CHAPTER
Disruptive, Impulse-Control,
and Conduct Disorders
Judith S. Gonyea and Vaune Kopeck
P layfulness, curiosity, adventurousness, creativity, and
even mischievousness are considered to be typical ele-
ments of human development and personality that are
often viewed positively and encouraged as elements of a ful-
filling life. However, these same characteristics may present a
Stories That Teach: Caregivers and
Films Depicting the Lived Experience
challenge when they are disruptive, uncontrolled, and inter-
fere with an individual’s ability to learn and comply with the
“rules” of the culture, community, family, and all the related
spaces that he or she occupies. When such characteristics
lead to behaviors that are potentially harmful to individu-
als and/or those around them and interfere with daily func-
tion, these individuals may be diagnosed with disruptive,
impulse-control, or conduct disorders.
This chapter specifically addresses the disorders that
reflect functional difficulty with self-control of ­ emotions
and behaviors that conflict with social norms or “­conduct,”
including ­
­ disruptive, impulse-control, and c­ onduct
disorders—all of which fall under the category of disrup-
tive behavior ­ disorder. These conditions include: oppo-
sitional ­ defiant  ­
disorder  (ODD), intermittent explosive
disorder,  ­ conduct disorder, antisocial personality disor-
der, ­pyromania, and kleptomania. Importantly, disruptive
­behavior disorders are frequently comorbid; that is, an indi-
vidual may have more than one diagnosis within the category.
Of note, attention deficit-hyperactivity disorder (ADHD)
was included with disruptive disorders in the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV); however, it is included with the neurodevelop-
mental disorders in DSM-5 (American Psychiatric Associa-
tion, 2013, pp. 15–16). Readers may benefit from referring to
Chapter 9: Attention Deficit-­Hyperactivity Disorder to com-
pare and contrast characteristics of these diagnoses.  severe behavioral disorder. A “lived experience” view
Once a diagnosis is made and intervention begins, occu-
pational therapy practitioners can play a key role in influ-
encing decisions regarding the management of disruptive,
impulse-control, and conduct disorders for individuals, their
families, and the systems within which they receive services.
Occupational therapists’ knowledge of the components
of function and the environment can help individuals and
families create options to manage reactivity, impulsivity, and
resistant behavior, giving each individual opportunities to
succeed in his or her own way. This can make the difference
between an individual’s exclusion from or conflict during
typical daily activities and his or her ability to fully partici-
pate in a functional daily routine.
10_Brown_Ch10.indd 143
10
Caregiving for a child with a behavioral disorder cre-
ates ongoing challenges and an unpredictable life course
for families. What might seem normal and routine one
day can become a source of chaos the next. High-level
emotions and hidden agendas fuel mistrust and fear
during the same developmental periods when stability
and consistency are thought to be foundations for the
development of healthy adults. Love and empathy are
constantly challenged as the parameters of “good behav-
ior” are stretched or broken. Families, educators, and
health-care professionals are challenged to embrace a
positive view of the future.
The movie The Good Son is an accurate depiction
of behaviors that many children and adolescents who
meet criteria for a disruptive behavior disorder display;
however, not all children display these behaviors with
the same intensity in which Henry displays them in the
movie. Although some of the children who display these
impulsive, aggressive, and dangerous behaviors meet
criteria for antisocial personality disorder when they
turn age 18, not all do. These children can respond pos-
itively to treatment with a multidisciplinary approach
which increases their ability to function productively in
their desired occupations.
No Letting Go (2015) and its short version partner
Illness (2013) were written and produced in collabora-
tion with Randi Silverman, a mother who has personally
experienced the challenges of living with a child with a
may provide the most realistic window into the needs
of individuals and families who are experiencing a be-
havioral disorder. In this film, the suggested diagnosis
is bipolar disorder, though the behaviors and challenges
faced by the family and others are certainly in line with
those faced across the spectrum of behavioral disorders
as well.
Although documentaries help us understand the ex-
periences and challenges of behavioral conditions, the
view developed via a feature length film helps viewers
step into the lives of those faced with these difficult
challenges. Scenes depicting a residential treatment
143
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 144 PART 2   ■  The Person
environment and counseling sessions help provide a
more realistic view of the intertwined emotions and
issues that behavioral uncertainty brings to both the
youth and those around them. Organizations such as
Parent to Parent and The Youth Mental Health Project
have embraced films such as No Letting Go as conversa-
tion starters around the topic of youth and family men-
tal health.
Disney Pixar’s Inside Out (2015) takes a more
child-oriented and holistic view of extreme behavior
with animation-enhanced positive outcomes. This film
can create talking points for younger children and fam-
ilies about a variety of behavioral and emotional chal-
lenges. Issues such as bullying, destruction of property,
and rage can all be highlighted via the animator’s lens.
Occupational therapy practitioners can play a vital
role in the management and treatment of behavioral
disorders by gaining a holistic view of their effects on
occupational performance. Films such as those men-
tioned can aid in this process when reflected upon
through an occupational lens. Occupational therapy
can also play an important advocacy role by sharing sto-
ries of success and supporting those who face the chal-
lenges of disruptive behavior disorders.
