Our Health Topics

Disruptive Behavior Disorders

  • Overview

    "Parents are an essential part of treatment for their child's disruptive behavior disorder. The most effective interventions we've seen are parent-based."

    Eugene d'Angelo, PhD, chief of Children's Division of Psychology

    When a child is acting out—disrupting activities, ignoring rules, goading others or erupting in defiance at being told “no”—the entire family feels the impact. You may feel helpless to control your child’s restlessness or anger, unsure how to respond or at a loss as to how to return some sense of stability and normalcy to the family environment. You may also find yourself with more questions—What’s wrong with my child? How can we keep our family together in the midst of all this chaos?—than answers. 

    Children’s Hospital Boston’s team clinicians are here to help. First, it might be beneficial to learn as much as you can about your child’s condition. 

    • Disruptive behavior disorders are a group of behavioral problems. They are called “disruptive” because affected children literally disrupt the people and activities around them (including at home, at school and with peers).
       
    • The most common types of disruptive behavior disorder are oppositional defiant disorder (ODD) and conduct disorder.
       
    • Children with oppositional defiant disorder display a persistent pattern of angry outbursts, arguments and disobedience. While this behavior is usually directed at authority figures, like parents and teachers, it can also target siblings, classmates and other children.
       
    • Conduct disorder is a far more serious condition that can involve cruelty to animals and people, other violent behaviors and criminal activity.

    It may also help you to know that you’re not alone. Disruptive behavior disorders are relatively common in children, and with the right care, these conditions can be treated successfully.

    How Boston Children's Hospital approaches disruptive behavior disorders

    Children’s Hospital Boston has a long history of pioneering important advances in behavioral and mental health for children and adolescents. Our Department of Psychiatry clinicians are committed to evidence-based treatments—therapies that have been tested and proven effective through careful scientific analysis, both here at our hospital and at top health centers around the world.

    At the same time, we practice medicine that’s patient-focused and family-centered. We never lose sight of the fact that your child is, first and foremost, an individual—not merely a patient—and we include your family at every stage of the treatment process.

    Here at Children's, our clinicians use several techniques to treat disruptive behavior disorders, including:

    • parenting modification strategies
    • social and emotional skills training for children
    • psychotherapy for the child and the family
    • if necessary, the addition of medication to the therapy plan

    Working with your clinician, you can make a difference for your child by learning and using new:

    • communication skills
    • parenting skills
    • conflict resolution skills
    • anger management skills
    Experience Journal gives kids, families an outlet
    The Experience Journal is an online resource for kids and caregivers dealing with a variety of medical and psychiatric illnesses. Topics in each journal range from “Having to Go to the Hospital” to “Things that Help” and “Words of Wisdom,” and are organized by age group for easier navigation.

    Disruptive behavior disorders: Reviewed by David R. DeMaso, MD
    © Children’s Hospital Boston; posted in 2011

    Contact Us


    Children's Hospital Boston
    300 Longwood Avenue
    Boston MA 02115
     617-355-6680


  • In-Depth

    Causes

    What causes oppositional defiant disorder (ODD)? 
    The exact cause of ODD isn’t known, but two theories help explain why a child could develop the disorder: the effect of developmental factors and the influence of learned factors.

    Developmental factors

    One theory suggests that children with ODD:

    • begin to experience problems in their toddler years
    • may have had an unusually hard time separating from parents (“standing on their own two feet,” so to speak) while younger
    • did not resolve their normal development issues in their younger years, leading to later behavioral problems

    Learned factors

    Another theory suggests that children with oppositional defiant disorder:

    • developed unusually strong levels of negativity and pessimism (two main traits of ODD) because a parent or other authority figure meted out excessive punishment or other forms of negative reinforcement
    • learned to associate the parent or authority figure’s negative reinforcement with receiving more attention, time and concern
    • started a pattern of acting out in order to receive more of this perceived “extra attention”

    Other possible factors may include:

    • permissive parenting, when a parent too often and too easily gives in to a child’s demands and doesn’t really teach them the “rules”
    • strong will in the child, which can be caused by any or all of the following:
    • ingrained personality or tempermental  characteristics
    • lack of positive attachment to a parent
    • significant stress or a lack of predictable structure in the home or community environment

    Learn more.

