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 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 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.

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.

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.

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.

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