Description of the Conditions
The fifth edition of the DSM (DSM-5; American Psychiat-
ric Association, 2013) resulted in the reorganization of sev-
eral diagnostic categories, and this chapter is reflective of
one such revision. Specific diagnostic criteria are provided
in the text that follows for the following specific disruptive,
impulse-control, and conduct disorders:
■■ Oppositional defiant disorder (ODD)
■■ Intermittent explosive disorder
■■ Conduct disorder
■■ Antisocial personality disorder
■■ Pyromania
■■ Kleptomania
Because diagnoses provide a gateway to specific interven-
tions, therapy practitioners need to be aware of how specific
conditions are viewed and managed, both medically and be-
haviorally, within their system and the systems into which
these individuals may be discharged. Clinicians should take
care not to view all individuals with any diagnosis in the same
way. Evaluating an individual’s presentation and behaviors,
rather than strictly applying a diagnostic criteria perspective,
is critical when assessing an individual’s role performance.
For example, not all individuals with a conduct disorder di-
agnosis present with the same behaviors and difficulties with
function.
Although the formal diagnostic criteria identify the
associated behaviors, intensity, and type, the impact on
function will be specific to each individual. Interven-
tion strategies should be individualized and designed to
increase the individual’s level of function in performing
valued occupational roles. This approach will enable occu-
pational therapy practitioners to better prepare these indi-
viduals for the occupational demands and expectations of
their environments.
10_Brown_Ch10.indd 144
Oppositional Defiant Disorder
To meet the criteria for ODD, an individual must display a
pattern of defiance lasting at least 6 months as evidenced by
at least four symptoms from the categories of angry/irritable
mood (e.g., is often touchy or easily annoyed), ­argumentative/
defiant behavior (e.g., often actively defies or refuses to com-
ply with requests from authority figures or with rules), and
vindictiveness (e.g., spitefulness). These symptoms must be
exhibited during an interaction with at least one individual
who is not a sibling (APA, 2013, pp. 219–220).
According to the DSM-5, the persistence and frequency of
these behaviors can differentiate between a behavior that is
within normal limits and one that is symptomatic. For chil-
dren under age 5, these behaviors should last for 6 months
and occur on most days. For individuals older than 5, the
behaviors should last for the duration of at least 6 months
and occur at least one time per week. An individual’s devel-
opmental level, gender, and culture should be considered
while determining whether the frequency and duration are
outside a normative range.
Intermittent Explosive Disorder
According to the DSM-5, intermittent explosive disorder is
characterized by recurrent behavioral outbursts that represent
a failure to control aggressive impulses. The disorder is man-
ifested by verbal aggression (e.g., temper tantrums, tirades,
verbal arguments, or fights) or physical aggression toward
property, animals, or other individuals. To meet diagnostic
criteria, these behavior outbursts must occur twice weekly,
on average, for a period of 3 months. Or, the individual must
have three behavioral outbursts involving damage of property
and/or physical assault involving physical injury against ani-
mals or other individuals within a 12-month period.
The magnitude of the individual’s recurrent outbursts
must be grossly out of proportion to the provocation or to
any precipitating psychosocial stressors. They must not be
premeditated or committed to achieve a tangible objective,
such as money, power, or intimidation. The outbursts must
cause the individual marked distress or impairment in occu-
pational or interpersonal functioning, or there must be asso-
ciated financial or legal consequences. Individuals diagnosed
with intermittent explosive disorder must be at least 6 years
of age or at an equivalent developmental level. For children
ages 6 to 18, aggressive behaviors associated with an adjust-
ment disorder should not be considered for this diagnosis
(APA, 2013, p. 221).
Conduct Disorder
Conduct disorder is characterized by longstanding behavior
that violates the rights of others and of social norms. Chil-
dren and adolescents with conduct disorder typically have
little remorse for their behavior (APA, 2013). The symptoms
of conduct disorder fall into four categories:
1. Aggression to people and animals (e.g., often initiates
physical fights or has been physically cruel to animals)
2. Destruction of property (e.g., has deliberately engaged
in fire setting with the intention of causing serious
damage)
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 CHAPTER 10  ■  Disruptive, Impulse-Control, and Conduct Disorders 145
3. Deceitfulness or theft (e.g., has stolen items of nontriv-
ial value without confronting a victim or shoplifting
without breaking and entering)
4. Serious violations of rules (e.g., is often truant from
school, beginning before age 13 years)
To be diagnosed with conduct disorder, the disturbance in
the individual’s behavior must cause clinically significant im-
pairment in social, academic, and/or occupational function-
ing. If the individual considered for this diagnosis is 18 years
of age or older, he or she must not meet criteria for the diag-
nosis of antisocial personality disorder (APA, 2013, p. 222).
Antisocial Personality Disorder
Antisocial personality disorder falls under the broader cat-
egory of Personality Disorders in the DSM-5. The diagnosis
of antisocial personality disorder is only given to individu-
als 18 years of age and older and only if there is a history of
symptoms of conduct disorder before age 15. Characteris-
tics for this disorder include a pervasive pattern of disregard
for and violation of the rights of others. An individual must
display three or more of seven specified behaviors, such as
failure to conform to social norms with respect to lawful be-
haviors, deceitfulness, irritability and aggressiveness, reck-
less disregard for safety of self or others, and lack of remorse.
Pyromania
Pyromania is an impulse-control disorder that involves de-
liberate and purposeful fire-setting on more than one oc-
casion (APA, 2013). The individual experiences tension or
arousal before the act of fire-setting and a sense of relief or
pleasure in the fire’s aftermath. Individuals with pyromania
have an intense fascination with fire.
