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Oppositional defiance disorder and conduct disorder

Oppositional defiant disorder (ODD) and conduct disorder (CD) are two common mental disorders that affect children and young adults. They are characterized by disruptive, defiant, and antisocial behaviours that violate the rights of others or the norms of society (Mash & Barkley, 2014). ODD is usually diagnosed before the age of eight, while CD is more prevalent in adolescence. ODD involves angry, irritable, argumentative, and vindictive behaviours, while CD involves aggression, deceitfulness, theft, vandalism, and violation of rules (American Psychiatric Association [APA], 2013). Both disorders are associated with negative outcomes such as academic failure, substance abuse, criminality, and mental health problems (Kimonis et al., 2014).

The aetiology of ODD and CD is complex and multifactorial, involving genetic, biological, psychological, and environmental factors. Some of the risk factors include low birth weight, prenatal exposure to toxins, brain abnormalities, temperament, cognitive deficits, poor parenting practices, family conflict, peer rejection, neighbourhood violence, and cultural influences (del Valle et al., 2001; Kimonis et al., 2014; Lahey, 2008). However, these factors are not deterministic and do not account for individual differences in the development and expression of ODD and CD. Moreover, some protective factors such as high intelligence, positive attachment, social support, and resilience can buffer the effects of risk factors and prevent or reduce the severity of ODD and CD (Kimonis et al., 2014).

The assessment and treatment of ODD and CD require a comprehensive and multimodal approach that involves multiple sources of information (e.g., interviews, observations, questionnaires) and multiple settings (e.g., home, school, community) (del Valle et al., 2001). The goals of assessment are to identify the nature and extent of the problem behaviours, the underlying causes and maintaining factors, the strengths and resources of the child and family, and the appropriate intervention strategies.

The goals of treatment are to reduce the frequency and intensity of the problem behaviours, to increase the prosocial and adaptive behaviours, to enhance the child’s self-regulation and social skills, to improve the parent-child and family relationships, and to prevent or minimize the long-term negative consequences of ODD and CD (Kimonis et al., 2014).

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The most effective treatments for ODD and CD are based on behavioural and cognitive-behavioural principles that target the child’s behaviour as well as the parent’s behaviour. Some of the evidence-based interventions include:

  • Parent management training (PMT), which teaches parents how to use positive reinforcement, consistent discipline, problem-solving skills, and communication skills to manage their child’s behaviour.
  • Child-focused interventions such as anger management training (AMT), which teaches children how to identify and cope with their anger triggers, express their emotions appropriately, and resolve conflicts peacefully.
  • Multi-systemic therapy (MST), which involves intensive family- and community-based services that address the multiple risk factors influencing the child’s behaviour.
  • Functional family therapy (FFT), which focuses on improving the family functioning by enhancing communication, problem-solving skills, emotional bonding, and positive parenting practices (del Valle et al., 2001; Kimonis et al., 2014).

The most effective treatments for ODD and CD are psychosocial interventions that involve the child or young adult; their parents or caregivers; their teachers; and other relevant professionals. These interventions may include parent training programs; cognitive-behavioural therapy; social skills training; anger management; problem-solving skills; family therapy; school-based programs; and multi-systemic therapy (NICE, 2013). Pharmacological interventions may be considered as an adjunct to psychosocial interventions for some children or young adults with severe symptoms or coexisting conditions that impair their functioning or response to treatment. However, the evidence for the efficacy and safety of medication for ODD and CD is limited and inconclusive (NICE, 2013).

Signs of ODD and CD

ODD is characterized by persistent patterns of defiant, disobedient, provocative or spiteful behaviour that violate age-appropriate social expectations, but do not seriously infringe on the rights of others or break major societal norms (NICE & SCIE, 2013).

CD is more severe and involves repetitive and persistent patterns of antisocial, aggressive or defiant behaviour that amount to significant and persistent violations of the basic rights of others or major age-appropriate societal norms or rules (NICE & SCIE, 2013). CD is more common in older children (11 to 12 years and older) and ODD is more common in those aged 10 years or younger (NICE & SCIE, 2013). Both disorders are more prevalent in boys than girls and have a strong association with socioeconomic disadvantage, maltreatment, family dysfunction and coexisting mental health problems, especially attention deficit hyperactivity disorder (ADHD) (Contact, n.d.; NICE & SCIE, 2013).

