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Mental Disorders and Disabilities Among Low-Income Children (2015)

Chapter: 7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder

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Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
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7

Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder

DIAGNOSIS AND ASSESSMENT

Disruptive behavior disorders (DBDs) of childhood include attention deficit hyperactivity disorder (ADHD) (discussed in Chapter 6), oppositional defiant disorder (ODD), conduct disorder (CD), intermittent explosive disorder, and disruptive behavior not otherwise specified. Some nomenclatures have added a new condition labeled “disruptive mood dysregulation disorder” as well, although almost no formal epidemiological data exist on this recent addition. Formally, behaviors and associated consequences that “violate the rights of others and/or that bring the individual into significant conflict with societal norms or authority figures” qualify children or adolescents for the diagnosis of DBD (APA, 2013, p. 461). Other than ADHD (which is addressed in Chapter 6), the two most commonly studied of these disruptive behavior disorders are ODD and CD, and the remainder of this section will deal only with these two as they are the only DBD categories of any significance to the Social Security program other than ADHD. ODD is defined both by the American Psychiatric Association and the World Health Organization as a longstanding pattern of hostile, defiant, or disobedient behavior. CD is also considered “disruptive” in that youths with CD have antisocial behaviors such as lying and stealing which can result in criminal, educational, and family consequences in addition to the impairment associated with these behaviors.

Because they share some antecedent risk factors and are both defined by challenging interactions with parents and other authority figures, ODD and CD are often linked as a single category in prevalence and epidemiologic

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

studies. However, several authors suggest that significant distinctions exist between the two; for example, there are inconsistent findings about gender differences in ODD, but CD has a very marked male-to-female risk ratio. These authors thus recommend reporting and studying these conditions separately (Burke et al., 2002; Maughan et al., 2004). In item analysis on risk scales, ODD and CD have a great deal of overlap, but they still appear to be separate constructs (Cavanagh et al., 2014).

The latest guidelines for assessing ODD/CD in children were issued in 2007 and 1997, for ODD and CD, respectively, by the American Academy of Child and Adolescent Psychiatry (Steiner et al., 1997, 2007). The diagnosis of ODD/CD requires a comprehensive diagnostic evaluation, which includes interviews with the child or youth, the primary caregiver, and collateral informants, such as teachers. Standardized reporting tools are recommended for gathering complete data from diverse informants, but no tool is thought to be specific, nor are there any biological markers for these disorders. It is not clear if the distinction between ODD and CD is important for the care of individual patients. It is important to note that because the ODD/CD diagnoses and symptoms are enmeshed in families and social interactions, the recommendations emphasize the importance of the clinicians’ relationships with both the family and patient in assessment and treatment.

A diagnosis of ODD/CD is made when children or adolescents present with aggression or related behaviors that result in persistent problems, including legal and social consequences, and when other causes are not present. These conditions generally do not remit quickly, and often present along a continuum, so ongoing care and follow-up is necessary.

The risk factors for ODD and CD are not well understood; however, it appears that genetic, environmental, and family factors all contribute. Therefore, a review of a child’s history should involve prenatal exposures, exposure to adverse childhood experiences, and cognitive or other developmental problems. It is also essential to assemble a history of the current illness, including age of onset, the environmental situations in which the symptoms are manifest, the duration of the symptoms, and any precipitating events or situations, and persons, places, or events that ameliorate or exacerbate the behavior problems should be noted. An assessment for other psychiatric problems, such as substance abuse, trauma-related symptoms, and ADHD, should also be conducted.

Because ODD and CD are known to cluster in families, it is important to obtain a family history of psychiatric disorders and medical conditions. In addition, the role of the family emotional, communicative, interactional, and coping styles and resources should be assessed.

