Conduct Disorders in Children and

Adolescents
What Is Conduct Disorder?

Children with conduct disorder repeatedly violate the personal or property rights of others and the basic
expectations of society. A diagnosis of conduct disorder is likely when symptoms continue for 6 months or
longer. Conduct disorder is known as a "disruptive behavior disorder" because of its impact on children
and their families, neighbors, and schools.

Another disruptive behavior disorder, called oppositional defiant disorder, may be a precursor of
conduct disorder. A child is diagnosed with oppositional defiant disorder when he or she shows signs
of being hostile and defiant for at least 6 months. Oppositional defiant disorder may start as early as the
preschool years, while conduct disorder generally appears when children are older. Oppositional defiant
disorder and conduct disorder are not co-occurring conditions.

What Are the Signs of Conduct Disorder?

Some symptoms of conduct disorder include:

 Aggressive behavior that harms or threatens to harm other people or animals;

 Destructive behavior that damages or destroys property;
 Lying or theft; and
 Truancy or other serious violations of rules;
 Early tobacco, alcohol, and substance use and abuse; and
 Precocious sexual activity.

Children with conduct disorder or oppositional defiant disorder also may experience:

 Higher rates of depression, suicidal thoughts, suicide attempts, and suicide;

 Academic difficulties;
 Poor relationships with peers or adults;
 Sexually transmitted diseases;
 Difficulty staying in adoptive, foster, or group homes; and
 Higher rates of injuries, school expulsions, and problems with the law.

advertisement How Common is Conduct Disorder?

Conduct disorder affects 1 to 4 percent of 9- to 17-year-olds, depending on exactly how the disorder is
defined (U.S. Department of Health and Human Services, 1999). The disorder appears to be more
common in boys than in girls and more common in cities than in rural areas.

Who Is at Risk?
Research shows that some cases of conduct disorder begin in early childhood, often by the preschool
years. In fact, some infants who are especially "fussy" appear to be at risk for developing conduct
disorder. Other factors that may make a child more likely to develop conduct disorder include:
  Early maternal rejection;
 Separation from parents, without an adequate alternative caregiver;
 Early institutionalization;
 Family neglect;
 Abuse or violence;
 Parental mental illness;
 Parental marital discord;
 Large family size;
 Crowding; and
 Poverty.

What Help Is Available for Families?

Although conduct disorder is one of the most difficult behavior disorders to treat, young people often
benefit from a range of services that include:

 Training for parents on how to handle child or adolescent behavior.

 Family therapy.
 Training in problem solving skills for children or adolescents.
 Community-based services that focus on the young person within the context of family and
community influences.

What Can Parents Do?

Some child and adolescent behaviors are hard to change after they have become ingrained. Therefore,
the earlier the conduct disorder is identified and treated, the better the chance for success. Most children
or adolescents with conduct disorder are probably reacting to events and situations in their lives. Some
recent studies have focused on promising ways to prevent conduct disorder among at-risk children and
adolescents. In addition, more research is needed to determine if biology is a factor in conduct disorder.

Parents or other caregivers who notice signs of conduct disorder or oppositional defiant disorder in a child
or adolescent should:

 Pay careful attention to the signs, try to understand the underlying reasons, and then try to
improve the situation.
 If necessary, talk with a mental health or social services professional, such as a teacher,
counselor, psychiatrist, or psychologist specializing in childhood and adolescent disorders.
 Get accurate information from libraries, hotlines, or other sources.
 Talk to other families in their communities.
 Find family network organizations.

People who are not satisfied with the mental health services they receive should discuss their concerns
with their provider, ask for more information, and/or seek help from other sources.

Important Messages About Children's and Adolescents' Mental Health:

 Every child's mental health is important.

 Many children have mental health problems.
 These problems are real and painful and can be severe.
 Mental health problems can be recognized and treated.
 Caring families and communities working together can help.
Disruptive Behaviour Disorder is an expression  used to describe a set of externalising
negativistic behaviours that co-occur during childhood; and which are referred to collectively
in the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV) as:
"Attention-Deficit and Disruptive Behaviour Disorders". There are three subgroups of
externalising behaviours:

Oppositional Defiant disorder (ODD)

Conduct Disorder (CD)
Attention Deficit Hyperactivity Disorder (ADHD)

Treatment for Oppositional Defiant and Conduct Disorder at the clinic is based on the
premise that these behaviours are the result of a combination of a metabolic dysfunction
and environmental factors. We approach treatment in a similar way to our treatment of
children and adolescents with ADHD. There is however an added emphasis on Counselling
and Behaviour Modification techniques. Please read our treatment model for ADHD.

OPPOSITIONAL DEFIANT DISORDER (ODD)

Oppositional Defiant Disorder (ODD) consists of a pattern of negativistic, hostile, and

defiant behaviour lasting at least 6 months, during which four (or more) of the following
behaviours are present:

 often loses temper

 often argues with adults
 often actively defies or refuses to comply with adults' requests or rules
 often deliberately annoys people
 often blames others for his or her mistakes or misbehaviour
  is often touchy or easily annoyed by others

  is often angry and resentful

  is often spiteful or vindictive

Each of the above is only considered diagnostic if the behaviour occurs more frequently
than is typically observed in children of comparable age and developmental level and if the
behaviour causes clinically significant impairment in social, academic, or occupational
functioning.

