- What is Disruptive Behaviour Disorder?
Disruptive Behavior Disorder (DBD) refers to Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). These conditions may be associated with neurodevelopmental disorders, Attention Deficit Hyperactivity Disorder (ADHD) or anxiety and mood disorders. Occasional defiant or impulsive behavior is perfectly normal in most of the young children. Nevertheless, when their behavior becomes extremely difficult and challenging, it is considered outside the norm for their age. Some symptoms are shared by all DBDs and DBDs are often associated with multiple mental disorders and environmental risk factors. Frequent risk factors for DBDs are emotional problems, mood disorders, family difficulties and substance abuse.
- What do we know about risk factors / cause of DBD?
Disruptive Behavior Disorder (DBD) is currently considered a multidetermined condition involving both biological and environmental factors, and most certainly resulting from different developmental trajectories. Although diverse, trajectories leading to Conduct Disorder (CD) are likely to share accumulation of risk factors and lack of protective factors.
Behavioral genetic studies show moderate influence of genetic factors in the etiology of DBD; influence of genetic factors appear to be highest in early-onset, pervasive CD and in children/adolescents with CD and callous-unemotional traits. Molecular genetic studies have shown associations between genetic variants of genes of the dopaminergic and serotoninergic systems and DBD. Some genetic factors moderate the impact of environmental adversity; for example, gene-environment interactions influence developmental risk for conduct problems, aggression and violence in children exposed to maltreatment (Caspi et al. 2002) .
Dysfunctional family relations as well as parental abuse/neglect, poor parenting and family adversity have been associated with development ad reinforcement of conduct problems. Parental psychopathology (especially a family history of CD/antisocial personality and substance use) are also related to an elevated risk for disruptive symptoms in offspring, including CD. During adolescence, influence of peers becomes increasingly important; some conduct problems may arise or be maintained by affiliation with deviant peers. On the contrary, familial and peer relationships can also attenuate the effect of other risk factors.
The impact of environmental factors may be modified by individual characteristics like temperament, social skills, and IQ. Difficult temperament, poor social skills and hostile attributions in interpersonal relationships, as well as low verbal IQ and school failure have been associated with CD.
Both Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) are risk factors for CD and frequent comorbidities. Comorbid ADHD/CD is particularly impairing and associated with poor functional outcome. Chronic illness and perinatal factors have also been associated with a heightened risk for CD in subsequent development.
Several other conditions are common comorbidities of DBD and should be systematically assessed. These include substance use/abuse, internalized disorders (depressive, anxiety disorders) and learning disorders.
- Diagnosis of DBD
It’s not that easy to diagnose Disruptive Behavior Disorder (DBD) because of the interplay of different symptom domains and risk factors in one child (e.g. CD, ADHD, mood disorder and dysfunctional family). Paediatricians, child psychiatrists or psychologists are able to make a diagnosis. In-depth interviews with parents, children and teachers, as well as behaviour checks or standardized questionnaires are an aid to diagnosis. Moreover, the earlier the diagnosis and the treatment are put in place, the better the outcome will be.
- Treatment of DBD
Various treatment options are in use:
- Behavioral approaches have the best evidence base in the treatment of Disruptive Behavior Disorders (DBD). Intensive programs, such as multisystemic therapy, involve a multidisciplinary team (generally including psychiatrists, neuro-psychologists, social workers, family therapists, nurses, educators, etc.) and an individually tailored treatment plan.
- Parental education (e.g. psychoeducation, parent management training). Psychoeducation informs parents about the disorder of their child and how parents could interact with him/her. Programs derived from Parent Management Training in group or individual settings, have shown efficacy in controlled trials to reduce oppositional behaviors. Their therapeutic impact is greater in Oppositional Defiant Disorder (ODD) than Conduct Disorder (CD) and in pre-pubertal children than adolescents. Social skills training and cognitive skills training, as well as family therapy can be part of a multisystemic treatment plan.
- Family therapy (e.g. improve communication and problem-solving skills)
- Cognitive and behavior therapy:
- Learning how to deal with emotions, thoughts and behaviors
- Learning how to improve social skills
- Learning how to manage negative emotions and stress through relaxation
- Treatment of associated conditions, such as learning disorder, mood disorder, substance abuse
Currently, there is no labeled medication for Conduct Disorder (CD) or aggression related to CD in children and adolescents with a normal IQ.
- Psychostimulants have shown efficacy in reducing disruptive behaviors in children with comorbid ADHD/CD but seem to have less impact on conduct symptoms without ADHD. Mood stabilizers and alpha-2-agonists have shown moderate effects on aggressive symptoms. Low doses of typical antipsychotics also reduce aggressive symptoms but their use is limited because of their neurological side effects.
- Risperidone is the most extensively studied newer generation antipsychotic, but the majority of trials have included participants with substandard IQ. More information is needed about efficacy in normal IQ children and adolescents with CD, maintenance of therapeutic effects, long term tolerance and safety. Although newer generation antipsychotics show a more favorable neurological side effect profile in comparison with typical antipsychotics, endocrine/metabolic side effects are frequent and potentially impairing side effects of these medications require specific vigilance in the pediatric population.
- What is the outcome of DBD?
Longitudinal studies analyzing Conduct Disorder (CD) symptoms along a dimension showed moderate to strong stability across ten years. CD severity (i.e. number of symptoms) seems to be a major predictor of later functional outcome in various domains (relational, professional, legal, mental and physical health.). Comorbid ADHD (especially the hyperactive/impulsive dimension) is associated with severity, persistence and early age of onset of CD.
Developmental continuity between Oppositional Defiant Disorder (ODD), CD and antisocial personality disorder is still a matter of debate. In DSM-IV, ODD is conceptualized as a developmental precursor of CD, whereas in ICD-10, ODD appears to be a less severe variant of CD. Follow-up studies indicate that that a significant proportion of children with ODD (about 40% in a community sample, 60% in a referred sample) will develop CD, but this progression is far from systematic. However, most children/adolescents with CD also meet criteria for ODD.
Progression from CD to antisocial personality follows a similar pattern: one third to a half of patients with CD will meet criteria of Antisocial Personality Disorder (ASPD) in adulthood, but a large majority of adults with ASPD also had CD in adolescence. Callous-unemotional traits, depression and substance use have predictive value for the progress of CD towards ASPD.