Information about a child’s functioning in a school setting should be obtained from the appropriate staff, such as the principal, teacher, school

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

psychologist or counselor, and nurse, once a release of information is granted. Teacher reports of behavior that use structured forms are often very helpful. Suspected disabilities in intellectual functioning, communication abilities, or motor skills should be evaluated. ODD and CD are, by definition, conditions that often involve social service agencies, such as foster care and juvenile justice. Agency reports of both symptoms and consequences are essential to proper diagnosis and treatment.

A thorough physical evaluation is needed to rule out medical causes. Medical conditions that cause agitation, aggression, or impulsive anger need to be considered. Routine laboratory tests (i.e., blood counts, renal and liver functions, thyroid functions, a toxicology screen, a pregnancy test, and urinalysis) are usually not indicated unless specific history or examination findings suggest the need. However, preventive screening for HIV, depression, and substance abuse are all indicated when age appropriate.

DEMOGRAPHIC FACTORS AND DURATION OF THE DISORDER

Age and gender trends in ODD are not pronounced, with some studies finding that boys are more likely to report symptoms consistent with ODD than are girls, but others showing no gender differences (Nock et al., 2007). In one of the largest and most representative samples, boys were much more likely to have ODD, but most of the additional symptoms reported for males were by teachers who have not been used in many epidemiologic studies (Maughan et al., 2004). This same study also noted that the typical decline in ODD reported in many studies is almost entirely contingent on whether ODD and CD are made exclusive because the symptoms do not decline, but CD diagnoses replace ODD.

Age

Age influences the prevalence rates of CD as well, although in some subtle ways. ODD is often shown to remit with age as CD rises with age; because these conditions are usually considered exclusive in prevalence estimates, this may simply be the result of reclassifications. Moreover, it is not clear if CD symptoms increase with age, but the severity of symptoms and aggression may increase as youths age. From cross-sectional data in three distinct samples, Copeland and colleagues estimated that 3 percent of preschoolers may be affected (Copeland et al., 2013).

Neither of these conditions is thought to be short-lived. ODD remits in roughly half of the population after 3 years (Biederman et al., 2008; Bunte et al., 2014), although the conversion to CD in these cases may not have been taken into account.

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

Socioeconomic Status

Both ODD and CD symptoms are more pronounced in children in low-income households and adolescents. In fact, neighborhood and environmental factors may play a strong role in producing such symptoms, with the poorest and most violent neighborhoods having the highest prevalence rates of ODD and CD behaviors (Loeber et al., 2000). Low parental educational attainment and low household income are independently associated with higher rates, and these demographic characteristics are thought to influence prevalence through disciplinary practices, scarcity, food insecurity, and their influence on access to peer support (CDC, 2013). Less clear is whether or not these findings extend to rural areas.

Race/Ethnicity

Race and ethnicity may or may not influence prevalence rates, depending on the extent to which income, urban residence, and parenting practices are taken into account. Nock suggests that race does less to influence total prevalence of CD and more to influence subtypes of CD, although these subtypes are not universally recognized (Nock et al., 2006).

COMORBIDITIES

Unfortunately, neither of these conditions occurs often in isolation. Both have extremely high rates of comorbidity, particularly with ADHD and mood and anxiety disorders (Chen et al., 2013). Children with ODD not only have high rates of comorbid mood disorders, but they even retain some of these other diagnoses when their ODD remits (Nock et al., 2007). According to parent and teacher reports, ODD almost always has associated mood, anxiety, or posttraumatic stress disorder symptoms (Angold et al., 1999; Cavanaugh et al., 2014; Copeland et al., 2013; Loeber et al., 2000). A meta-analysis by Angold and colleagues found that the odds ratio of ADHD co-occurring with CD is 10.7, the odds ratio of CD co-occurring with depression is 6.6, and the odds ratio of CD co-occurring with anxiety disorder is 3.1. Substance abuse disorders are also frequently occur with DBDs and are also one of the symptoms of CD (Angold et al., 1999).