Oppositional Defiant disorder is not diagnosed if the behaviours occur exclusively during
the course of a Psychotic or Mood Disorder or if Conduct Disorder is diagnosed.

CONDUCT DISORDER
The DSM-IV categorises conduct disorder behaviours into four main groupings: (a)
aggressive conduct that causes or threatens physical harm to other people or animals, (b)
non- aggressive conduct that causes property loss or damage, (c) deceitfulness or theft,
and (d) serious violations of rules. Conduct Disorder consists of a repetitive and persistent
pattern of behaviours in which the basic rights of others or major age-appropriate norms or
rules of society are violated. Typically there would have been three or more of the
following behaviours in the past 12 months, with at least one in the past 6 months:

AGGRESSION TO PEOPLE AND ANIMALS

 often bullies, threatens, or intimidates others

 often initiates physical fights
 has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle,
knife, gun)
 has been physically cruel to people
 has been physically cruel to animals
 has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
 has forced someone into sexual activity

DESTRUCTION OF PROPERTY

 has deliberately engaged in fire setting with the intention of causing serious damage
 has deliberately destroyed others' property (other than by fire setting)

DECEITFULNESS OR THEFT 

 has broken into someone else's house, building, or car

 often lies to obtain goods or favours or to avoid obligations (i.e., "cons" others)
 has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery)

SERIOUS VIOLATIONS OF RULES

 often stays out at night despite parental prohibitions, beginning before age 13 years
  has run away from home overnight at least twice while living in parental or parental surrogate

home (or once without returning for a lengthy period)

 is often truant from school, beginning before age 13 years

SUBTYPES OF CONDUCT DISORDER

There are two subtypes of conduct disorder outlined in DSM-IV, and their diagnosis differs
primarily according to the nature of the presenting problems and the course of their
development.
The first, childhood-onset type, is defined by the onset of one criterion characteristic of
conduct disorder before age 10. Children with childhood-onset conduct disorder are usually
male, and frequently display physical aggression; they usually have disturbed peer
relationships, and may have had oppositional defiant disorder during early childhood. These
children usually meet the full criteria for conduct disorder before puberty, they are more
likely to have persistent conduct disorder, and are more likely to develop adult antisocial
personality disorder than those with the adolescent-onset type (American Psychiatric
Association, 1994).

The second, the adolescent-onset type, is defined by the absence of conduct disorder prior
to age 10. Compared to individuals with the childhood-onset type, they are less likely to
display aggressive behaviours. These individuals tend to have more normal peer
relationships, and are less likely to have persistent conduct disorders or to develop adult
antisocial personality disorder. The ratio of males to females is also lower than for the
childhood-onset type (American Psychiatric Association, 1994).
Severity of symptoms

Conduct disorder is classified as "mild" if there are few, if any, conduct problems in excess
of those required for diagnosis and if these cause only minor harm to others (e.g., lying,
truancy and breaking parental rules). A classification of "moderate" is applied when the
number of conduct problems and effect on others are intermediate between "mild" and
"severe". The "severe" classification is justified when many conduct problems exist which
are in excess of those required for diagnosis, or the conduct problems cause considerable
harm to others or property (e.g., rape, assault, mugging, breaking and entering) (American
Psychiatric Association, 1994).

CO-MORBIDITIES AND ASSOCIATED DISORDERS

Children with conduct disorder are part of a population within which there are higher
incidences of a number of disorders than in a normal population. The literature abounds
with studies indicating the comorbid relationships between Attention Deficit Hyperactivity
Disorder, Conduct Disorder, Oppositional Defiant Disorder, Learning Difficulties, Mood
Disorders, Depressive symptoms, Anxiety Disorders, Communication Disorders, and
Tourettes Disorder. (American Psychiatric Association, 1994; Biederman, Newcorn, &
Sprich, 1991). A high level of co-morbidity (almost 95%) was found among 236 ADHD
children (aged 6-16 yrs) with conduct disorder, ODD and other related categories (Bird,
Gould, & Staghezza Jaramillo, 1994). In an 8 year follow-up study, Barklay and colleagues
(1990) found that 80% of the children with ADHD were still hyperactive as adolescents and
that 60% of them had developed Oppositional Defiant or Conduct Disorder.

PREVALENCE OF CONDUCT DISORDER.

According to research cited in Phelps & McClintock (1994), 6% of children in the United
States may have conduct disorder. The incidence of the disorder is thought to vary
demographically, with some areas being worse than others. For example, in a New York
sample, 12% had moderate level conduct disorder and 4% had severe conduct disorder.
Since prevalence estimates are based primarily upon referral rates, and since many children
and adolescents are never referred for mental health services, the actual incidences may
well be higher (Phelps & McClintock, 1994) .

COURSE OF CONDUCT DISORDER

The onset of conduct disorder may occur as early as age 5 or 6, but more usually occurs in
late childhood or early adolescence; onset after the age of 16 years is rare (American
Psychiatric Association, 1994). The results of research into childhood aggression have
indicated that externalising problems are relatively stable over time. Richman and
colleagues for example, found that 67% of children who displayed externalising problems at
age 3 were still aggressive at age 8 (Richman, Stevenson, & Graham, 1982). Other studies
have found stability rates of 50-70%. However, these stability rates may be higher due to
the belief that the problems are episodic, situational, and likely to change in character
(Loeber, 1991).

