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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.p

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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
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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.p

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.p

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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:p

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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).

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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.

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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) .
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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.

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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.



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.
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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).

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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).

   




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).

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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.

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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)

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.
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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.
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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.

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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.

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