Fire-setting is a dangerous and challenging behavior to
manage, but it is not always predictive of later diagnosis of
pyromania. Children and adolescents, in particular, may
experiment or use fire-setting as a challenge to authority, but
are not fixated on the fire itself or its outcomes (Bowling &
Omar, 2014). When diagnosed, in occupational terms, this
may be noted as an extreme “preoccupation” with fire that
interferes with other occupations. Pyromania is associated
with other types of impulsive behavior including alcohol and
marijuana use disorders and conduct disorder, as well as his-
tories of trauma (Huff, 2014; Vaughn et al, 2010).
Kleptomania
Kleptomania is an impulse disorder that is associated with
tension or anxiety that is relieved by stealing. The stolen ob-
jects are not needed for personal use or for their monetary
value, the stealing is not committed to express anger or ven-
geance and is not in response to a delusion or a hallucination,
and the stealing is not better explained by another disorder.
Kleptomania, which is a relatively rare disorder, needs
to be differentiated from patterns of stealing or shoplifting
that are relatively common behaviors among those of all ages
(Schreiber, Odlaug, & Grant, 2011). Kleptomania has been
diagnosed and treated in children (Yilmaz & Bilgic, 2014) as
well as adults across cultures with some promising outcomes
(Christianini et al, 2015).
10_Brown_Ch10.indd 145
Etiology
Research efforts continue to investigate factors that influence
the development and age of onset of disruptive behavior
disorders. Because these conditions are often accompanied
by other psychiatric diagnoses, such as ADHD and fetal al-
cohol syndrome (FAS), it is sometimes difficult to specify a
causative factor (Centers for Disease Control and Prevention
[CDC], 2013).
Genetics and parenting have been identified as factors that
influence the development of disruptive disorders. Alemany,
Rijsdijk, Haworth, Fananas, and Plomin (2013) looked at
genetic associations through the study of twin pairs. Parental
negativity and the evolution of behavior problems were ana-
lyzed, noting a high influence of heredity at age 4 years with a
slight reduction of influence by age 12 years, when common
environmental influence was more strongly factored in. Par-
ent and colleagues (2011) found that “harsh discipline was
related to disruptive behavior of both boys and girls, whereas
only permissive discipline was related to disruptive behavior
of boys” (p. 531). Corporal punishment (Evans, Simons, &
Simons, 2012) has been linked in male adolescents to con-
duct problems, including problems with self-control and a
“hostile view” of relationships for both males and females.
Verbal abuse is noted to create anger and a “hostile view” in
both males and females.
Environmental factors that have been shown to influence
the emergence and diagnosis of disruptive behaviors include
classroom atmosphere and management (Bean, 2013; Sayal,
Washbrook, & Propper, 2015) and a history of trauma, mal-
treatment, and neglect (Zelechoski, Sharma, Beserra, Miguel,
DeMarco, & Spinazzola, 2013). An Icelandic study noted
that for girls, consumption of excessive amounts of caffeine
(e.g., sports drinks) has been linked to both “violent b
­ ehaviors
and conduct disorders” (Kristjansson, ­Sigfusdottir, Frost, &
James, 2013). Unhealthy sleep patterns may also contribute
to or exacerbate patterns of oppositional defiance and other
conduct problems among adolescents (Lin & Yi, 2015).
Some researchers suggest that a lack of early intervention
for childhood problem behaviors may lead to the presence of
more severe disorders, such as conduct disorder in adoles-
cence and psychopathology in adulthood (Brent & Loeber,
2015; Copeland, Miller-Johnson, Keeler, Angold, & Costello,
2007; Dodge et al, 2015).
Ongoing neurological research suggests low responsivity
in the amygdala is an underlying factor in the development
of disruptive behavior disorders (Bertocci et  al, 2014; Fin-
ger et  al, 2011; White et  al, 2012). Reduced “connectivity”
between the amygdala and the prefrontal cortex is believed
to influence the effectiveness of “automatic” emotional reg-
ulation and subsequent behaviors (Bertocci et al, 2014). The
individual may subsequently react before he or she can effec-
tively assess a situation that triggers an emotional response.
Discovering underlying factors that influence behavioral reg-
ulation may provide more insight regarding intervention and
the potential progression of behavioral challenges through
time (­Bertocci et al, 2014). Similarly, Larson and colleagues
(2013) noted that adults diagnosed with psychopathology
may become so fixated or “goal directed” that they are unre-
sponsive to environmental cues that would typically come
from the amygdala to the prefrontal cortex, including those
that evoke fear or startle.
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 146 PART 2   ■  The Person
The Lived Experience
Note: This lived experience is presented in the form of an interview
with the occupational therapist. It also includes a poem by Curtis.
Curtis is an 18-year-old biracial male who has had significant
involvement with the juvenile detention system. Curtis cur-
rently attends 12th grade in a residential treatment facility for
adolescents, where he is working diligently to utilize treatment
to overcome challenges in his life in order to obtain his high
school diploma and pursue his career goals in forensic science.
Target behaviors being addressed in treatment include
property destruction, aggression, suicidal ideation with history
of attempts, self-injurious behaviors (e.g., cutting and poor
impulse control), and familial problems.