    What causes conduct disorder?
    Conduct disorder is a highly complex condition, and its causes aren’t fully understood. It’s likely that both genetic and environmental factors influence children who develop conduct disorder. Many of these children have a family history of:

    However, children from well-functioning families can—and do—develop conduct disorder, too.

    Signs and symptoms

    What are the symptoms of a disruptive behavior disorder?

    Symptoms of oppositional defiant disorder (ODD)
    Signs of ODD include:

    • frequent temper tantrums
    • excessive arguments with adults
    • refusing to comply with adult requests
    • always questioning rules
    • refusing to follow rules
    • behavior intended to annoy or upset others
    • blaming others for misbehavior or mistakes
    • becoming easily annoyed with others
    • frequently demonstrating an angry attitude
    • speaking harshly or unkindly to others
    • behavior designed to seek revenge

    Symptoms of conduct disorder
    Children and adolescents with conduct disorder display behaviors that deliberately ignore or abuse the feelings and rights of others. Warning signs may include:

    • aggressive behaviors toward others, including bullying or making threats
    • misinterpreting others’ behaviors as threatening
    • inability to tolerate frustration, restrictions or rules (either at home or at school)
    • chronic lying without remorse
    • stealing or destroying property
    • fighting
    • substance abuse

    The most serious behaviors resulting from conduct disorder can include:

    • using, or threatening to use, weapons
    • abusing or mistreating animals
    • physically attacking others

    These behaviors must always be taken seriously.To protect both your child and others, you should involve mental health professionals and—in cases of violent threats or acts—law enforcement authorities immediately. 

    Join Children’s in fighting for mental health reform

    Children’s is working with other health care providers, nonprofit organizations, educators and families statewide to advocate for a comprehensive reform of the Massachusetts mental health system for kids and families. Learn how you can help.

    Questions to ask your doctor

    You and your family play an essential role in your child’s treatment for a disruptive behavior disorder. It’s important that you share your observations and ideas with your child’s treating physician, and that you have all the information you need to fully understand the treatment team’s explanations and recommendations. 

    You’ve probably thought of many questions to ask about your child’s disorder and treatment. It’s often very helpful to jot down your thoughts and questions ahead of time and bring them with you, along with a notebook, to your child’s appointment. That way, you will have all of your questions in front of you when you meet with your child’s treating clinician and can make notes to take home with you. (If your child is old enough, you can encourage him or her to write down questions, too.)
     
    Initial questions to ask your doctor might include:

    • What type of disruptive behavior disorder do you believe my child has?
    • What criteria did you use to reach this diagnosis?
    • Is there any other condition my child may have?
    • What are the goals of treatment for my child?
    • Is my child’s behavior potentially dangerous for himself, our family or others?
    • If so, what precautions do you recommend?
    • What role should I play in my child’s treatment?
    • Will you be working with my child’s other caregivers?
    • How can I tell if my child is making progress?
    • How long do you expect my child to need therapy?
    • How should I involve my child's school in treatment?
    • How should I explain my child's condition to other members of the family?
    • Will you prescribe medication for my child? If so, what are the possible side effects of this medication?
    • What other resources can you point me to for more information?

     

    FAQ

    Q: Can I prevent my child from developing a disruptive behavior disorder?
    A: While there is no way to completely prevent a child from developing a disruptive behavior disorder, you may be able to lessen the seriousness of your child’s disorder by seeking treatment from a qualified mental health professional as soon as warning signs emerge.

    Q: How can I distinguish signs of a disruptive behavior disorder from the typical challenging behavior most kids display?
    A: Determining whether your child has a disruptive behavior disorder can be difficult, since most children show some of the symptoms every now and then (especially when they’re tired, hungry or upset). 

