Disruptive,

impulse control
and conduct
disorders
Introduction
• Conceptual controversy: late-onset disruptive behavior disorders as a different disorder?

• s differentiate among early-onset disruptive behavior disorder, with symptoms observable before age 10
years, and later-onset disruptive behavior disorders, with no noticeable signs until adolescence.

•
Diagnostic criteria

• In DSM-5, oppositional defiant disorder is characterized by an angry mood and defiant behavior.

• In DSM-5, eight symptoms are listed. Examples of symptoms include losing one’s temper, deliberately irritating
others and blaming others for one’s own mistakes. Four or more of the eight symptoms must be present.

• In DSM-5, the symptoms must be displayed toward at least one person who is not a sibling.
• In DSM-IV, there are no specific guidelines as to how often a symptom must occur. However, in DSM-5, precise
guidelines have been added. For example, children under 5 are required to display the symptoms on more days than
not for a minimum of
6 months. Additionally, in individuals aged 5 or older, symptoms must be present at least once a week for a
minimum of 6 months.

• In DSM-IV, individuals diagnosed with conduct disorder cannot be diagnosed with oppositional defiant disorder.
However, in DSM-5, this restriction has been removed.
Differences between DSM-IV and DSM-5
criteria for conduct disorder

• In both DSM-IV and DSM-5, conduct disorder involves the violation of major rules and expectations.

• In both DSM-IV and DSM-5, the age of onset determines the code. If at least one of the listed conduct
issues is present before age 10, the individual falls into the childhood- onset type. However, if no criteria
are met before age 10, the individual is said to have the adolescent-onset type.

• Both versions list fifteen symptoms (conduct problems). Three or more must be observed within a period
of at least 1 year. Examples of conduct problems include being physically cruel, destroying property and
stealing.
Specifiers
• Both versions list the following specifiers: “mild,” to be used if few conduct problems are observed and
only minor harm is caused (e.g., lying); “moderate,” to be used if
the number of conduct issues and the amount of harm caused are above “mild” and below “severe”
(e.g., deliberate destruction/vandalism); and “severe,” to be used if many conduct problems are present
or the conduct problems cause substantial harm (e.g., physical aggression).
• In DSM-5, an additional specifier, “with limited prosocial emotions,” has been
added. This specifier is used if the individual displays at least two of the following characteristics for at
least 1 year: lack of guilt, lack of empathy, lack of concern about performance or shallow affect.
Prevalence
• Disruptive behavior disorders are the most frequent reason for referrals of children and
adolescents to mental health professionals in the United States .
• In the UK, the Office for national Statistics estimated in 1999 that 5.3 percent of
children and adolescents displayed conduct problems severe enough to necessitate
professional treatment
• A weighted rate of 17% was found for common child psychiatric disorders, with a a
greater number of behavioural disorders, followed by anxiety and mood disorders in
Pakistan (2013)
Sex Differences
• Boys are two to four times more likely than girls to develop any form of disruptive/conduct disorder

• However, the ratio is even more imbalanced when one considers life-course-persistent conduct disorder,
which is estimated to occur ten to fifteen times more frequently among boys than girls

• Girls, of course, are not necessarily angels during the preschool years. Although they are usually not
aggressive in physical ways, they are known to aggress in subtle non-physical ways such as spreading
nasty rumours and getting other children to exclude the targets of their displeasure from playgroups

• Such relational aggression continues throughout the lifespan and is more typical among girls and
women according to most studies

• However, argue convincingly that, according to the most authoritative statistics available, physical
violence by adolescent girls has in fact declined over the past few decades.
Cultural differences in prevalence
•
The anthropological study indicates that cultures significantly influence how aggressive or non-
aggressive children become. One key factor is the amount of adult aggression children are exposed
to.
• Aggression tended to be highest in more individualistic countries – countries where many citizens
base their self-concepts on their identities as individuals and value individual prerogative – in
comparison with more collectivistic countries, where the prevailing values emphasize belonging to
groups.

• aggression was lowest in countries where value tended to be placed on moral engagement and on
egalitarianism (which is by no means synonymous with individualism).
Probable causes and concurrent
impairment

• Genetics
• They inherit decreased base line autonomic nervous activity they required highre level of stimulataion to
optimal arousal
• Stimulation seeking Theory
• Children and adolescent with DBD and CD may accomplish greater stimulation and arousal by
engaging in sensation-seeking, high-risk activities.
• fearlessness theory
• is that the low autonomic nervous system activity among children with disruptive behavior
disorders results in a reduction in their fear of punishment
Structural and Functional
Physiology
• An important distinction has been drawn between aggression that is either reactive or instrumental in
nature (Blair, 2010).

• reactive aggression occurs in response to a trigger, something that proves to be frustrating or

threatening to an individual, and is characterized by an attack (often angry) on what is thought to be the
source of the trigger (e.g., a child hits a peer if he thinks the peer stepped on his foot).