Age of onset of ODD seems to be associated with the development of severe problems later
in life, including aggressiveness and antisocial behaviour. However, not all conduct
disordered children have a poor prognosis. Studies suggest that less than 50% of the most
severe cases become antisocial as adults. Nevertheless, the fact that this disorder continues
into adulthood for many people conveys that it is a serious and life-long dysfunction
(Webster-Stratton & Dahl, 1995).

While not all ODD children develop conduct disorder, and not all conduct disorder children
become antisocial adults there are certain risk factors that have been shown to contribute to
the continuation of the disorder. The risk factors identified include; an early age of onset
(preschool years), the spread of antisocial behaviours across settings, the frequency and
intensity of antisocial behaviours, the forms that the antisocial behaviours take, having
covert behaviours at an early age and also particular parent and family characteristics.
However, these risk factors do not fully explain the complex interaction of variables involved
in understanding the continuation of Conduct Disorder in any one individual.

CAUSES OF CONDUCT DISORDER

There is evidence from research into causes of conduct disorders that indicates that several
biological and environmental factors may contribute to the development of the disorder.

Neurological Dysregulation

The high co-morbidity rate of Conduct Disorder with ADHD, Tourettes syndrome and other
disorders known to be due to neurological dysregulation suggests that Conduct Disorder
may be a co-manifestation of the same underlying dysregulation. Although there are no
studies to our knowledge, which have directly investigated the neurological basis for
conduct disorder, there is ample clinical evidence indicating that when treating ADHD with
Neurotherapy, and Nutrient supplementation, Conduct Disorder abates. It appears that
Neurotherapy may address the underlying dysregulation and facilitate clinical treatment
using cognitive and behavioural interventions. More research is needed in this area to
determine whether Neurotherapy is directly responsible for this abatement or whether the
resultant improvement in attention, and reduction in hyperactivity promotes better self
image which in turn improves behaviour.

Child Biological Factors

Considerable research has been carried out into the role of child temperament, the tendency
to respond in predictable ways to events, as a predictor of conduct problems. Aspects of the
personality such as activity levels displayed by a child, emotional responsiveness, quality of
mood and social adaptability are part of his or her temperament. Longitudinal studies have
found that although there is a relationship between early patterns of temperament, and
adjustment during adulthood, the longer the time span the weaker this relationship
becomes.

A more important determinant of whether or not temperamental qualities persist has been
shown to be the manner in which parents respond to their children. "Difficult" infants have
been shown to be especially likely to display behaviour problems later in life if their parents
are impatient, inconsistent, and demanding. On the other hand "difficult" infants, whose
parents give them time to adjust to new experiences, learn to master new situations
effectively. In a favourable family context a "difficult" infant is not at risk of displaying
disruptive behaviour disorder at 4 years old.

Cognitions may also influence the development of conduct disorder. Children with conduct
disorder have been found to misinterpret or distort social cues during interactions with
peers. For example, a neutral situation may be construed as having hostile intent. Further,
children who are aggressive have been shown to seek fewer cues or facts when interpreting
the intent of others. Children with conduct disorder experience deficits in social problem
solving skills. As a result they generate fewer alternate solutions to social problems, seek
less information, see problems as having a hostile basis, and anticipate fewer consequences
than children who do not have a conduct disorder (Webster-Stratton & Dahl, 1995).

School-Related Factors

A bidirectional relationship exists between academic performance and conduct disorder.

Frequently children with conduct disorder exhibit low intellectual functioning and low
academic achievement from the outset of their school years. In particular, reading
disabilities have been associated with this disorder, with one study finding that children with
conduct disorder were at a reading level 28 months behind normal peers (Rutter, Tizard,
Yule, Graham, & Whitmore, 1976).

In addition, delinquency rates and academic performance have been shown to be related to
characteristics of the school setting itself. Such factors as physical attributes of the school,
teacher availability, teacher use of praise, the amount of emphasis placed on individual
responsibility, emphasis on academic work, and the student teacher ratio have been
implicated (Webster-Stratton & Dahl, 1995).

Parent Psychological Factors

It is known that a child's risk of developing conduct disorder is increased in the event of
parent psychopathology. Maternal depression, paternal alcoholism and/or criminalism and
antisocial behaviour in either parent have been specifically linked to the disorder.

There are two views as to why maternal depression has this effect. The first considers that
mothers who are depressed misperceive their child's behaviour as maladjusted or
inappropriate. The second considers the influence depression can have on the way a parent
reacts toward misbehaviour. Depressed mothers have been shown to direct a higher
number of commands and criticisms towards their children, who in turn respond with
increased noncompliance and deviant child behaviour. Webster-Stratton and Dahl suggested
that depressed and irritable mothers indirectly cause behaviour problems in their children
through inconsistent limit setting, emotional unavailability, and reinforcement of
inappropriate behaviours through negative attention (Webster-Stratton & Dahl, 1995).

Familial Contributions

Divorce, Marital Distress, and Violence

The inter-parental conflicts surrounding divorce have been associated with the development
of conduct disorder. However, it has been noted that although some single parents and their
children become chronically depressed and report increased stress levels after separation,
others do relatively well. Forgatch  suggested that for some single parents, the events
surrounding separation and divorce set off a period of increased depression and irritability
which leads to loss of support and friendship, setting in place the risk of more irritability,
ineffective discipline, and poor problem solving outcomes. The ineffective problem solving
can result in more depression, while the increase in irritable behaviour may simultaneously
lead the child to become antisocial.

