. There is a difference between aggression and violence. Violence has an intent to harm while aggression is used to get their way (Lack, 2010).
Another subtype of aggression and antisocial behavior, is instrumental (goal-directed) versus hostile (inflicting pain is the goal). For the latter type, the inflicting of pain is characterized as the intent of the behavior observed (Mash & Barkley, 2003). Some levels of instrumental aggression are normative for toddlers, but extreme levels of hostile aggression demand further assessment for any age group (Mash & Barkley, 2003).
The third subtype group is proactive (bullying) versus reactive (retaliatory). Both types of aggression are highly related to each other, but they use different kinds of social-cognitive information-processing deficits and distortions (Mash & Barkley, 2003).
The fourth subtype group is direct versus indirect/relational. Direct can be described as verbal and physical manifestations, while indirect or relational are described as “getting even” by having a third party retaliate which can occur through rumors (Mash & Barkley, 2003). Indirect aggression is seen more often in females (Lack, 2010).
The final subtype is broadly, overt versus covert. Overt is exemplified by most of the types of physically aggressive actions noted throughout this section. Covert refers more to non-aggressive behaviors such as lying, stealing, destroying property, etc.

ASB diagnostic history

There has been research on differences in ASB children for over 60 years. The earlier research focused on “under-socialized” versus “socialized” behaviors (Lack, 2010). The DSM-III changes included operational criteria for CD, four subtypes (socialized versus under-socialized and aggressive versus non-aggressive), and introduced a mild version called “oppositional disorder”. The DSM-III-R changed it significantly by increasing the number of symptoms needed, the subtypes became groups/socialized type, solitary/aggressive, and undifferentiated and “oppositional disorder” was renamed ODD. The DSM-IV-TR kept these two categories seperated and introduced several other differences (Lack, 2010).

ODD features

There is a recurrent pattern of negative, defiant, disobedient, and hostile behavior toward authority figures. It is important to remember that this is toward authority figures and not their peers. This occurs outside of normal developmental levels and leads to impairment in functioning (Lack, 2010).

DSM-IV-TR criteria

• Displaying four (or more) of the following behaviors consistently over at least a six month period;
• 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 misbehavior
• is often touchy or easily annoyed by others
• is often angry or resentful
• is often spiteful or vindictive
  Behavior problems cause clinically significant impairment in social, academic, or occupational functioning. The behaviors are not part of a psychotic or mood disorder. Criteria not met Conduct Disorder or Antisocial Personality Disorder (Lack, 2010).

CD features

Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. There are four main categories of symptoms’ aggressive conduct that threatens physical harm, non-aggressive conduct that causes property damage, deceitfulness or theft, and serious violation of rules (Lack, 2010).

DSM-IV-TR criteria

Have to have three (or more) symptoms in the past 12 months, with at least one in the last six months. The behavior problems cause clinically significant impairment in social, academic, or occupational functioning. Criteria not met for Antisocial Personality Disorder if above age 18.

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 (such as 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 (mugging, purse snatching, extortion, armed robbery)
• has forced someone into sexual activity

Destruction of property

• has deliberately engaged in fire setting with the intent of causing serious damage
• has deliberately destroyed others’ property (by means other than fire setting)

Deceitfulness or theft

• has broken into someone else’s house, building, or car
• often lies to obtain goods or favors or to avoid obligations (cons others)
• has stolen items on nontrivial value without confronting a victim (shoplifting, but without B&E, forgery)\

Serious violations of rules

• often stays out at night despite parental prohibitions (beginning before the age of 13 years)
• has run away from home overnight at least twice while living in a parental home.
• is often truant from school (beginning before the age of 13 years)

CD subtypes

• Child-Onset Type: onset of at least one criteria before age 10.
• Adolescent-Onset Type: absence of any criteria before age 10.
• Unspecified Onset
• Code severity: mild, moderate, severe

Viability of CD and ODD

Both disorders are divergent from ADHD, but still distinct from ADHD. They do show significant overlap in behavioral pattern and risk factors (Lack, 2010). The difference is that those with ADHD do not mean to perform those behaviors.
There is a difference developmental course for those diagnosed with ODD only, diagnosed with ODD and then CD, and those diagnosed only with CD. There is currently no strong evidence for discontinuity of symptoms in CD predicting course. ODD is characterized by normal, developmentally appropriate behaviors and is often criticized for this fact in the popular press. Most with CD have ODD, but not all. Most with ODD do not have CD. The number of possible symptoms in CD diagnosis guarantees heterogeneity of the disorder. It can have overt, covert, or mixed presentation. The DSM-IV has included warnings not to ignore environmental context of aggressive behaviors (Lack, 2010). In some situations a behavior can be beneficial or adaptive, such as running away from an abusive home is beneficial.