Curtis’s involvement with the juvenile services department
is a result of first- and second-degree assault charges, malicious
destruction of more than $1,000 of property, and false statements
to a police officer. Curtis lives in a single-parent household.
When Curtis was 4 years old, his father assaulted his mother
severely, resulting in a traumatic brain injury. Curtis has been
the primary caretaker for his mother since he was a child. It has
been reported that Curtis robbed and stole from others in order
to care for his family and provide for the household.
Q: If someone were trying to get to know you, how would you
describe yourself?
A: I am an outgoing person who likes to meet new people and
take on new challenges in life. I try to strive to do my best. My
biggest interest is sports. I am also good at technology and
school. My main goal is to make the right decisions in life and
better myself every day as a person. My goal is to be a better
man than I was yesterday. That would mean self-improvement
and to try to be a better person as much as you can. I would
like to be better at controlling my anger and defiance, my tone
of voice, and respect level with people I speak with. I would like
to gain skills that will help me maintain my composure. Some
of the triggers to my negative behaviors are disrespect toward
females, people being aggressive, and people calling me names.
My roles in life are mediator, son, and brother. I am a m
­ ediator
because I am always the person who tries to calm the situation
down and make everybody see the positive inside a situation
and why it shouldn’t be a problem. I am a brother, I have two
sisters. Being a son to my mom and a positive family member is
a very important role. I am a caretaker for my mom. My mom
is disabled. She can still perform normal functions but she does
not process information the way the rest of us do, so she can’t
do everything at the house by herself. I try to step up and be
the man of the house, take care of her, get groceries, cook
dinner, and make sure the house is clean. Being my mother’s
caretaker has affected the way I react to things and how I go
about life. I had to grow up at a young age and didn’t have as
much chance to have a childhood.
Q: What does a typical day look like for you?
A: On a school day I wake up early, shower, do personal hygiene,
get dressed, then try to plan how my day is going to go before
I actually start the day. I take public transportation to school.
When I get to school I try to avoid distractions and go to my
classes. After school I either play basketball, volunteer at the rec.
10_Brown_Ch10.indd 146
center, or hang out with my friends and play the game system.
On a weekend I wake up, take a shower, eat breakfast, and see
what my mom, sisters, or nephews have planned. If they have
plans I join up with them; if not, I hang out with my friends.
We have social time; go to the rec. center, play basketball, play
football, or go to the mall.
Q: What is your community like?
A: I don’t live in a really bad neighborhood but it can be violent
sometimes. For the most part my neighborhood is quiet without
much going down.
Q: Has the environment that you live in either negatively or
positively impacted your ability to reach your goals?
A: I believe that it has negatively impacted my goals because the
people I tend to surround myself with in the community have
stopped me from going to get my education and doing right.
Q: Do you see any barriers that could be in the way of you
pursuing your goals?
A: My mother’s health because I plan on taking care of her until
the day she dies. If she is not in good health then she is going
to be my main focus. This may prevent me from pursuing my
career and do the things I want to do if my mother is not OK. I
have committed some criminal acts in the past but that is behind
me now. People tend to look at me wrong. Like in high school
they automatically assume that I am going to do something
wrong. If I try to apply for a job they may think they can’t trust
me because of the decisions I made when I was 14.
Q: Are there any supports that you feel you will need to accom-
plish your goals?
A: People need to provide me with motivation; I like to get a pat
on the back. You should always do the right thing but the extra
pat on the back, the extra push motivates people and it helps
you feel like you just helped someone or influenced someone
in a positive way. I use my nephews a lot as motivation. My
family and my community keep telling me to stay on the right
track for doing the right thing. I want to do the right thing to
prove people wrong and show them I am not the person I was.
People shouldn’t judge just because a person messed up when
they were younger. People change.
Q: Is there anything else you would like people to know about you?
A: I come from a broken home. I didn’t really have a father there
much and when he was there he wasn’t a positive role model in
my life and wasn’t a good person. So, for me to actually come
as far as I did and be the person I am today, I’m actually proud
of myself. I’ve been through a lot of struggles and seen a lot
of negative things. I haven’t really made a lot of good choices
in my life but I feel like now I’m ready to take on my life and
actually be a positive person and make my life better. I came a
really long way and lately I’ve been doing really well and have
changed into a positive person.
In Curtis’s Words
When things look down, look up
I came a long way from broken homes and rainy days,
no father, and mom had a lot of bills to pay.
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 CHAPTER 10  ■  Disruptive, Impulse-Control, and Conduct Disorders 147
The Lived Experience—cont’d
But she can’t, she’s disabled, no job or money for the rent,
We barely got by off the checks from the government.
I had to grow up quick, be the man my father wasn’t,
my mom trying to get her mind back, so she was busy strugglin’.
I had to provide for my family while I was still a youngin’,
broke the law to eat, had to commit a lot of crimes.
It’s a real deep feelin’ when you see your best friend die,
felt like I was at war, death lookin’ me in the eyes.
I was almost in the ground, thank the lord I survived.
It’s when I went to jail I knew I had to change my fate,
I wanted to see my mom proud when I looked her in the face.
But when I came home, people labeled me with names,
Prevalence
The CDC (2013) reflected data from the National School
Child Health Survey (NCHS) indicating that, by parent
report, 4.6% of children aged 3 to 17 years had a history
of a behavioral or conduct problem such as ODD or con-
duct disorder, and an estimated 3.5% of children had a
current behavioral or conduct problem. This is in addition
to data reflecting the presence of ADHD, which is often
co-occurring.