    A child with a disruptive behavior disorder, however, will:

    • display these symptoms much more often than other children
    • consistently demonstrate behavioral issues for a period of at least six months
    • often have problems with school and friendships as a direct result of the behavior

    Q: Why is my child acting this way?
    A: Your child may be acting out for a number of reasons, including:

    • a chemical imbalance in his brain
    • responding to stresses in his environment
    • expressing a need for attention
    • “testing the waters” to gauge how much he can get away with
    • mimicking behavior observed in others who act in problematic ways

    Q: Are disruptive behavior disorders permanent?
    A: Since these disorders are behavioral conditions, they’re considered to last as long as the problematic behaviors persist. As they age, children with disruptive behavior disorders may have a greater tendency to argue, refuse to comply with requests, blame others for mistakes, deliberately irritate others or act in disruptive ways than their peers (and in the case of conduct disorder, the behaviors can be much more serious—including violent and criminal behavior).

    However, early treatment can give your child—and your family—critical tools for replacing the behavior with appropriate, constructive new patterns. 

    Q: Does having a disruptive behavior disorder put my child at greater risk of developing more serious problems as an adult?
    A: The likelihood of a child with a disruptive behavior disorder experiencing greater difficulty as an adult depends upon the child’s individual circumstances. 

    In cases of oppositional defiant disorder (ODD), as the child ages, his diagnosis may change from ODD—which involves behavior that is problematic, annoying and hostile, but not violent or extremely aggressive—to the much more serious diagnosis of conduct disorder

    Most children diagnosed with ODD are not automatically going to develop conduct disorder. It’s important, however, for parents to closely monitor the behavior of their child and seek treatment from a credentialed professional as early in the child's life as possible.

    Q: What should I do to ensure my family is safe during an outburst?
    A:
    If your child has oppositional defiant disorder or conduct disorder, it’s important that you have a safety plan, in those cases where it is needed, in place to protect both your child and others should hostile, threatening or intimidating behaviors escalate.

    Your clinician will work with you to develop a plan that includes when you should seek emergency support. 

    Q: What is the “black label warning” I keep hearing about when it comes to certain psychiatric medications?
    A: Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

    Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

    If your child is prescribed any medication during treatment, your clinician will carefully go over the specifics of the drug, as well as any potential side effects you should watch for.

    At Children’s Hospital Boston, our team has years of experience managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We always closely monitor your child for any sign of a negative response to the medication, and are always here to answer your questions and address any concerns you may have. 

    If you suspect your child may have a disruptive behavior disorder, it is important to speak with a qualified mental health professional as soon as possible. By closely working with a treatment team, you can help your child go on to enjoy a fulfilling family, school and personal life. 

    Battling spaceships helps kids learn to control anger

    Joseph Gonzalez-Heydrich, MD, chief of Children’s Psychopharmacology Clinic, along with colleagues Peter Ducharme, LICSW, and Jason Kahn, EdD, developed the RAGE-Control Game—a game in the tradition of the popular arcade staple “Space Invaders” that teaches children to: 

    • focus on tasks at hand
    • react appropriately to stressful situations
    • inhibit impulses 
    • keep their heart rate down

    The effectiveness of the RAGE-Control Game as a possible alternative to psychiatric medication is now being tested through a clinical trial on the Children’s Inpatient Psychiatry Service.

    Read a Boston Globe article about the RAGE-Control game.

  • Tests

    The first step in treating your child's disruptive behavior disorder is forming an accurate and complete diagnosis.

    Diagnosing oppositional defiant disorder
    At Children’s Hospital Boston, a mental health clinician (typically a child and adolescent psychiatrist, child psychologist or psychiatric social worker) makes the diagnosis of oppositional defiant disorder after doing a comprehensive psychiatric assessment with you and your child. During this assessment, you will be asked to talk about your child’s behavioral problems and to give an overview of your child’s family history, medical history, school life and social interactions. Learn more about how Children’s diagnoses ODD.

