Mental Health and Illness - Disruptive Disorders

Children and adolescents with disruptive disorders, which include oppositional defiant disorder and conduct disorder, display antisocial behaviors. Like separation anxiety, the diagnosis of a disruptive disorder largely depends on assessing whether behavior is age appropriate. For example, just as clinging may be considered normal for a toddler but abnormal behavior in an older child, toddlers and very young children often behave aggressively—grabbing toys and even biting one another. When, however, a child older than five displays such aggressive behavior, it may indicate an emerging oppositional defiant or conduct disorder.

It is important to distinguish isolated acts of aggression or the normal childhood and adolescent phases of testing limits from the pattern of ongoing, persistent defiance, hostility, and disobedience that is the hallmark of oppositional defiant disorder (ODD). Children with ODD are argumentative, lose their tempers, refuse to adhere to rules, blame others for their own mistakes, and are spiteful and vindictive. Their behaviors often alienate them from family and peers and cause problems at school.

Family strife, volatile marital relationships, frequently changing caregivers, and inconsistent child-rearing practices may increase risk for the disorder. Some practitioners consider oppositional defiant disorder a gateway condition to conduct disorder. According to the Surgeon General's report, estimates of the prevalence of ODD range from 1% to 6%, depending on the population and the way the disorder was evaluated. Prepubescent boys are diagnosed more often with ODD than girls of the same age, but after puberty the rates in both genders are equal.

Children or adolescents with conduct disorder are aggressive. They may fight, sexually assault, or behave cruelly to people or animals. Because lying, stealing, vandalism, truancy, and substance abuse are common behaviors, adults, social service agencies, and the criminal justice system often view affected young people as "bad" rather than mentally ill. The American Academy of Child and Adolescent Psychiatry describes an array of generally antisocial behaviors that when exhibited by children or adolescents suggest a diagnosis of conduct disorder. These actions and behaviors include:

• bullies, threatens, or intimidates others
• often initiates physical fights
• uses a weapon such as a bat, brick, knife, or gun that could cause serious physical harm
• physically cruel to people or animals
• steals from a victim while confronting them
• engages in coercive or forced sexual activity
• deliberately sets fires with the intention to cause damage
• deliberately destroys others' property
• breaks into a building, house, or car
• lies to obtain goods or favors, or to avoid obligations
• steals items without confronting a victim
• often stays out at night despite parental objections
• runs away from home
• often truant from school

Conduct disorder severely compromises the lives of affected children and adolescents. Their schoolwork suffers, as do their relationships with adults and peers. The Surgeon General's report found that youths with conduct disorders have higher rates of injury and sexually transmitted diseases (STDs) and are likely to be expelled from school and have problems with the law. Rates of depression, suicidal thoughts, suicide attempts, and suicide are all higher in children and teens diagnosed with conduct disorders. Children in whom the disorder presents before age ten are predominantly male. Early onset places them at greater risk for adult antisocial personality disorder. More than one-quarter of severely antisocial children become antisocial adults.

The origins of conduct disorder have not been pinpointed, but, like other mental disorders, it is probably caused by some combination of biological and psychosocial factors. Psychosocial risk factors for conduct disorder include maternal rejection, separation from parents with no surrogate caregiver, early institutionalization, family neglect, abuse or violence, parental marital conflict, large family size, overcrowding, and poverty. In these circumstances children may lack feelings of attachment to their parents or families, and later, to the community. Eventually they express these feelings of alienation by behaving with disregard for societal rules and values. Some mental health practitioners describe affected individuals as appearing to lack a moral compass.

To date there are no medications that have proven effective in treating conduct disorder. While psychosocial interventions can reduce their antisocial behavior, living with a child or teen with a conduct disorder stresses the entire family. Support programs train parents how to positively reinforce appropriate behaviors and how to strengthen the emotional bonds between parent and child. Identifying and intervening with high-risk children to enhance their social interaction and prevent academic failure can mitigate some of the potentially harmful long-term consequences of conduct disorder.