More detailed studies into the effects of parental separation and divorce on child behaviour
have revealed that the intensity of conflict and discord between the parents, rather than
divorce itself, is the significant factor. Children of divorced parents whose homes are free
from conflict have been found to be less likely to have problems than children whose
parents remained together but engaged in a great deal of conflict, or those who continued
to have conflict after divorce. Webster noted that half of all those children referred to their
clinic with conduct problems were from families with a history of marital spouse abuse and
violence.

In addition to the effect of marital conflict on the child, conflict can also influence parenting
behaviours. Marital conflict has been associated with inconsistent parenting, higher levels of
punishment with a concurrent reduction in reasoning and rewards, as well as with parents
taking a negative perception of their child's adjustment.

Family Adversity and Insularity

Life stressors such as poverty, unemployment, overcrowding, and ill health are known to
have an adverse effect on parenting and to be therefore related to the development of
conduct disorder. The presence of major life stressors in the lives of families with conduct
disordered children has been found to be two to four times greater than in other families.

Mothers' perception of the availability of supportive and social contact has also been
implicated in child contact disorder. Mothers who do not believe supportive social contact is
available are termed "insular" and have been found to use more aversive consequences with
their children than non-insular mothers (Webster-Stratton & Dahl, 1995)

Parent Child Interactions

Research has suggested that parents of children with conduct disorder frequently lack
several important parenting skills. Parents have been reported to be more violent and
critical in their use of discipline, more inconsistent, erratic, and permissive, less likely to
monitor their children, as well as more likely to punish pro-social behaviours and to
reinforce negative behaviours. A coercive process is set in motion during which a child
escapes or avoids being criticised by his or her parents through producing an increased
number of negative behaviours. These behaviours lead to increasingly aversive parental
reactions which serve to reinforce the negative behaviours.

Differences in affect have also been noted in conduct disordered children. In general their
affect is less positive, they appear to be depressed, and are less reinforcing to their parents.
These attributes can set the scene for the cycle of aversive interactions between parents
and children.

Other Family Characteristics

Birth order and size of the family have both been implicated in the development of conduct
disorder. Middle children and male children from large families have been found to be at an
increased risk of delinquency and antisocial behaviours.

Psychophysiological and Genetic Influences

Studies have found that neurological abnormalities are inconsistently correlated with
conduct disorder (Kazdin, 1987). While there has been interest in the implication of the
frontal lobe limbic system partnership in the deficits of aggressive children, these problems
may be the consequence of the increased likelihood for children with conduct disorder to
experience abuse and subsequent head injuries (Webster-Stratton & Dahl, 1995).

While twin studies have found greater concordance of antisocial behaviour among
monozygotic rather than dizygotic twins, and adoption studies have shown that criminality
in the biological parent increases the likelihood of antisocial behaviour in the child, genetic
factors alone do not account for the development of the disorder.

Final Word on Aetiology

While the risk factors outlined have been shown to be implicated in the development of
conduct disorder, it is important to note that not all children exposed to these factors
develop a conduct disorder. Rather, the evidence suggests that in those children who do
develop conduct disorders have an aetiology comprised of a combination of these factors
(Webster-Stratton & Dahl, 1995). There is strong evidence that 75% of ADHD children with
hyperactivity develop behavioural problems including 50% conduct disorder and 21%
antisocial behaviour (Klein & Mannuzza, 1991).
Treatment
A number of interventions have been identified which are useful in reducing the prevalence
and incidence of conduct disorder. Interventions consist of prevention and treatment,
although these should not be considered as separate entities. Prevention addresses the
onset of the disorder, although the child has not manifested the disorder, and treatment
addresses reduction of the severity of the disorder. In mainstream Psychology, prevention
and treatment for Conduct Disorder primarily focuses on skill development, not only for the
child but for others involved with the child, including the family and the school
environments. As previously discussed there may be clinical advantages in applying
nutritional supplementation and Neurotherapy where appropriate with Conduct Disorder
clients, if the client appears to respond to this form of neurological intervention, followed by
cognitive and behavioural intervention. The following paragraphs considers three
interventions, that assist in preventing and treating conduct disorder; child training, family
training, and school and community interactions.

Child Training
Child training involves the teaching of new skills to facilitate the child's growth, development
and adaptive functioning. Research indicates that as a means of preventing child conduct
disorder there is a need for skill development in the area of child competence. Competence
refers to the ability for the child to negotiate the course of development including effective
interactions with others, successful completion of developmental tasks and contacts with the
environment, and use of approaches that increase adaptive functioning (Kazdin, 1990). It
has been found that facilitating the development of competence in children is useful as a
preventative measure for children prior to manifestation of the disorder rather than as a
treatment (Webster-Stratton & Dahl, 1995).

Additionally, treatment interventions have been developed to focus on altering the child's
cognitive processes. This includes teaching the child problem solving skills, self control
facilitated by self statements and developing prosocial rather than antisocial behaviours.
Prosocial skills are developed through the teaching of appropriate play skills, development
of friendships and conversational skills. The social development of children provides them
with the necessary skills to interact positively in their environment. A child's development of
cognitive skills provides a sound basis from which to proceed. However, cognitive
development should not be considered in isolation, but as part of a system, which highlights
the need to include the family in the training process.