Children and young adults with ODD may exhibit behaviours such as general defiance of adults’ wishes, disobedience, angry outbursts with tantrums, physical aggression to other people (especially siblings and peers), destruction of property, arguing, blaming others for things that have gone wrong, and annoying and provoking others (CKS & NICE, 2023).

Children and young adults with CD may display behaviours such as swearing, lying, stealing outside the home, persistent rule-breaking, physical fights, bullying other children, cruelty to animals, setting fires, being cruel to and hurting other people, assault, robbery using force, vandalism, breaking and entering houses, stealing from cars, driving and taking away cars without permission, running away from home, truanting from school, and misusing alcohol and drugs (CKS & NICE, 2023).

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Both disorders require early identification and intervention to prevent negative outcomes in adulthood, such as antisocial personality disorder, criminality, substance misuse and poor mental health (NICE & SCIE, 2013).

Impulse control

Impulse control is the ability to regulate one’s emotions, thoughts, and actions in response to external or internal stimuli. Impulse control disorders are characterized by a failure to resist an impulse, drive, or temptation that is harmful to oneself or others. Some examples of impulse control disorders are kleptomania, pyromania, intermittent explosive disorder, and pathological gambling.

Oppositional defiant disorder (ODD) and conduct disorder (CD) are two types of disruptive behaviour disorders that involve problems with impulse control, albeit in different ways. ODD is defined as “a pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 months” (American Psychiatric Association [APA], 2013, p. 462). CD is defined as “a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated” (APA, 2013, p. 469).

The behaviour of a child or young adult with ODD suggests that they hate being controlled by society or their loved ones. They tend to be defiant, disobedient, provocative, and spiteful towards authority figures. They may also have frequent tantrums, argue with others, blame others for their mistakes, and annoy or provoke others (NICE, 2013).

The behaviour of a child or young adult with CD suggests that they have little regard for the rights, feelings, or welfare of others. They tend to be aggressive, violent, cruel, deceitful, and destructive. They may also engage in antisocial behaviours such as stealing, lying, vandalism, arson, assault, robbery, bullying, cruelty to animals, and running away from home (NICE, 2013).

The relationship between ODD and CD is complex and not fully established. Some researchers consider ODD as a milder form of CD or a precursor to CD. Others view ODD and CD as distinct but overlapping disorders that share some common features but differ in severity and prognosis. According to the DSM-5 (APA, 2013), about 30% of children with ODD develop CD later in life. Conversely, about 50% of children with CD have a history of ODD. Moreover, many children and young adults with ODD or CD have coexisting mental health problems such as attention deficit hyperactivity disorder (ADHD), anxiety disorders, mood disorders, substance use disorders, or personality disorders (APA, 2013; NICE, 2013).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

CKS & NICE. (2023). Conduct disorders in children and young people. Retrieved from https://cks.nice.org.uk/topics/conduct-disorders-in-children-young-people/

Contact. (n.d.). Conduct disorder and oppositional defiant disorder. Retrieved from https://contact.org.uk/conditions/conduct-disorder-and-oppositional-defiant-disorder/

Del Valle P., Kelley S. L., & Seoanes J. E. (2001). The “oppositional defiant” and “conduct disorder” child: A brief review of etiology, assessment, and treatment. Behavioral Development Bulletin, 10(1), 36–41. https://doi.org/10.1037/h0100481

Kimonis E. R., Frick P. J., & McMahon R. J. (2014). Conduct and oppositional defiant disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology, (3rd ed., pp. 145–179). The Guilford Press.

Lahey B. B. (2008). Oppositional defiant disorder, conduct disorder, and juvenile delinquency. In T. P. Beauchaine & S. P. Hinshaw (Eds.), Child and adolescent psychopathology (pp. 335–369). John Wiley & Sons, Inc.

Mash, E. J., & Barkley, R. A. (2014). Child psychopathology (3rd ed.). The Guilford Press.

NICE & SCIE. (2013). Conduct disorders in children and young people: recognition, intervention and management. Retrieved from https://www.nice.org.uk/guidance/cg158/documents/conduct-disorders-in-children-and-young-people-final-scope2

NICE. (2013). Antisocial behaviour and conduct disorders in children and young people: recognition and management [CG158]. https://www.nice.org.uk/guidance/cg158

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