Prevalence rates

With shifting diagnostic criteria over the past 20 years it was hard to get good long-term data. The median estimates of 3% for ODD. There are higher rates of self-report and about 1-3% from parent-report. CD estimates from 1-10%, depending on criteria (Lack, 2010).

Sex differences

There are initially no sex differences in activity level, noncompliance and other types of difficult temperament traits. By elementary school, evident sex differences occur, with males showing more of every type of aggression. This ma be that females’ developmental course steers them more toward internalizing problems and may also be the differences in externalizing symptoms in females (such as sexual promiscuity, substance use, and somatization). ODD rates are equal in early childhood, but males predominate by early elementary years. CD rates in childhood and preadolescence show a 4:1 male-female ratio. Sex differences seem to disappear by adolescence. The differences are notable in indirect/relational aggression, where females show much higher rates (Lack, 2010).

Comorbidity

Large amounts of co-morbid problems appear in both ODD and CD. There is a co-morbidity with ADHD that is associated with worse outcomes, such as ASPD and higher levels of aggression. Also, there is a co-morbidity with academic problems. They are mediated by presence of ADHD in middle childhood. The snowball effect can be seen in this situation. It is also co-morbid with internalizing problems. Social withdrawal forms of anxiety appear to be predictive of more aggression, while fear and inhibition are related to less aggression. There is a high co-morbidity with depression, but the relationship between them is uncertain.

Risk factors

Child factors:

• difficult temperament from birth
• hyperactivity (if co-occurs with CD)
• impulsivity
• substance use
• aggression
• early-onset of disruptive behaviors
• withdrawal
• low intelligence/executive function/information processing problems

Family factors:

• parental substance abuse
• modeling of antisocial/delinquent behavior by parents
• parental history of mental problems, particularly father’s ASB and mother’s depression.

Peer factors:

• Rejection by peers
• association with delinquent peers/siblings

Parenting practices:

• poor parent-child relations
• poor supervision/communication
• physical punishment
• parental neglect/abuse
• maternal nicotine use during pregnancy
• teenage/single parenthood
• disagreement on discipline among parents
• high turnover of caretakers
• carelessness in allowing access to weapons

School factors:

• poor academic performance
• being older than classmates
• weak bonding to school
• low educational aspirations
• low school motivation
• poor school system

Neighborhood factors:

• neighborhood disadvantage or poverty
• disorganized neighborhood
• availability of weapons
• media portrayal of violence

Assessment and diagnosis

Structured or semi-structured clinical interview that should cover developmental and family history, DSM-IV ODD/CD symptoms, and symptoms of typical co-morbid problems (such as ADHD, LDs, anxiety/mood disorders, etc.). There should also be parent, teacher and self-reports of behaviors. Some good scales to use include BASC and CBCL for overall screeners. This is due to a high co-morbidity with ADHD, that some may want to use specific measures.

Treatment

Treatment outcomes are much better for ODD than for CD. Effective treatments are based on operant conditioning and social-cognitive learning principles.
There are four empirically supported treatments:
1.) Contingency management programs: they establish clear behavioral goals to shape towards appropriate behavior, monitor the child’s progress toward goals, reinforce appropriate steps toward these goals, and provide consequences for inappropriate behavior.
2.) Parent Management training (PMT): the goal is to teach the parents how to develop and implement structured contingency management programs at home. It also focuses on improving parent-child interactions, changing antecedents to problem behaviors, improving parent’s monitoring of child’s behavior and using more effective discipline strategies. It is a very Skinnerian technique.
3.) CBT approach: the goal is to overcome deficits in social cognition and problem solving. Also includes role-playing and modeling. Also there is stimulant medication which is useful in children with ADHD who have co-occurring behavior problems.
4.) Multisystemic therapy (MST): it grows out of a family systems approach. Intensive treatments that see problems in children’s behavior as stemming from a larger family context. It focuses on the role of the misbehavior in the family, then adjusting how the family responds and reacts to both the child and each other.

References for ODD & CD

Lack, C. W. (2010). Abnormal Psychology. Retrieved 2010, from Caleb W. Lack, Ph.D: http://www.caleblack.com/psy4753.html
Mash, E. J., & Barkley, R. A. (2003). Child Psychopathology (2 ed.). New York, NY: The Guilford Press.