This is an informative chapter about disruptive behavior disorders (Conduct Disorder and Oppositional Defiant Disorder). None of this information in here or other chapters can be used to diagnose people. Only psychiatry professions are obligated to diagnose. Psychopathology chapters are review and summary of Textbook “David H. Barlow, V. Mark Durand (2014) Abnormal Psychology: An Integrative Approach” and lecture notes.

Conduct Disorder and Oppositional Defiant Disorder

Not only important in children but also related to serious behavior problems in later life.
Aggression in childhood is the best predictor of aggression in later life, and many children with conduct disorder go on to become serious juvenile offenders and criminals as adults.
A persistent pattern of misbehavior in a child or in an adolescent in at least three of the four categories within the preceding year.

Conduct Disorder Symptoms

1. Aggression toward people and animals.

The child or adolescent bullies, threatens, picks fights, and is cruel to people and animals or forces others into sexual activities.

2. Destruction of property.

The child or adolescent deliberately destroys the property of others, for example, by setting fires.

3. Deceitfulness or theft.

The child or adolescent breaks into buildings or cars, lies to get what he or she wants, steals, or commits forgery.

4. Serious violations of rules.

The child or adolescent younger than 13 stays out all night despite rules to the contrary, runs away from home or is often truant from school.

Conduct Disorder Epidemiology

Conduct disorder usually begins in childhood or adolescence.
<10 yrs: Childhood onset.
10 yrs>: Adolescent onset.

Under the age of 18;
6-16% of males.
2-9% of females.
In some individuals, the disorder diminishes as the individuals approach adulthood, but in other individuals, it persists into adulthood, and the individuals are constantly in trouble.
Individuals with conduct disorder are at increased risk for;
- Drug abuse.
- Criminal behavior.
- Suicide.

Conduct Disorder Explanations

Psychodynamic Theories:

Child's relationship with his or her parents.

Learning Theories:

The inappropriate behaviors are learned through imitation and reward. Individuals who observe aggression in others subsequently perform more acts of aggression.
In one classic study, it was found that mothers who used aggressive child-rearing methods, such as severe punishment for misbehavior, had children who were more aggressive than those of mothers who used less aggressive methods (Sears, Maccoby, & Levin, 1957).

The link between aggression in mothers and aggression in children may be due to genetic factors or aggressive and unmanageable behavior in children may bring out aggression in parents.

With regard to the learning of conduct disorder, the link between conduct disorder and sociocultural factors: One of the best predictors of who will develop conduct disorders is socioeconomic status (Lahey et al., 1995).

Statistically, African Americans are more likely than other ethnic groups to develop conduct disorder, but analyses have revealed that ethnicity per se has nothing to do with the development of the disorder. Instead, African Americans were overrepresented among those with conduct disorder only because they were overrepresented in the lower socioeconomic classes.

Lower-class membership could contribute to the development of conduct disorder in a variety of ways, but one of the strongest is learning. That is, the rewards and role models for antisocial behavior that is available in the lower classes can contribute to the development of the disorder.

In some cases, a diagnosis of conduct disorder may be misapplied to individuals in high-crime areas, who are using behaviors such as fighting to protect themselves.

The Conduct Disorder diagnosis should be applied only when the behavior in question, symptomatic of an underlying dysfunction within the individual and not simply a reaction to the immediate social context.

That is, conduct disorder involves behaviors that are generated by the individual, not elicited by a situation.

Three physiological factors that contribute to conduct disorder:

1.Maternal smoking during pregnancy;

Maternal smoking probably affects brain development, an as a consequence it results in substantial increases in conduct problems, particularly aggressive and violent behaviors. Indeed, boys whose mothers had smoked 10 cigarettes (less than half a pack) per day during pregnancy were four times more likely to be diagnosed with conduct disorder than were boys whose mothers did not smoke (Weissman et al., 1999)

The more cigarettes a woman smoked during pregnancy, the more likely it was that her offspring committed a violent crime. This finding is important not only because the effect is strong, but because smoking during pregnancy is a cause of conduct disorder that can be avoided more easily than many of the other causes.
The rate of smoking in general is down, but there has not been a decrease in heavy smoking among pregnant women (Magno Zito et al., 2000)

2.Low levels of serotonin;

Serotonin is important because it plays a role in the inhibition of punished responses. (Soubie, 1986).For example, if an animal has learned to inhibit a response because the response has been followed by punishment but then the animal's level of serotonin is lowered with a drug, the animal will disregard the possibility of punishment and make the response.