    Diagnosing conduct disorder
    Conduct disorder is typically diagnosed if a child has done three or more of the following within a 12-month period:

    • showed aggression toward animals or people
    • destroyed or stolen property
    • lied and been deceitful
    • seriously violated parental or school rules

    A child with conduct disorder experiences noticeably dysfunctional relationships at home, at school and with peers as a result of these behaviors.

    If my child is diagnosed with a disruptive behavior disorder, what happens next?
    Your child’s mental health clinician will help explain the disorder and answer any questions you or your child may have. The next step is developing a mutually agreed-upon treatment plan that works for you, your child and your family.

  •  

    It's entirely natural that you may be scared, anxious and confused right now about your child's condition and well-being; a behavioral disorder can be frightening for any parent. But you can rest assured that here at Boston Children's Hospital, your child is in good hands.

    Importantly, at Children's, we consider psychiatric medication to be part of a “two-step approach,” along with talk therapy. We never prescribe medication as a standalone treatment method. Learn more about how Children's Psychopharmacology Clinic works with families and caregivers to determine whether medication can help. 

    Treatments for oppositional defiant disorder

    Oppositional defiant disorder is typically treated with one or more of the following methods: 

    Parenting modification
    Your involvement as a parent is crucial to the treatment of your child's oppositional defiant disorder. Here at Children's, we've learned that the best approach to ODD is helping parents learn new strategies, like how to anticipate problematic behavior, manage outbursts and implement consistency in the child's daily routine.

    Social-emotional skills training
    Building on the parenting modification techniques, therapy for ODD also focuess on providing social-emotional skills training for your child. Through the course of therapy sessions with the clinician, your child will learn:

    • new skills for identifying and managing feelings
    • how to get along better with others
    • strategies for making good decisions that are based on thinking rather than feeling 

    Learn more about parenting modification strategies and social-emotional skills training for ODD. 

    Psychiatric medication
    In addition to therapy, your clinician may recommend medication to treat your child's oppositional defiant disorder. There currently are no drugs prescribed specifically for the condition, but certain symptoms can respond very well to medication in conjunction with talk therapy. Learn more about commonly prescribed psychiatric medications.

    Treatments for conduct disorder

    Children and adolescents with conduct disorder tend to have another mental health problem, such as an anxiety disorder or mood disorder (such as depression); in these cases, it's essential that both conditions be treated at the same time.

    Conduct disorder itself requires complex, careful and long-term treatment, and methods usually involve a combination of intensive psychotherapy and psychiatric medication.

    Some children with conduct disorder need to stay in a residential treatment center where they can be removed from their usual environment, managed appropriately and separated from others until their behavior is stabilized and safe.

    Learn more about commonly prescribed psychiatric medications.

    Long-term outlook

    What is the long-term outlook for children with a disruptive behavior disorder?

    Oppositional defiant disorder

    Oppositional defiant disorder responds very well to the treatments listed above when delivered by qualified clinicians. Although some children grow out of their ODD in time, these disorders can go on to cause continued problems without timely professional intervention. 

    Children and adolescents who are not treated for ODD are likely to experience:

    • difficult relationships with parents and other authority figures
    • failure at school
    • juvenile delinquency 

    As they age, they may be at greater risk for conduct disorder, and so close monitoring by family and health professionals is essential.

    Conduct disorder

    The earlier in the child's life conduct disorder symptoms emerge, the more difficult the prognosis.

    Children with conduct disorder may develop antisocial personality disorder and violent/criminal behaviors later in life, especially if their symptoms go untreated. For these reasons, it's essential to treat conduct disorder as soon as possible to help the child and family restore and maintain a healthy, functional quality of life.

    Coping and support

    Guiding your child and family through treatment for a disruptive behavior disorder can be overwhelming, and we're here to help. Boston Children's Hospital offers the following resources for comfort and support: 

    • Children's Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families and health professionals are welcome to use the Center's services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.
       