Because of the frequent clinical appearance of mood symptoms in association with behavioral problems, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, includes disruptive mood dysregulation disorder, a new condition that requires both behavioral and mood symptoms. Limited information on prevalence is available at this time.

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

FUNCTIONAL IMPAIRMENT

The assessment of impairment in ODD/CD is challenging for several reasons. As already noted, DBDs seldom occur in isolation, and it is not usually possible in the clinical setting to determine the contribution of ODD/CD to an impairment separately from the contribution from the comorbid conditions. Second, impairment in relationships and functioning in usual roles is a core part of the definition and symptoms of ODD/CD. Thus, there is a tautology to discussing the extent to which these disorders cause impairment because the definitions are composed by the extent of impairment. Finally, the extent of impairment in ODD/CD is most reliably reported by parents and teachers rather than patients. However, these individuals often have involved and highly charged and damaged relationships with the patient. Consequently, the reporting of impairment may not be independent of the emotional involvement of the reporter.

Regardless of these factors, it is clear that impairment in ODD/CD, especially when left untreated, is marked. Children with ODD experience greater school failure and more suspensions and expulsions. Their home relationships are often disrupted, and they are less successful at peer relationships. With increasing age, symptoms shift from impairment and disruption of family and school life, to societal infractions and encounters with the legal system. Adolescents with CD demonstrate higher levels of aggression and more school failure, drug abuse, and arrests than adolescents without CD (Biederman et al., 2008; Burke et al., 2014; Johnson et al., 2015). The extent of these impairments is largely contingent on the number of risk and resiliency factors in the environment, such as positive peer relationships and consistent availability of supports and services in the home or school setting.

TREATMENT AND OUTCOMES

Preventive interventions are known to be effective in reducing the intensity and frequency of ODD/CD. However, the effective interventions studied to date are broad-based classroom and community interventions that have long-term preventive effects. They are discussed further in other Institute of Medicine documents (NRC and IOM, 2009).

Treatment for ODD/CD involves psychotherapeutic interventions or psychopharmaceutical agents, or both. The Agency for Healthcare Research and Quality (AHRQ) has compiled the most recent review of the efficacy of both types of interventions. In general, psychosocial interventions are the most widely studied in the United States and elsewhere, have the largest effects documented, and are even more effective when both child and parent are the targets of interventions.

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

AHRQ identified 58 studies that met the criteria for rigorous methods examining psychosocial interventions (AHRQ, 2014). These studies fell into two categories: preschool ODD intervention studies and adolescent CD intervention trials. For the former, the three primary interventions studied were Incredible Years, Parent Child Interaction Therapy, and the Positive Parenting Program. Each of these interventions was associated with moderate to large effect sizes, with more intensive participation yielding greater improvements in parent–child relationships, decreased parental distress, improved classroom behavior, reduced frequency of anger and outbursts, and reductions in overall behavior symptom scores (Dretzke et al., 2005; Fossum et al., 2008). For CD, multisystemic therapy and brief strategic family therapy were the most frequently studied interventions. The effect sizes were less impressive for older children with CD than for younger children, but psychosocial interventions such as multi-systemic therapy and Functional Family Therapy, among several similar programs, consistently produced reductions in adolescent aggression, legal problems, and parental conflict as well as improvements in school function and other prosocial behaviors. No significant negative side effects of these psychosocial interventions were identified for either group of psychosocial interventions.

Most studies of pharmaceutical agents were industry funded and short term. Results were mixed. They included trials of antipsychotics, anti-epileptics, and ADHD agents, but no agent achieved consistent positive effects, and no high-quality studies of combinations of pharmaceutical agents and psychosocial interventions were identified. Several of the psychotropic medications had significant side effects in the trials of ODD/CD treatment.