Conduct disorder, often co-occurring with ADHD, has
been strongly linked to substance use disorders in adulthood
(Sung, Erkanli, & Costello, 2014). Conduct disorder is conse-
quently well represented within the prison population, often
in combination with other disorders including substance
abuse disorder. A meta-analysis by Young et al (2015) noted
the prevalence of combined ADHD and conduct disorder in
prisons for those younger than 18 at 61%, and for those older
than 18 at 29%.
Gender Considerations
The CDC (2013) indicates that the prevalence of conduct
disorders among males is twice that of females, with rates
of diagnosis increasing with age. Most of the disruptive be-
haviors are more prevalent in males than females, with the
exception of ODD, which is equally common in adolescent
girls and boys (APA, 2013). However, the ways in which
disruptive behavior manifest itself appear to differ between
genders. A longitudinal study of the aggressive-disruptive
behavior trajectory looked at “early starter” data for females
and males collected annually from grades 1 to 5 and at life
outcomes at ages 19 to 20 (Bradshaw, Schaeffer, Petras, &
­Ialongo, 2010). Several trajectories were noted. Three female
trajectories were “chronic high aggressive-disruptive be-
havior,” “low moderate aggressive-disruptive behavior,” and
“low aggressive-disruptive behavior.” Three male trajectories
were “chronic high aggressive-disruptive behavior,” “increas-
ing aggressive-disruptive behavior,” and “low aggressive-­
disruptive behavior” (p. 959). Risk of criminal or life-altering
behavior exists to varying degrees across all these cohorts.
10_Brown_Ch10.indd 147
A threat to my community, they said I wasn’t safe.
It was really time to change and be a better man,
than that busy sperm donor people call my dad.
I’ve been working really hard to not be defined by my past,
I want a life worth living, is that too much to ask?
The moral of the story is you should never give up,
I’ve been thru the worst and I still look up.
If I can come this far and still make a change,
Then any one of you can change any day.
Just always think positive and look for a meaning,
Because every one of you is on this earth for a reason.
Some females may demonstrate less “externalizing” of
aggression, such as striking out physically or verbally at
others, than male counterparts. Females therefore may be
less likely to have a diagnosis of conduct problems; how-
ever, the trajectory of “internalized” aggressive feelings in
females may be more extreme. A study of detained females
in the ­Netherlands indicated that female adolescents, who
identify aggressive or violent feelings but typically don’t act
upon them or turn their aggression inward, may demonstrate
stronger outward aggression or violence in early adulthood
(Krabbendam et al, 2014).
Cultural Considerations
Cultural differences from community to nation can influence
the perception of these strongly behaviorally based disorders.
This difference was noted in a study of African American boys
and girls from lower-income families who showed a greater
tendency for earlier onset of conduct disorder (­ Kilgore,
­Snyder, & Lentz, 2000) when compared with their Caucasian
counterparts. African American boys are “2.28 times more
likely” to be placed in special education for behavioral con-
cerns and that these “externalizing behaviors” are often linked
to decreased neighborhood safety (Barrett & Katsiyannis,
2015; Bean, 2013). Consequently, African American boys are
at greater risk for later incarceration (Vaughn et al, 2008).
Identification of disorders may be culturally referenced,
and therapists working with international or multicul-
tural populations should consider these regionally or cul-
turally specific beliefs and expectations. Among Latinos,
impulse-control disorder, conduct disorder, and intermittent
explosive disorder were associated with homelessness and
may be reflective of reduced social networks because of these
unacceptable acting-out behaviors (Oh & DeVylder, 2014). In
contrast, the same study noted that Asians were more likely
to be taken into family members’ homes and less likely to dis-
close problems with behavior until they are at a more severe
stage (Oh & DeVylder, 2014).
In the Virgin Islands (Dudley-Grant, 2001), treatment for
conduct disorder and other similar disorders continues to
emerge as this culture becomes increasingly influenced by
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 148 PART 2   ■  The Person
E vid en ce- B a sed Pra ct i ce
D isruptive behaviors can be a reaction to environmental
stressors. Individuals from racial minority groups experi-
ence unique stressors related to racial discrimination. Martin
and colleagues (2011) sought to better understand the over-
representation of black American youth in the criminal justice
system. They found that 80% of black youth experienced
some form of discrimination by age 13 and that many individ-
uals also regularly experienced discrimination. In addition, the
researchers found a relationship between perceived personal
discrimination and delinquency.
■■ Efforts to reduce racial discrimination have the potential to
prevent criminal behavior.
■■ Occupational therapy practitioners are often present in
school settings, one of the places where discrimination
­frequently occurs.
■■ Occupational therapy practitioners working with children
and youth should include efforts to reduce discrimination
within their practice settings.
Martin, M. J., McCarthy, B., Conger, R. D., Gibbons, F. X., Simons, R. L.,
Cutrona, C. E., & Brody, G. Ho. (2011). The enduring significance of
racism: Discrimination and delinquency among Black American Youth.
Journal of Research in Adolescence, 21, 662–676.
Western beliefs and practices. Its predominantly black cul-
ture has historically created its own more inclusive standards
for family relationships that are less influenced by white or
European standards.