    • The Advocating Success for Kids (ASK) Program at Children's provides multidisciplinary evaluation, referral and advocacy services for children under age 14 who are experiencing behavioral, emotional, learning or developmental problems, either at home or at school. ASK works with children who receive their primary care either at Boston's Bowdoin Street Community Health Center, Martha Eliot Health Center or Joseph M. Smith Community Health Center or at Children's Primary Care Center. For more information about ASK, please call 617-355-4690.
       
    • The Experience Journal was designed by Children's psychiatrist-in-chief David DeMaso, MD, and members of his team. This online collection features thoughts, reflections and advice from kids and caregivers dealing not only with physical illnesses like asthma and diabetes, but also with behavioral and mental health conditions like ADHD and depression.

    View Children's comprehensive guide for patients and families.

     

    Helpful links

    Please note that neither Boston Children's Hospital nor the Department of Psychiatry at Children's unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

    Helpful links for parents

    Helpful links for teens

    Helpful links for younger children

  • Research & Innovation

    Here at Children’s Hospital Boston, we refine our treatment methods through careful analysis of sophisticated scientific data. Our research program is one of the largest and most active of any pediatric hospital in the world, and our research in psychiatry and psychology supports our goal of enhancing mental health care for all children and families.

    We continue to work toward critical new insights that can propel advances in preventing, diagnosing and treating behavioral and mental health disorders. Our progress in the laboratory strengthens the exceptional care we provide at each child's bedside.

    Among our current research projects with promise for treating disruptive behavior disorders are:

    Incorporating mindfulness as a parenting modification strategy
    A Children's study examines mindfulness techniques, which combine elements of traditional Buddhist meditation with the practice of consciously reflecting on one’s thoughts. Should these techniques prove useful, they will be added to the parenting modification strategies we teach as part of our family treatment plans for oppositional defiant disorder.

    Using a computer game to teach children emotional control
    Using advances in neurobiology and computer science, Children's clinicians are designing special interventions to help kids better control their emotions. Psychopharmacology Clinic chief Joseph Gonzalez-Heydrich, MD, working with colleagues, has developed a computer game called “RAGE-Control (Regulate And Gain Emotional Control).” Using the popular arcade staple “Space Invaders” as a model, RAGE-Control teaches children to simultaneously focus, react, inhibit impulses and keep their heart rate down. The game is now being tested in a clinical trial. Read a Boston Globe article about the game.

    Clinical trials

    It’s possible that your child will be eligible to participate in one of Boston Children's Hospital's current clinical trials. These studies are useful for a multitude of reasons:

    Some trials are designed to evaluate the effectiveness of a particular drug, treatment or therapy on a specific disease; others help doctors to better understand how and why certain conditions occur. At any given time, we have hundreds of clinical trials underway. Of course, your motives as a parent needn’t be entirely altruistic—you’ll naturally want to know how taking part in a trial can immediately benefit your child. If your child’s physician recommends participation in one of Children’s clinical trials, that likely means that your child’s physician believes that the plan outlined in that trial represents the absolute best, latest care your child can possibly receive.

    And participation in any clinical trial is completely voluntary: We will take care to fully explain all elements of the treatment plan prior to the start of the trial, and you may remove your child from the medical study at any time.

    Find a clinical trial

    To search current and upcoming clinical trials at Children’s, go to:
    http://www.childrenshospital.org/research/clinical/Search.cfm

    To search the NIH’s list of clinical trials taking place around the world, go to:
    http://www.clinicaltrials.gov/ct2/search

    Improving mental health care around the world
    Learn how Children’s is improving the coordination of psychiatric care for at-risk children and families.

    Mental health and genetics

    Children’s Hospital Boston led a study that suggests that deprivation and neglect not only can lead to behavioral problems, but may also affect children’s chromosomes and possible shorten life span. Learn more about this research in the Children’s newsroom.

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