This regard for punishment is similar to what we see in the behavior of individuals with conduct disorder.
Evidence linking low levels of serotonin to conduct disorders and aggression in humans (Coccaro et al., 1996; Finn et alo, 1998; Lahey et al., the Rogeness et al., 1992; Zubieta & Alessi, 1993)

That is, low levels of serotonin were linked to high levels of subsequent aggression.

3.High levels of testosterone (in both men and women);

Specifically, in both to men and women, high levels of testosterone are related to high levels of aggression, and the higher the levels of testosterone, the more violent the aggression.

What leads to those deviant biochemical levels?

The best explanation for chronically low levels of serotonin and high levels of testosterone is genetics. Biological children of parents with conduct disorder have high rates of the disorder even when they are adopted at birth and raised by parents who do not have the disorder. Furthermore, identical twins are more likely to both have conduct disorder than are nonidentical twins.

The interaction of causes:

Physiological factors can provide a predisposition to conduct disorder, and then observing others who behave inappropriately may lead to specific symptoms such as aggressive acts.

Conduct Disorder: Treatments

Conduct disorder requires different approaches to treatment, depending on the suspected cause.

If it is suspected that conduct disorder was learned, the strategy may be to punish the behavior. It might also be effective to reward alternative behaviors that are more appropriate, but unfortunately, that is rarely done.

Some evidence for the effectiveness of punishment is provided by a study of the arrest records of almost 30,000 males in Denmark (Brennan, 1994). The results indicated that among those who were arrested for personal-property offenses such as breaking and entering or car theft, 52% of those who were not punished after their first arrest were arrested in the future, versus only 20% of those who were punished after their first arrest. In other words, punishment resulted in a 32% reduction in future illegal behavior. Furthermore, among individuals who were arrested multiple times, those who were consistently punished were less likely to be arrested in the future than individuals who were punished inconsistently. However, it is important to note that even among individuals who were consistently punished following three or four arrests, there was still a recidivism rate of 67%. In other words, punishment can be effective, but there are individuals for whom punishment does not appear to be effective.

Punishment by itself is often ineffective because it serves to suppress the inappropriate behavior only temporarily;
what is needed is to learn and be rewarded for alternative appropriate behavior. That is, it is not enough to say ''Don't do that'' and punish the behavior; it is also essential to say "Do this instead'' and then reward the better behavior.

In fact, there is now considerable evidence that early education in combination with social support can be effective for reducing delinquency in children who are at high risk (Yoshikawa, 1994).

For individuals for whom punishment and education are not effective, the problem may be low levels of serotonin that lead to impulsivity, and for those individuals, it may be effective to use a drug that increases the levels of serotonin. (Ghaziuddin & Alessi, 1992).

Oppositional Defiant Disorder

Children and adolescents with this disorder often lose their temper, argue with adults, refuse to comply with the requests of adults, deliberately annoy people, are easily annoyed by others and are frequently angry, resentful, spiteful, or vindictive.

Case Work

“I`m not right up here”

Phillip, age 12, was suspended from a small town Iowa school and referred for psychiatric treatment by his principal. The following note came with him;

This child has been a continual problem since coming to our school. He does not get along on the playground because he is mean to other children. He disobeys school rules, teases the patrol children, steals from the other children, and defies all authority. Phillip keeps getting into fights with other children on the bus.He has been suspended from cafeteria privileges several times for fighting, pushing, and shoving. After he misbehaved one day at the cafeteria, the teacher told him to come up to my office to see me. He flatly refused, lay on the floor, and threw a temper tantrum, kicking and screaming. The truth is not in Phillip. When caught in actual misdeeds, he denies everything and takes upon himself an air of injured innocence. He believes we are picking on him. He is in bad attitude when he is refused anything. When asked why he does these things, he points to his head and says, "Because I'm not right up here."This boy needs help badly. He does not seem to have friends. His aggressive behavior prevents the children from liking him. Our school psychologist tested Phillip, and the results indicated average intelligence, but his school achievement is only at the third- and low fourth-grade level.