In the United States, blended communities may c­reate
challenges when culturally referenced behaviors are
“­evaluated” by educators or health-care providers from
­different cultural backgrounds. Concerns have focused on
racial/ethnic differences among teachers and students as
potential factors in the higher rate of special education place-
ment. Analysis of the Nurse-Family Partnership data (Bean,
2013) indicated that externalizing behaviors may be similarly
identified by same race/ethnicity teachers; however, the dis-
proportionate placement into special education still provides
a reason for concern regarding potential cultural influences
or bias (Bean, 2013).
Course
Disruptive behavior disorders are diagnosed in children
and adolescents, although their characteristics may be rec-
ognized within the adult population and then diagnosed as
antisocial personality disorder. Research into their charac-
teristics in the latter life stage continues to emerge (Sung
et al, 2014).
In childhood and early adolescence it is more common
to see nonphysically aggressive behaviors such as steal-
ing and vandalism (Lacourse et  al, 2010). At this point in
time, preventive interventions are likely to be most effec-
tive. Most individuals with conduct disorder do not go on
to develop antisocial personality disorder in adulthood; for
these individuals, the disruptive behavior is limited to ado-
lescence (Black, 2015). On the other hand, for individuals
10_Brown_Ch10.indd 148
with severe and multiple symptoms of conduct disorder,
there is a greater likelihood the condition will result in a
long-term ­deviant and criminal lifestyle. Once diagnosed
with ­antisocial ­personality disorder in adulthood, the condi-
tion is generally considered chronic and treatment resistant,
although ­behaviors tend to moderate with advanced age.
Understanding the course of disruptive behavior disor-
ders is important to occupational therapy practitioners, who
are often involved with children and adolescents throughout
their academic careers. Early prevention focusing on life-stage
transitions may result in better long-term outcomes.
Impact on Occupational
Performance
Each developmental stage and life transition presents a new
challenge to the individual with a disruptive, impulse-control,
or conduct disorder. Behavioral ­management strategies are
complex and often require situational adjustment as the
individual faces changes across environments. Changes in
body systems related to development (e.g., puberty, adult-
hood, aging, and menopause), weight gain/loss, and illness
can influence the effectiveness of medications and require
the individual to seek medical attention. Changing life
roles may require skills that are not well developed within
the individual’s current self-management plan. Early iden-
tification of these changes can prevent a crisis or need for
hospitalization.
Individuals with disorders that are manifested through
anxiety, aggression, or distress when their sense of control
is threatened (e.g., conduct disorder and ODD) may find
themselves unable to follow protocols in the classroom or
workplace, such as arriving on time or taking directions
from others. This may restrict their ability to adjust to a new
classroom as a child, or to a new workplace or job type as
an adult. Research is exploring the association between these
disorders and poor academic outcomes, with subsequent
concerns for employability (Sayal et al, 2015).
Similarly, difficulty following societal rules can result in
ongoing legal issues that may ultimately lead to incarcera-
tion. In each case, the ability to assess future environments,
plan ahead, and develop coping and/or self-management
strategies is the key to success. Adult services may further
emerge as research follows younger individuals diagnosed
with disruptive, impulse-control, and conduct disorders into
adulthood and maturity. Understanding the complex and
often comorbid effects of these conditions will better prepare
occupational therapy practitioners to address occupational
challenges.
Activities of Daily Living and
Instrumental Activities of Daily Living
The individual with impulsivity and disruptive/conduct
challenges may focus little to no attention on self-care and
day-to-day activities. Impulsivity, irritability, or fixation
on social or emotional agendas make accessing and di-
recting higher level executive processing an ongoing chal-
lenge. Sleep habits and routines may be erratic, with the
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 CHAPTER 10  ■  Disruptive, Impulse-Control, and Conduct Disorders 149
resulting sleep deprivation and fatigue enhancing prob-
lems with cognition, conduct/irritability, and overall daily
­performance (Lin & Yi, 2015). Comorbid substance abuse
and/or self-medication, including caffeine dependency,
may further influence mood, increase irritability, and
­facilitate violence among both adolescents and young adults
(­Kristjansson et al, 2013).
For children and adolescents, a difficult home life and/or
harsh parenting may influence performance of ADLs/IADLs
through the influence of corporal punishment and/or emo-
tional abuse (Evans et al, 2012). Hygiene, self-maintenance,
and care of others in adult life may all be compromised as
the individual struggles to focus, identify daily needs and
demands, and prioritize according to societal expectations.
Academics and Employment
Academic and work environments are filled with unpredict-
able situations and expectations that may trigger a reactive
sensory state within individuals with impulsivity/conduct
related challenges. Without ongoing support and develop-
ment of self-management strategies, these individuals may
see their ability to participate in desired occupations re-
stricted or prohibited.
Social and sensory strategies including awareness of high-
risk environments may enable individuals with d ­ isruptive,
impulse-control, and conduct disorders to analyze their
environment, self-monitor, and effectively participate in
both academic and work settings.
Role of Occupational Therapy
The disruptive behavior disorders are often perceived as con-
ditions that affect others more than the individual with the
diagnosis. However, disruptive behaviors are a reaction to
some challenge faced by the individual. Occupational ther-
apy practitioners are uniquely qualified to assess the impact
of cognitive, sensory processing, and emotion regulation
concerns as they relate to behaviors that others view as prob-
lematic. Interventions can then target these concerns and, in
doing so, will often allay the difficult behavior.