Family Intervention
A child's family system, has an important role in the prevention and treatment of conduct
disorder. The child needs to be considered as a component of a system, rather than as a
single entity. Research supports the notion that parents of conduct disordered children have
underlying deficits in certain fundamental parenting skills. The development of effective
parenting skills has been considered as the primary mechanism for change in child conduct
disorder, through the reduction of the severity, duration and manifestation of the disorder.

A number of parent training programs have been developed to increase parenting skills.
Research indicates that the parent training programs have been positive, indicating
significant changes in parents' and children's behaviour and parental perception of child
adjustment. Research suggests that parents who have participated in parent training
programs are successful in reducing their child's level of aggression by 20 - 60 %.

Various training programs have been developed, which focus on increasing parents' skills in
managing their child's behaviour and facilitating social skills development. The skills focused
on, include parents learning to assist in administration of appropriate reinforcement and
disciplinary techniques, effective communication with the child and problem solving and
negotiation strategies..

A further component of parental training incorporates behavioural management. This

involves providing the family with simple and effective strategies including behavioural
contracting, contingency management, and the ability to facilitate generalisation and
maintenance of their new skills, thus encouraging parents' positive interaction with their
child.

However, although these interventions assist parents in developing effective parenting

skills, a number of families require additional support. There are various characteristics
within the family system that can have an impact on parents' ability to cope. This includes
depression, life stress and marital distress. Research suggests that family characteristics are
associated with fewer treatment gains in parent training programs. As indicated by
Webster-Stratton and Dahl (1995), several programs have expanded upon the standard
parent training treatment. These programs have incorporated parents' cognitive,
psychological, and marital or social adjustment. Through addressing the parent's own issues
it assists their ability to manage and interact positively with the child.

School and Community Education

A child's' environment plays an active role in the treatment of conduct disorder and as a
preventative measure. A number of interventions have been developed for schools and the
community in relation to conduct disorder. The various programs outlined in this paper have
a primary focus involving the skill development for the child in the areas of problem solving,
anger management, social skills, and communication skills.
School based programs
There are various preventative programs devised which focus on specific cognitive skill
development of a child. A number of programs developed focus on encouraging the child's
development in decision making and cognitive process. In addition school based programs
have involved teaching the child interpersonal problem solving skills, strategies for
increasing physiological awareness, and learning to use self talk and self control during
problem situations.

In addition to prevention programs, a number of treatment interventions have been

developed for children where conduct disorder has manifested. The treatment programs
focus on further skill development, including anger management and rewarding appropriate
classroom behaviour, skill development of the child including the understanding of their
feelings, problem solving, how to be friendly, how to talk to friends, and how to succeed in
school. As Webster and colleagues describe, one school based program has been designed
to prevent further adjustment problems, by rewarding appropriate classroom behaviour,
punctuality, and a reduction in the amount of disciplinary action. In addition, the program
provided parents and teachers with the opportunity to focus on specific problems of a child
and for these to be addressed.

Community programs
Community based interventions have also addressed both treatment and prevention. A
number of programs have been developed, and focus on involving the youths in activity
programs and providing training for those activities. The children are rewarded for
attendance and participation in the programs.

The treatments discussed are helpful in reducing the prevalence and incidence of conduct
disorder. In their application it is important to provide an integrated multidisciplinary
approach to treatment in multiple settings and by providing relevant nutritional
supplements, Neurotherapy and behaviour training as appropriate.

Conclusion
Conduct disorder is very common among children and adolescents in our society. This
disorder not only affects the individual, but his or her family and surrounding environment.
Conduct disorder appears in various forms, and a combination of factors appear to
contribute to its development and maintenance. A variety of interventions have been put
forward to reduce the prevalence and incidence of conduct disorder. The optimum method
appears to be an integrated approach that considers both the child and the family, within a
variety of contexts throughout the developmental stages of the child and family's life.

Oppositional Defiant Disorder

Oppositional Defiant Disorder is defined as an enduring pattern of uncooperative, defiant, and hostile
behavior toward authority figures that does not involve major antisocial violations, is not accounted for by
the child's developmental stage, and results in significant functional impairment. A certain level of
oppositional behavior is common in children and adolescents.

It should be considered a disorder only when the behaviors are more frequent and intense than in
unaffected peers and when they cause dysfunction in social, academic, or work-related oppositional defiant
disorder, oppositional disorder, defiant.

For at least 6 months, these person's show defiant, hostile, negativistic behavior; 4 or more of the
following often apply:-

Losing temper.
Arguing with adults.
Actively defying or refusing to carry out the rules or requests of adults.
Deliberately doing things that annoy others.
Blaming others for own mistakes or misbehavior.
Being touchy or easily annoyed by others.
Being angry and resentful.
Being spiteful or vindictive.

The symptoms cause clinically important distress or impair work, school or social functioning.

The symptoms do not occur in the course of a Mood or Psychotic Disorder.

 The symptoms do not fulfill criteria for Conduct Disorder.

If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder.

ASSOCIATED FEATURES:

Learning Problem
Depressed Mood
Hyperactivity
Addiction
Dramatic or Erratic or Antisocial Personality

Differential Diagnosis:

Some disorders have similar or even the same symptoms. The clinician, therefore, in his/her diagnostic
attempt, has to differentiate against the following disorders which need to be ruled out to establish a
precise diagnosis

Conduct Disorder;
Mood Disorders;
Psychotic Disorders;
Attention-Deficit/Hyperactivity Disorder;
Mental Retardation; impaired language comprehension;
Typical feature of certain developmental stages

CAUSE:

No systematic research into the causes of oppositional defiant disorder has been conducted. Its etiology
is believed to be multifactorial. Genetic and environmental factors are probably combined. Children with
oppositional defiant disorder are more likely to have family history of disruptive behavior disorders,
substance-use disorders, or mood disorders.