The psychiatrist learned from Phillip's grandmother that he was born when his mother was a senior in high school. Her parents insisted that she keep the baby and help rear him; most of his upbringing has been by his grandparents. Phillip was "3 months premature," and a "blue baby," requiring oxygen for 24 hours. Shortly after his birth, Phillip's mother ran off with a man, married him, and had a second child. The marriage broke up, and she left this child with its father. Phillip has had no contact with his mother since she left him.

Phillip's toilet training was not successful, and he remained a bed-wetter for some years. At age 5, his maternal grandparents adopted him because they were afraid that his mother might someday claim him. He showed anxiety at separation from his grandmother when he began school.

He was then in a serious car accident, in which his grandmother was injured and one person in the other car killed. Phillip did not appear to be injured but seemed to have some transient memory loss, probably a direct, immediate result of the impact. Subsequently, he had nightmares, fear of the dark, and an exacerbation of his fear of separation from his grandmother.

Phillip's school progress was not good. He repeated third grade and then was in a special class for underachievers. His grandmother recalls that Phillip's teacher complained that he "could never stay in his seat."

A few months before the consultation, Phillip was seen in a mental health clinic and placed on some mild tranquilizers. A 3-month return appointment was arranged, but the school suspended him before that date. Phillip's antisocial behavior began when he was in grade and a pattern of fighting, lying, and stealing has persisted for years. This disturbance of conduct, lasting more than 6 months justifies the diagnosis of Conduct Disorder. Because the disturbance began before age 10, it is noted as Childhood Type. Because his behavior problems did not cause more than minor harm to others and he does not have many of the other symptoms of Conduct Disorder, such as cruelty to animals or people, using a weapon, setting fires, or running away from home, the severity noted as Moderate. Phillip was admitted to the children's unit of a state mental hospital. After 8 months he was discharged as having received "maximal hospital benefit," with a statement that "the prognosis is not favorable." He returned to school in his small community. Over the next two years, Phillip's behavior gradually deteriorated, with much involvement in name calling, fights, and refusals to obey school personnel. He was suspended following the discovery in his locker of a tape recorder that was missing from a school office.

At this time his grandparents recognized that they could no longer cope with him and accepted his commitment to long-term treatment in the state mental hospital. Phillip's course in the hospital was stormy. He made himself unpopular with his peers by repeatedly stealing from them. When caught, he would lie or refuse to answer. He had a foul mouth and used derogatory, insulting language. As a result of his behavior, he spent much time in seclusion. While in seclusion he destroyed his mattress by cutting it with a piece of glass.

He was generally hostile and uncooperative and; when crossed, would become combative. Hospital personnel controlled him only with difficulty and frequently had bruised shins to show for it. When Phillip lost control, he seemed to do so completely, and communication became impossible until he had been overpowered and had time to cool down.

His relations with staff began to improve as they persisted in showing interest and good will in spite of his assaultiveness. His relations with his peer group improved much more slowly. Real progress begin when he assigned to work with some of the maintenance staff. He enjoyed this work and often did a good job.

When Phillip was age 16, he was transferred from the adolescent ward to a closed adult men`s ward. Here his combativeness rapidly diminished and his adjustment accordingly improved. Phillip ascribed this improvement to the fact that he was no longer in contact with other poorly controlled adolescents, who tended to stir him up and provoke him.

After about 3 months, he was returned to the home of his grandparents and, when last seen (6 weeks later), was making a satisfactory adjustment. He attended school in the morning and worked in a gas station in the afternoon in the school-work program.

(Note: The Improvement in Phillip's behavior provides some hope that he will not be one of the many children with Conduct Disorder who go on to develop Antisocial Personality Disorder.)