For example, children and adolescents with sensory
­processing issues expressed as tactile defensiveness may act
out in violent ways when they feel that their personal space
is compromised. When the individual is able to recognize the
trigger, he or she can employ strategies to address the con-
cern. Chapters 20, 22, and 25 in the text on cognition, sensory
processing, and emotion regulation provide more detailed
information about occupational therapy intervention.  ­Department of Health and Human Services, 2011). Mandates
In addition, individuals with disruptive behavior dis-
orders may lack important skills to succeed in social
relationships, school, and work. Many times their disrup-
tive behavior excludes them from participation in typi-
cal activities (e.g., spending the night at a friend’s house,
being a member of a sports team), thereby resulting in a
lack of opportunity to experience typical developmental
milestones. Chapters 26, 51, and 52 in the text on com-
munication, education, and work, provide more detailed
information about occupational therapy interventions that
promote participation.  interventions work for aggressive behaviors, it is when the
10_Brown_Ch10.indd 149
Evi de nce -Base d Pr ac tic e
A systematic review and meta-analysis of parent manage-
ment training found consistently positive findings in
reducing disruptive behaviors (Michelson et al, 2013). This
review has greater external validity because it included in-
terventions that were tested in real world practice settings.
Twenty-eight randomized controlled trials were included in the
review and most of the interventions used a group format and
homework.
■■ Occupational therapy practitioners often use parent train-
ing as a component of intervention when working with
children and youth. This research supports parent training.
■■ Occupational therapy practitioners are less likely to use a
group approach for parent training, but this study suggests
that they should consider the benefits of providing inter-
vention to groups of parents and incorporating homework
in that training.
Michelson, D., Davenport, C., Dretzke, J., Barlow, J., & Day, C. (2013).
Do evidence based interventions work when tested in the “real world?”
A systematic review and meta-analysis of parent management training
for the treatment of childhood disruptive behavior. Clinical Child and
Family Psychological Review, 16, 18.
Intervention
Table 10-1 outlines common intervention approaches for
individuals with disruptive behavior disorders and identifies
the accompanying chapters in this text that provide more de-
tailed information about those approaches. 
Medications
The growing body of knowledge and research regarding
medications, indications, and contraindications makes the
use of medications to treat disruptive, impulse-control, and
conduct disorders a complex process. Conflicting adminis-
tration guidelines, based upon age and the conditions being
addressed, as well as concerns regarding potential side effects
of medications mandate careful selection and monitoring of
each medication. Concern regarding proper dosage and re-
porting of side effects is ongoing, as many of the individu-
als receiving medication for these disorders are children of
varied ages with a mixed presentation of signs and symp-
toms. Federal guidelines mandate that drug manufacturers
issue more specific information about medication use (U. S.
such as these help to ensure that prescription guidelines are
geared toward the populations they are meant to address.
The use of medication is often intended to help control
problematic behaviors and to enable the individual to better
participate in related therapies and to engage in necessary
activities of daily living. Physicians are faced with challeng-
ing decisions and need to work closely with treatment teams
to provide comprehensive, multimodal intervention. In some
cases, medication may be secondary to other interventions.
Dr. Drew Pate, MD, notes that, “generally, if pharmacologic
11/12/18 12:04 pm
 150 PART 2   ■  The Person

TABLE 10-1 Common Intervention Approaches for Disruptive Behavior Disorders

Approach
Anger Management
Cognitive Orientation to Daily
Occupational Performance
(COOP)
Dunn Model of Sensory
Processing
Zones of Regulation and Alert
Program
Sensory Rooms
Mindfulness
Re-entry programs
Whole School Mental
Health Promotion (including
Comfortable Cafeteria and
Refreshing Recess)
Target(s) of Intervention
Unpleasant emotions
Problem-solving in the context
of occupational performance
Sensory processing needs in
the context of occupational
performance
Develop self-regulation
strategies for managing states
of alertness
Providing sensory input that is
calming
Enhancing emotional well-being
Independent living and
adaptive coping
Academic achievement and
social participation
Chapters With
Brief Synopsis Additional Information
Developing alternative methods for Chapter 25: Emotion
managing emotions.
A four-step strategy of goal, plan, do, Chapter 20: Cognition
check is taught to help the individual
problem-solve a particular occupational goal.
Creating environments or material that meet Chapter 22: Sensory
the individual’s sensory processing needs. Processing
Programs provide systems to help individuals Chapter 22: Sensory
identify state of alertness so that they can Processing
apply strategies to achieve desired level of
alertness.
In treatment settings a room is created that Chapter 22: Sensory
contains calming sensory input. Individuals Processing
can use the room whenever they feel
agitated, angry, or frustrated.
Therapist teaches a form of meditation that Chapter 25: Emotion
focuses awareness nonjudgmentally on the
present.
Skills training for independent living and Chapter 39: Mental Health
development of coping skills to promote Practice in Criminal Justice
successful reintegration from the criminal Systems
justice system to community living.
Creating environments that promote Chapter 50: Occupational
interaction between all children and support Therapy’s Role in School
well-being of all students. Mental Health

aggression is occurring in the context of another disorder
such as autism or a mood disorder. If a kid has conduct dis-
order or ODD that is not in the context of another diagnosis
then the traditional therapeutic interventions are behavioral
programs and parent training or multi-systemic family ther-
apy” (personal communication, March 25, 2015).