Treatment:

Extremely few studies are available on the treatment outcome of oppositional defiant disorder.

Counseling and Psychotherapy [ See Therapy Section ]:

A variety of treatment approaches are commonly employed in clinical practice, including behavior therapy,
various forms of family therapy, parent management training, and dynamic psychotherapy.

Psychoanalytic Psychotherapy: In its purest form, two types of problems bring an individual to a
psychologist's office: Problems emerging from a patient's past life (the patient's developmental trauma
and experiences) and problems which appear to arise from current internal and external stressors. It is
rarely, if ever, that this separation of problems is that pure. In reality, current problems are superimposed
on old and chronic problems which the patient has carried for an extended period. The skilled doctor is
able to see the impact of the past upon the response to present stressors. An initial means of conceiving
of psychotherapy is understanding that it is a means of creating a professional atmosphere in which old
feelings and fantasies can be brought to the surface so that they may be studied, understood and
resolved.
Psychotherapist believe that the unconscious motives along with unresolved conflicts lead to maladapted
behavior.  They believe that to develop a normal personality,  a person successful go through five
psychosexual stages:

 Oral - Birth to 1 year:  Sucking.

 Anal - 1 to 3 years:  Holding and releasing urine and feces.
 Phallic - 3 to 6 years:  Pleasure in genital stimulation.
 Latency - 6 to 11 years:  Sexual instincts develop.
 Genital - Adolescence:  Sexual impulses return.

Inadequate resolution of any of these stages lead to flawed personality development.  

Behavior therapy is a combination of the systematic application of principles of learning theory to to the
analysis and treatment of behavior. It involves more than principles of learning and conditioning, however,
and uses the empirical findings of social and experimental psychology. The emphasis is placed upon the
observable and confrontable and not inferred mental states or constructs. The doctors seeks to relate
problematic behaviors (symptoms) to other observable physiological and environmental events. This
involves behavioral analysis of what is occurring (and has occurred) and means of altering the behavior. 

The early development of behavior therapies occurred in the 1960s and 1970s and at that time, this
mode of psychological care was defined as the systematic application of learning theory to the analysis
and treatment of behavioral disorders. This is too narrow of a definition and today, behavior therapy
draws not only upon principles of learning theory and conditioning but upon empirical findings from
experimental and social psychology. The doctor relates that patients and their disorders to to observable
events from physiological or environmental factors rather than inferring that they arise as a result of
unseen/unrecognized/unconscious conflicts or trauma. Behavioral analysis, noting the events which lead
to motor or verbal behaviors, is used to assist the patient in understanding cause-effect relationships and
means of disrupting/discontinuing the maladaptive or counterproductive behaviors. Behavior Therapies
have a wide range of application in phobic, maladaptive habit, and compulsive behaviors.

In systematic desensitization, the patient can overcome maladaptive anticipatory anxiety that is evoked
by situations or objects by approaching the feared situations gradually and in a psychophysiologic state
that inhibits the experience of anxiety. A variety of deep muscle relaxation procedures induces a
psychophysiological state that counterconditions the anxiety response. A graded list or hierarchy of
anxiety-provoking scenes which are associated with the patient fears is prepared. The patient then
approaches the deconditioning of anxiety by beginning, in fantasy (mental imagery), with the least anxiety
provoking scene and progressing up the hierarchy. The clinical goal is for the patient to be able to vividly
imagine the previously most anxiety-evoking scene with equanimity. This capacity translates to real life
situations but is most successful when real life situations are also used during the course of resolving
each scene in the hierarchy.

Clinical Hypnosis is an attentive, receptive, focal concentration while the individual has a concurrent
awareness but a constriction of peripheral events. It is very similar to visual focus and peripheral vision.
Those items in the center are sharp, detailed and colorful while those in the periphery are less noticeable.
It is very similar to being so absorbed in that which a person is reading that they enter the world of the
book and often fail to note things occurring around them. There are psychological, sensory, and
motor/behavioral changes during hypnosis. The individual may have the ability to alter perceptions,
dissociate from events and have amnesia for part of the hypnotic experience. The patient has the
tendency to comply with the doctor, but this suggestibility and willingness has limitations. EEG
(electroencephalographic) studies suggest that the brain is experiencing resting arousal and that they are
not asleep. Unfortunately, clinical hypnosis as performed by your doctor can become confused with
mythology and stage performers who use similar approaches to entertain an audience. See
Hypnotherapy Pages
 Group psychotherapy is effective and appeals to many patients and doctors. The same number of
doctors can treat more patients, and it may be combined with individual psychotherapy. In some
countries, the group psychotherapeutic approach has exceeded the individual approach. As the nuclear
family and religion has become diverse, and in some instances, fragmented, the psychotherapy group
may meet the strong need to belong, affiliate and assist others. Many doctors see a group size of 8 to 10
patients as optimal, but groups may vary in size from 3 to 15. Weekly or twice monthly sessions of 1-2
(1½ most common) hours seems to be the average. Groups of differing ("heterogenous") patient needs
may be helpful, but there are some group psychotherapy where all share the same expressed need or
disorder. In some instances the group is thought of as a doctor who is expressed through other group
members: as each group member grows stronger, he/she provides assistance in interpretation, insight
and decision making to other group members.