Findings

  • The diagnosis of ODD or CD requires a comprehensive diagnostic evaluation. There are no biological markers for ODD or CD.
  • There is insufficient evidence of trends in the distribution of ODD and CD by either sex or age. Differences in the rate of diagnosis by sex have not been uniformly documented.
  • ODD and CD tend to be persistent problems. The conversion of ODD to CD may account for at least some of the remissions of ODD cited in the literature.
  • The disruptive behavior disorders of childhood (ODD and CD) frequently co-occur with other mental disorders in children, in particular, ADHD, mood disorders, and anxiety disorders. The co-occurrence of these disorders with other mental disorders causes significant functional impairment in many children who are Supplemental Security Income recipients.
Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
  • Early preventive interventions show promise for reducing ODD occurrence. Psychosocial interventions involving both parents and child are documented to provide the greatest therapeutic benefit.

REFERENCES

AHRQ (Agency for Healthcare Research and Quality). 2014. Psychosocial and pharmacologic interventions for disruptive behavior disorder. Evidence-based Practice Center Systematic Review Protocol. http://effectivehealthcare.ahrq.gov/ehc/products/555/1932/disruptivebehavior-disorder-protocol-140701.pdf (accessed on July 20, 2015).

Angold, A., E. J. Costello, and A. Erkanli. 1999. Comorbidity. Journal of Child Psychology and Psychiatry 40(1):57–87.

APA (American Psychiatric Association). 2013. Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: APA.

Biederman, J., C. R. Petty, C. Dolan, S. Hughes, E. Mick, M. C. Monuteaux, and S. V. Faraone. 2008. The long-term longitudinal course of oppositional defiant disorder and conduct disorder in ADHD boys: Findings from a controlled 10-year prospective longitudinal follow-up study. Psychological Medicine 38(7):1027–1036.

Bunte, T. L., K. Schoemaker, D. J. Hessen, P. G. van der Heijden, and W. J. Matthys. 2014. Stability and change of ODD, CD and ADHD diagnosis in referred preschool children. Journal of Abnormal Child Psychology 42(7):1213–1224.

Burke, J. D., R. L. Loeber, and B. Birmaher. 2002. Oppositional defiant and conduct disorder: A review of the past 10 years, part II. Journal of the American Academy of Child & Adolescent Psychiatry 41(11):1275–1293.

Burke, J. D., R. Rowe, and K. Boylan. 2014. Functional outcomes of child and adolescent oppositional defiant disorder symptoms in young adult men. Journal of Child Psychology and Psychiatry 55(3):264–272.

Cavanagh, M., D. Quinn, D. Duncan, T. Graham, and L. Balbuena. 2014. Oppositional defiant disorder is better conceptualized as a disorder of emotional regulation. Journal of Attention Disorders, January 30 [Epub ahead of print]. http://jad.sagepub.com/content/early/2014/01/30/1087054713520221 (accessed July 3, 2015).

CDC (Centers for Disease Control and Prevention). 2013. Mental health surveillance among children, United States, 2005–2011. Morbidity and Mortality Weekly Report Supplement 62(2):1–35.

Chen, M. H., T. P. Su, Y. S. Chen, J. W. Hsu, K. L. Huang, W. H. Chang, T. J. Chen, and Y. M. Bai. 2013. Higher risk of developing mood disorders among adolescents with comorbidity of attention deficit hyperactivity disorder and disruptive behavior disorder: A nationwide prospective study. Journal of Psychiatric Research 47(8):1019–1023.

Copeland, W. E., A. Angold, E. J. Costello, and H. Egger. 2013. Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. American Journal of Psychiatry 170(2):173–179.

Dretzke, J., E. Frew, C. Davenport, J. Barlow, S. L. Stewart–Brown, J. Sandercock, S. Bayliss, J. Raftery, C. Hyde, and R. Taylor. 2005. The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children. Health Technology Assessment 9(50):1–250.

Fossum, S., B. H. Handegård, M. Martinussen, and W. T. Mørch. 2008. Psychosocial interventions for disruptive and aggressive behaviour in children and adolescents. European Child & Adolescent Psychiatry 17(7):438–451.