• Instrumental aggression involves purposeful behaviors that are implemented with a goal in
mind and that are not necessarily linked to emotions like anger (e.g., a child steals a peer’s notebook so
the peer cannot do her homework that night).
Structural and Functional
Physiology
• In humans, the basic threat system response that accompanies reactive aggression is
believed to be regulated by regions of the prefrontal cortex (PFC); specifically, the
medial, orbital and inferior frontal areas.
• research conducted using animals has indicated that response to threats, such
as in reactive aggression, is supported by a neural system involving the
amygdala, hypothalamus and periaqueductal gray matter
• Brain regions that support goal-directed behaviors, such as the motor cortex
and the caudate are thought to be involved in instrumental aggression or anti-
social behavior.
• because engaging in anti-social behavior involves weighing the costs and
benefits of making certain choices through one’s behavior, it is believed that
the amygdala and the orbitofrontal cortex (OFC) are integrally involved
• Effective prefrontal regulation inhibits reactive aggression.
Role of Neurotransmitters

• Children with disruptive behavior disorders are

found in most studies to have lower serotonin
levels than either typically developing children
or children with internalizing disorders, such as
anxiety or depression.
Cognitive dimensions of disruptive behavior
disorders

• One important way in which their thinking is maladaptive consists of faulty attributions of intent.

• cue detection:
• They tend more than non- aggressive children to reach a conclusion about a social situation
based on very little information,
• emotion dysregulation

Children with disruptive aggression not only have distorted thoughts but also struggle with how
they feel certain emotions.
Family factors
Insecure child–parent attachment

• Children with disruptive behavior disorders are often characterized by a history of insecure child–parent
attachment. Importantly, this seems to apply to both child–mother and child–father attachment

• disorganized or controlling attachment patterns tend to characterize the parenting of aggressive children.

• inconsistent, ineffective and/or harsh parenting

Children raised with high or moderate levels of physical discipline tend, on the whole, to engage in higher
levels of anti-social behavior as adolescents than children of parents who used low levels of physical
discipline or none at all
Coercive” processes in child–parent
“

interaction

• "Coercive" processes in child-parent interaction refer to patterns where

negative behaviors from both the child and parent escalate, creating a
mutually reinforcing cycle of conflict and aggression.

• Coercive interactions between a child and parent often start with something minor, like a child whining. Instead of ignoring it,
the parent reacts negatively, escalating the situation. The child learns that such behavior grabs the parent's attention,
reinforcing the whining. This cycle may continue, with the parent scolding and, in some cases, resorting to physical
punishment. Different parents may handle this situation more consistently.
Peer influences
Having the wrong friends

• According to the homophily principle (e.g., Haselager et al., 1998),

children (and adults) tend to befriend others who resemble them.

• Accordingly, many children and adolescents with disruptive behavior

disorders tend to have friends who are also aggressive.
Models byVitaro, Boivin and Tremblay (2007)

•
In an additive model, the negative impact of having an aggressive friend is considered separate from any individual
risk factors or contextual risks.
• Imagine a teenager with a pre-existing tendency towards aggression due to personal factors or experiences. In an
additive model, if this teenager also befriends an aggressive peer, the negative influence of the friend is considered
separately from the individual's existing risk factors

• On the other hand, an interactive model assumes that an aggressive friend intensifies pre-existing tendencies for
aggression in an individual, operating more like a multiplier than an addition to existing risks. In this case, the
friend's influence interacts with the individual's pre-existing proclivities, creating a more amplified effect on
aggressive behavior.
• In the collateral model, the friend doesn't directly influence
aggression. Instead, it's the child or adolescent's pre-existing
inclination toward aggression that coincidentally leads to both
the friendship and the aggressive behavior.
 Prevention and treatment

• Parent training
summary is based on reviews by Farley et al. (2005)

• These programs may be delivered to parents individually or in groups.

• positive reinforcement for appropriate behavior
• with a mild consequence if needed for misbehavior, such as removal for a few minutes to a time-out
corner.
• intervention focused on reinforcing prosocial behaviors and cooperation,
• Written contracts negotiated individually between parents and children constitute an important part of the
program
individual and group interventions for children
– anger management

• to recognize the situations that may trigger their anger.

• interpret these situations in as objective a way as is possible.
• Problem-solving is introduced
• to help consider alternatives to both holding one’s feelings in and explosive, aggressive outbursts
• the appropriate, assertive expression of their feelings.
• In typical anger-management programs, participants keep logs of their daily experiences with anger and
the impulses to act on anger.
• They review these logs with their therapists, who assist them in evaluating their handling of the situations
•
social skills training

• Some authors use the term social skills to refer to the overt behavioral skills that are needed for effective
interpersonal interaction, others include underlying thinking skills

• Many social skills programs combine these components (e.g., Schneider and Byrne, 1987); social skills
components are

• often combined as well with such behavior- modification techniques as token reinforcement for use of
the skills learned

• Modeling methods are sometimes used to demonstrate the exact social skill that a trainee may lack.

• Aggression Replacement Training, it might be established that a group participant is deficient in the skill
of standing up for his rights.
Case Formulation

A child Abc, 9 years old presented with frequent refusal to comply with rules, instructions, or requests from
authority figures. He sometimes engaged in physical aggression towards peers, family members, or
authority figures. Verbal aggression, including threats, insults, and defiance. Strained relationships with
family members, marked by conflicts, inconsistent discipline, or lack of communication. Quick temper, mood
swings, or emotional outbursts.

a) Differentiate it with CD

b) Write case formulation reaching to probable diagnosis