Clinical biofeedback instrumentation provides information (data) to a patient about normally

involuntary physical processes that are below threshold (outside of awareness). The patient, with these
data, can adjust behavioral, cognitive (mental) and affective (emotional) processes and learn to control
these physical processes. The term was first employed during WWII and the term behavioral medicine
was first utilized in 1973 to describe integration of behavioral and biomedical sciences for the diagnosis,
treatment, rehabilitation and prevention of illness as well as promotion of health. Not only can
biobehavioral methods be effective in the management of specific symptoms and rehabilitation, but these
approaches are often useful for patients who are resistant to other forms of treatment. See Biofeedback
Pages

Dialectical behaviour therapy (DBT) is a longer term cognitive behavioural treatment devised for
borderline personality disorder which teaches patients skills for regulating and accepting emotions and
increasing interpersonal effectiveness.

Eclectic therapies Many NHS therapists formulate the patient's difficulties using more than one
theoretical framework and choose a mix of techniques from more than one therapy approach. The
resulting therapy is pragmatic, tailored to the individual. These generic therapies often emphasise
important non-specific factors (such as building the therapeutic alliance and engendering hope). By their
nature, they are more idiosyncratic and difficult to standardise for the purposed of randomsied controlled
trials research.

Eye movement desensitisation and reprocessing (EMDR) is a form of imaginal exposure treatment for
post-traumatic conditions where the traumatic event is recalled whilst the client makes specific voluntary
eye movements.

Focal psychodynamic therapy identifies a central conflict arising from early experience that is being
re-enacted in adult life producing mental health problems. It aims to resolve this through the vehicle of the
relationship with the therapist giving new opportunities for emotional assimilation and insight. This form of
therapy may be offered in a time-limited format, with anxiety aroused by the ending of therapy being used
to illustrate how re-awakened feelings about earlier losses, separations and disappointments may be
experienced differently.

Psychopharmacotherapies are based upon the realization that the brain is not chemically responding
in a functional fashion. This has to do with chemicals within the brain and central nervous system called
neurotransmitters which must not only exist but exist in balance for thought, emotion and behavior to have
regulation. Vigorous research on these chemical agents have existed since the mid 1950s. As a result of
this research, we better understand how the brain's function is regulated and how best to assist those
who suffer from dysregulation of these neurotransmitters. Acetylcholine and norepinephrine were among
the first investigated followed by dopamine (dihydoxyphenylethylamine) and indoleamine serotonin.
Quantitatively, these are only minor transmitters in the brian but they serve major roles in emotional
behavior. The anticonvulsants, neuroleptics, antidepressants and anxiolytic agents are ever being refined.
They are not addictive agents although some patients become dependent upon the anti-anxiety
(anxiolytic agents) when they are not prescribed in an appropriate schedule. Non-medical abuse of the
anti-anxiety drugs is actually uncommon. These anxiolytic agents were excessively prescribed in the past,
and some clinicians became hesitant to prescribe them. Appropriately used, the drugs are both safe and
beneficial. See Psychopharmacology Pages

Marital and Sexual Psychotherapies deal with not only environmental, situational and phase of life
problems which confront relationships but deal with concurrent problems in communication and conflict.
Problems that occur within a relationship often emerge from interactional problems, the nature of
feedback which couples provide each other, the difficulties in maintaining functional balance within the
relationship, and the struggles for power and control which emerge. While interactional problems within a
marital system may result in, and sometimes from, sexual conflicts, these are not the sole causes, nor
even necessarily the primary causes. It is quite possible for a couple to have a functional sexual
relationship and a dysfunctional emotional relationship. Relationship problems may emerge or worsen as
a result of sexual dysfunction. By the time the couple consults a doctors, it is questionable as to whether
sole resolution of the sexual problem, via medication for example, will make the marriage again functional
unless other intervention (e.g. marital psychotherapy) is concurrently provided.  See Counselling Pages

Short-term dynamic psychotherapies (STDP) work well for nonresistant patients whose resolution of
problems do not become steeped in long term transferential problems relating to the doctor and for whom
problems are significant but not overwhelmingly complex. Such patients often have some beginning
insight or awareness of potential causes of their problems. Treatment begins with a comprehensive
diagnostic examination which determines whether the problems/disorder can be appropriately treated by
a particular psychotherapeutic technique. The doctor also determines whether the patient has the
strength to confront the underlying causes for their problems and that there is the potential for positive
response to short term intervention. As in psychoanalysis or psychoanalytic psychotherapies, STDP does
involve examination of of the means by which unconscious needs and drives influence a patient's
behavior and functional capacity.

Client-centered psychotherapy arose during the period of 1938-1950 and broadened the scope of
patients treated by this approach in the 60s and 70s. The characteristics that distinguished this form of
patient care included the belief that specific characteristics of the doctor were necessary and sufficient for
effective treatment; rejection of the medical/disease model and focus upon the growth model of patient
change; the immediate (rather than emotionally distant) accessibility of the doctor; focus upon the
experiences of the patient; focus upon the patient's ability to live within the moment; concern for
personality change rather than personality structure; and belief that the process applies to all patients
rather than a select group; application of all knowledge of the impact of psychotherapy upon the
interpersonal process. Many patients reported significant gains after only brief treatment exposure in
contrast to the greater time period perceived required by other modes of treatment.