The medications most frequently noted for use with
disruptive disorders include antipsychotics, lithium, and
anticonvulsants (Pringsheim, Hirsch, Gardner, & Gorman,
2015) (a&b). The use of neuroleptics, specifically risperidone
(Risperdal), is often used in the presence of other medica-
tions for associated disorders, including ADHD or mood
disorder (Findling, Aman, Eerdekens, Derivan, & Lyons,
2004; Ozsarfati & Koren, 2015; Reyes, Buitelaar, Toren,
Augustyns, & Eerdekens, 2014).
Of particular concern to occupational therapy practi-
tioners working with these populations is the ways in which
the effects and side effects of medication influence occupa-
tional engagement and quality of life. For example, ­olanzapine
(Zyprexa) has shown promise for comorbid ADHD and dis-
ruptive behavior disorder in adolescents, but the excessive
weight gain associated with the medication may make it chal-
lenging for long-term use (Holzer, Lopes, & Lehman, 2013).
Similarly, quetiapine (Seroquel) and risperidone (Risperdal)
have shown promise in the treatment of comorbid bipolar II
disorder and conduct disorder, but increased body mass was
also noted as a long-term concern (Masi, Milone, Stawinoga
Veltri, & Pisano, 2015). In situations where a medication or
its side effect changes the ability of an individual to engage
in occupation, the occupational therapy practitioner should
share these findings with the treatment team and provide
appropriate recommendations.
Here’s the Point
■■ Individuals with disruptive behavior disorders require
specialized evaluation and management to handle the
demands of community, work, and educational settings.
■■ The additional challenges that individuals with disruptive
behavior disorders face, although not insurmountable,
require specialized evaluation and management.
■■ When unmanaged, these disorders can lead to dysfunc-
tion that endures throughout a lifetime, restricting free-
dom, work, interpersonal relationships, and engagement
in the most meaningful occupations.
■■ An individual must not only understand the expected
behaviors and attitudes required, but also manage his or
her own impulses and needs.
■■ Occupational therapy’s comprehensive focus on sensory
processing, cognitive, motor, and psychosocial functions,
as well as awareness of the lifestyle considerations, provide
a dynamic perspective to the individual; the family; and
the treatment, educational, or vocational team.

10_Brown_Ch10.indd 150 11/12/18 12:04 pm

 CHAPTER 10  ■  Disruptive, Impulse-Control, and Conduct Disorders 151
Apply It Now
1. The Lived Experience: PEO Analysis
After reading The Lived Experience about Curtis, complete
a PEO analysis using the template in Appendix A. Consider
the following guiding questions:
■■ What roles has Curtis assumed both in the past and present?
■■ What features of the person, environment, and occupation
may have led to his troubles?
■■ What features of the person, environment, and occupation
have caused him to see a different future for himself?
■■ What barriers will he face?
■■ What facilitators are available to contribute to his success?
2. Classroom Observation
■■ Visit typical elementary, middle school, and high school
classrooms.
■■ For each daily activity (including transitions), identify the
cognitive, social, and performance expectations required
for each. Completing this activity with a partner or team
may help you catch more of the details.
Resources
The American Academy of Child and Adolescent
Psychiatry (AACAP)
3615 Wisconsin Avenue, NW
Washington, DC 20016-3007
Phone: 202-966-7300
Fax: 202-966-2891
Website: http://www.aacap.org
U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services
Administration (SAMHSA)
PO Box 2345
Rockville, MD 20847
Toll-free: 800-789-2647
Fax: 240-221-4295
TDD: 866-889-2647
Website: http://mentalhealth.samhsa.gov
American Occupational Therapy Association
Practice Guidelines
• Bazyk, S., & Arbesman, M. (2013). Occupational therapy
practice guidelines for mental health promotion, prevention and
intervention for children and youth. Bethesda, MD: AOTA Press.
Child Mind Institute
• A nonprofit organization that includes resources and practical
advice for families and professionals.
https://childmind.org/
Research Guide for Parents and Caregivers
• John M. Eisenberg Center for Clinical Decisions and
Communications Science. (2016). Treating disruptive behavior
disorders in children and teens: A review of the research for
parents and caregivers. Rockville MD: AHRQ Comparative
Effectiveness Reviews.
This can be accessed free online at: https://www.ncbi.nlm.nih
.gov/books/NBK396562/
• Parent to Parent: http://parenttoparentnys.org
• Youth Mental Health Project: http://ymhproject.org
10_Brown_Ch10.indd 151
■■ Pay careful attention to the way in which directions
are given, what knowledge ability is assumed, and how
behavioral expectations are reinforced.
■■ Compare and contrast the demands across grade levels
and appropriate strategies for inclusion of students with
disruptive behavior disorders in these settings.
Describe the experience in your Reflective Journal.
Reflective Questions
Reflect on how you felt after one of these activities.
For the classroom observation:
■■ How did the setting influence your comfort and/or your
observations?
■■ If you had been in a different setting, how might the
experience have changed?
■■ Do you have personal memories of this grade level and its
demands that may have influenced your observations?
■■ Have you ever lost control or become angry, agitated, and
so on? If not, what helped you cope?
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