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Am J Psychiatry. Author manuscript; available in PMC 2018 January 11.
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Am J Psychiatry. 2016 November 01; 173(11): 1073–1074. doi:10.1176/appi.ajp.2016.16080971.

The neurobiology of disruptive behavior disorder

R. James R. Blair
Section of Affective and Cognitive Neuroscience, National Institutes of Health, 9000 Rockville
Pike, Bethesda, MD, 20892

Disruptive behavior disorder compromises conduct disorder (CD), defined as the persistent
violation of the rights of others and age-appropriate norms, and oppositional defiant disorder
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(ODD), characterized by angry/irritable mood, argumentative/defiant behavior, or

vindictiveness. CD and ODD are some of most prevalent of child psychiatric disorders. They
confer considerable costs to society and are associated with relatively poor long-term
prognoses. The meta-analytic review published in this issue (1) summarizes the findings of
24 functional magnetic resonance imaging studies of patients with these disorders and
provides useful information regarding their pathophysiology. The authors conducted several
meta-analyses of these studies: one omnibus analysis contrasting youth with disruptive
behavior disorder/conduct problems across all tasks and then several sub-meta-analyses that
examined group differences on tasks grouped according to whether they involved “hot”
executive functioning, “cool” executive function or emotion processing. Core findings of the
omnibus meta-analysis are that, across tasks, youth with disruptive behavior disorder/
conduct problems showed under-activation in rostral and dorsal anterior cingulate and
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medial prefrontal cortex and ventral caudate. However, the sub-meta-analyses revealed that
these results were primarily driven by the “hot” executive function fMRI studies. It is
perhaps worth considering here what “hot” executive functioning is. As the authors point
out, previous work has distinguished between “hot” and “cool” executive functions as
motivationally and emotionally significant tasks versus more abstract tasks (2). However, it
is important to note that almost all of the “hot” executive functioning tasks were
reinforcement-based decision-making tasks (the participant is choosing whether to respond
to objects based on whether their choices are likely to engender reward or punishment).
Indeed, as the authors state, this dysfunction “may be the neural underpinning for evidence
that perturbed reward-based decision making is key to conduct disorder”. The other two sub-
meta-analyses examining the “cool” executive function and emotion processing tasks
respectively both revealed temporal abnormalities with emotion processing tasks also linked
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to consistent under-responsiveness in prefrontal cortex.

This review is important both for identifying consistent regions of dysfunction in patients
with CD/ODD but also by concentrating attention on the neurodevelopmental nature of this

Correspondence: Dr. James Blair, National Institutes of Health, National Institute of Mental Health, Section of Affective and Cognitive
Neuroscience, 9000 Rockville Pike, Building 15k, Room 300-E, MSC 2670, Bethesda, MD, 20814, USA, 301-435-6059 (Tel.),
301-594-9959 (Fax), jamesblair@mail.nih.gov.
Conflict of Interest Statement
The authors declare no competing financial interests.
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disorder. Reviews such as this stress the importance of neurobiology to the early
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development of these pernicious disorders.

It is interesting to consider the current findings in the context of the on-going discussion
about how we should approach the definition of psychiatric disorders. Should they be
considered categorically distinct entities with separable forms of pathophysiology?
Alternatively, should we adopt a more dimensional approach as envisaged by the by the
Research Domain Criteria (RDoC) (3); i.e., should we consider neural systems and their
associated functions and how these, when compromised give rise to specific symptom sets
(i.e., clusters of behaviors that appear to occur together) that may be shared across
disorders? The authors argue that the hot executive function decision-making deficits may be
“key to conduct disorder” potentially implying a more categorical view. But decision-
making deficits, or at least reduced reward responsiveness, are not only seen in CD but also
in several other psychiatric conditions including attention deficit hyperactivity disorder
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(ADHD) and depression (4, 5). As such, we might want to consider these findings from a
RDoC perspective. The difficulty here though is that the symptom sets associated with
reduced reward responsiveness remains unclear. Reduced reward responsiveness has been
linked to impulsiveness in patients with ADHD (4) but anhedonia in patients with depression
(5). Moreover, there are other forms of decision-making deficit that may be more directly
related to the expression of conduct problems. Specifically, in our own work, we find
evidence that the relative inability to recruit regions involved in avoidance behavior as a
function of expected value relates to level of conduct problems (6, 7). In other words, while
healthy youth recruit regions such a dorsomedial frontal and particularly inferior frontal/
anterior insula cortices as they are attempting to avoid a poor choice as a function of how
poor the choice is, youth with conduct problems do this to a significantly reduced extent.
Moreover, the level of their impairment is positively related to their level of conduct
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problems. In short, further work is going to be necessary to identify the symptom sets
associated with specific forms of dysfunction in the neuro-cognitive systems involved in
reward-punishment decision-making and to determine the extent to which these forms of
dysfunction, and associated symptom sets, are seen across disorders.

The cool executive function and emotional processing sub-meta-analyses both revealed
temporal cortex dysfunction in the disruptive/conduct problems group -albeit in different
temporal regions. This is interesting because, as the authors note, structural imaging studies
have relatively consistently identified structural deficits in these regions (8). However, while
these findings, consistent within both structural and functional studies, stress the
neurodevelopmental nature of the disorder, their functional significance remains elusive. The
authors suggest that the temporal lobe dysfunction might reflect attention problems.
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However, it should be noted that regions classically implicated in either top down attention
or endogenous orientation (e.g., frontal and parietal regions) were not seen to be
dysfunctional in the youth with conduct problems in this meta-analysis. One possibility is
that they reflect atypical development within temporal cortex as a secondary consequence of
dysfunction in other structures that more directly incur risk for conduct problem symptom
sets. As such, they would reflect the neuro-developmental nature of the disorder without
incurring a risk for a specific symptom set. Alternatively, or additionally, these forms of

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temporal lobe dysfunction may incur a risk for a specific symptom set that has yet to be
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specified.

The emotional processing task sub-meta-analysis also revealed decreased right dorsolateral
prefrontal activation in the youth with conduct problems. The authors suggest that this
implies that youth with conduct problems show poor frontal top-down cognitive control over
emotion processing. This may be correct. There is an argument that at least some youth with
conduct problems show overly responsive emotional responses that would be consistent with
poor frontal top-down control (9). However, most studies find reduced emotional
responsiveness in youth with conduct problems and it is worth noting that this sub-meta-
analysis also revealed reduced activity in left temporal pole. Reduced temporal pole activity
during emotional processing tasks does not suggest disinhibited responding but rather
reduced responding. Reduced emotional responding is unlikely to reflect reduced top down
control. Importantly, the flow of information between frontal and temporal cortices is not
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one-way but interactive. Activity in dorsolateral prefrontal cortex can be stimulated by

salient visual stimuli represented in more posterior regions (10). As such, it is perhaps more
likely that the decreased right dorsolateral prefrontal activation reflects reduced attention
towards the under-processed emotional features.

In conclusion, this meta-analytic review stresses the neurodevelopmental nature of disruptive

behavior disorder. It strongly suggests that attention to the neuro-cognitive systems
underpinning reward/punishment-based decision-making is critical. Moreover, it reminds us
that, as the field progresses, we concentrate on the functional implications of specific forms
of dysfunction and the incurred risk for specific forms of symptom set.

References
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