Cognitive Behavioral Psychotherapy is based upon a theory of psychopathology, set of

psychotherapeutic principles,  and knowledge based upon empirical investigation. It is based upon
information-processing theory and social psychology. Aside from being effective with a wide range of
disorders, it appears to enhance the impact of medications used to treat such disorders and has appeal in
that it is active, structured and time-limited. Pain, phobias, and mood disorders as well as
psychophysiologic (psychosomatic) disorders have been treated successfully with this treatment
approach. Errors in our thinking leading to self-defeating assumptions, incorrect interpretation of
information, and lack of adequate problem solving planning are believed to be at the heart of our
problems. Treatment assist the patient in identifying, testing the reality of, and correcting dysfunctional
beliefs underlying our thinking and to assist the patient in modifying the thoughts and behaviors which
emerge.

Relaxation Techniques in this form of therapy the patient is helped to resolve stresses that can
contribute to the particular disorder. Breathing re-training and other skills are taught in which the patient is
actively involved in developing skills that are useful for a lifetime. Can take time to achieve results and
treatment benefits are limited to active use of the techniques.

Adlerian Therapy   Adlerian Therapy is a growth model.  It stresses a positive view of human nature and
that we are in control of our own fate and not a victim to it.  We start at an early age in creating our own
unique style of life and that style stays relatively constant through the remained of our life.  That we are
motivated by our setting of goals,  how we deal with the tasks we face in life,  and our social interest.  The
therapist will gather as much family history as they can.  They will use this data to help set goals for the
client and to get an idea of the clients' past performance.  This will help make certain the goal is not to low
or high,    and that the client has the means to reach it.  The goal of Adlerian Therapy is to challenge and
encourage the clients' premises and goals.  To encourage goals that are useful socially and to help them
feel equal.  These goals maybe from any component of life including,  parenting skills,  marital skills,  
ending substance-abuse,   and most anything else.  The therapist will focus on and examine the clients'
lifestyle and the therapist will try to form a mutual respect and trust for each other.  They will then mutually
set goals and the therapist will provided encouragement to the client in reaching their goals.  The
therapist may also assign homework,   setup contracts between them and the client,  and make
suggestions on how the client can reach their goals.

Existential Therapy Focuses on freedom of choice in shaping one's own life.  Teaches one is
responsible to shape his / her own life and a need for self-determination and self-awareness.  The
uniqueness of each individual forms his / her own unique personality,  starting from infancy. Existential
therapy focuses on the present and on the future.  The therapist try's to help the client see they are free
and to see the possibilities for their future.   They will challenge the client to recognize that he / she
themselves were responsible for the events in their life. This type of therapy is well suited in helping the
client to make good choices or in dealing with life.

Gestalt Therapy  Gestalt therapy integrates the body and mind factors,  by stressing awareness and
integration.  Integration of behaving,  feelings,  and thinking is the main goal in Gestalt therapy.   Client's
are viewed as having the ability to recognize how earlier life influences may have changed their life's. The
client is is made aware of personal responsibility,  how to avoid problems,  to finish unfinished matters,  to
experience thing in a positive light,  and in the awareness of now.   It is up to the therapist to help lead the
client to awareness of moment by moment experiencing of life.  Then to challenge the client to accept the
responsibility of taking care of themselves rather then excepting others to do it.  The therapist may use
confrontation,   dream analysis,  dialogue with polarities,  or role playing to reach their goals.  This may
include treatment of crisis intervention,  marital / family therapy,  problem in children's behavior,  
psychosomatic disorders,   or the training of mental health professionals.

Rational-emotive and Cognitive-behavioral Therapy  Rational-emotive therapy is a highly action-oriented

and deals with the client's cognitive and moral state.  This therapy stresses the clients ability of thinking
on their own and in their ability to change.   The rational-emotive therapist believes that we are born with
the ability of rational thinking but that my fall victim to irrational thinking.  They stress the clients ability to
think,  in making good judgments,  and in taking action.    The therapist will use directed therapy.  The
therapist believes that a neurosis is a result of irrational behavior and irrational thinking.  The Rational-
emotive and Cognitive-behavioral therapist believe the clients problems are rooted in childhood and in
their belief system,  that was formed in childhood.   Therapy will include method is solving and dealing
with emotional or behavior problems.  The therapist will help the client to eliminate any self-defeating
outlooks they may have and to view life in a rational way.  The therapist will never have a personal
relationship with the client.  The therapist will think of the client as a student and themselves as the
teacher.

Reality Therapy   The reality therapist teaches the client ways to control the world around them and how
to meet their personal needs.   They believe that the client can and will change their life for the better.  
The reality therapist focuses on the what and the why of the clients actions.   They point out what the
client doing and in getting them to evaluate it.  A behavioral or emotional problem is a direct result of the
clients believe and feelings about themselves. The therapist will help the client evaluate their behaviors
and feelings,  to challenge them to become more effective at meeting their needs.

Transactional Analysis  Transactional analysis focus on the clients cognitive and behavior functioning. 
The therapist helps the client evaluate their past decisions and how those decisions affect their present
life.   They believe self-defeating behavior and feelings can be overcome by an awareness of them.  The
therapist believes that the clients personality is made up of the parent,  adult,  and child.  They believe
that it is important for the client to examine past decisions to help their make new and better decisions.