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×

Johnson, V. A., A. H. Kemp, R. Heard, C. J. Lennings, and I. B. Hickie. 2015. Childhood-versus adolescent-onset antisocial youth with conduct disorder: Psychiatric illness, neuropsychological and psychosocial function. PLoS ONE 10(4):e0121627.

Loeber, R., J. D. Burke, B. B. Lahey, A. Winters, and M. Zera. 2000. Oppositional defiant and conduct disorder: A review of the past 10 years, part I. Journal of the American Academy of Child & Adolescent Psychiatry 39(12):1468–1484.

Maughan, B., R. Rowe, J. Messer, R. Goodman, and H. Meltzer. 2004. Conduct disorder and oppositional defiant disorder in a national sample: Developmental epidemiology. Journal of Child Psychology and Psychiatry 45(3):609–621.

Nock, M. K., A. E. Kazdin, E. Hiripi, and R. C. Kessler. 2006. Prevalence, subtypes and correlates of DSMV conduct disorder in the National Comorbidity Survey Replication. Psychological Medicine 36:699–710.

Nock, M. K., A. E. Kazdin, E. Hiripi, and R. C. Kessler. 2007. Prevalence, correlates and persistence of oppositional defiant disorder: Results from the National Comorbidity Survey Replication. Journal of Child Psychology and Psychiatry 48(7):703–713.

NRC and IOM (National Research Council and Institute of Medicine). 2009. Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: The National Academies Press.

Steiner, H., AACAP Work Group on Quality Issues, J. Dunne, W. Ayeres, V. Arnold, E. Benedek, R. S. Benson, G. A. Bernstein, W. Bernet, O. Bukstein, J. Kinlan, H. Leonard, and J. McClellan. 1997. Practice parameter for the assessment and treatment of children and adolescents with conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36(10 Suppl):12S–139S.

Steiner, H., L. Remsing, AACAP Work Group on Quality Issues, V. Arnold, J. Beitchman, R.S. Benson, W. Bernet, O. Bukstein, J. Kinlan, D. Rue, J. Shaw, U. Schoettle, S. Stock, and H. Walter. 2007. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry 46(1):126–141.

Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
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Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
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Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
Page 151
Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
Page 152
Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
Page 153
Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
Page 154
Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
Page 155
Suggested Citation:"7 Clinical Characteristics of Oppositional Defiant Disorder and Conduct Disorder." National Academies of Sciences, Engineering, and Medicine. 2015. Mental Disorders and Disabilities Among Low-Income Children. Washington, DC: The National Academies Press. doi: 10.17226/21780.
×
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Children living in poverty are more likely to have mental health problems, and their conditions are more likely to be severe. Of the approximately 1.3 million children who were recipients of Supplemental Security Income (SSI) disability benefits in 2013, about 50% were disabled primarily due to a mental disorder. An increase in the number of children who are recipients of SSI benefits due to mental disorders has been observed through several decades of the program beginning in 1985 and continuing through 2010. Nevertheless, less than 1% of children in the United States are recipients of SSI disability benefits for a mental disorder.

At the request of the Social Security Administration, Mental Disorders and Disability Among Low-Income Children compares national trends in the number of children with mental disorders with the trends in the number of children receiving benefits from the SSI program, and describes the possible factors that may contribute to any differences between the two groups. This report provides an overview of the current status of the diagnosis and treatment of mental disorders, and the levels of impairment in the U.S. population under age 18. The report focuses on 6 mental disorders, chosen due to their prevalence and the severity of disability attributed to those disorders within the SSI disability program: attention-deficit/hyperactivity disorder, oppositional defiant disorder/conduct disorder, autism spectrum disorder, intellectual disability, learning disabilities, and mood disorders. While this report is not a comprehensive discussion of these disorders, Mental Disorders and Disability Among Low-Income Children provides the best currently available information regarding demographics, diagnosis, treatment, and expectations for the disorder time course - both the natural course and under treatment.

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