Disruptive Behavior Disorders

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.

Our team of 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.

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.

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

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:

• Substance abuse problems
• Antisocial behavior or antisocial personality disorder
• Mood disorders like depression and bipolar disorder
• Schizophrenia

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

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

Diagnosing oppositional defiant disorder

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.

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 your child is in good hands.

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.

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. 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 focuses on providing social-emotional skills training for your child. Through the course of therapy sessions with the clinician, your child will learn:

• 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

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. Read 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.

Read about commonly prescribed psychiatric medications.

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.

We have a long history of pioneering important advances in behavioral and mental health for children and adolescents. Our Department of Psychiatry and Behavioral Sciences 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.

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

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?

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

Helpful links for parents

• Oppositional Defiant Disorder Parent Support Group at DailyStrength.org
• Parent Support Forum at ConductDisorders.com

Helpful links for teens

• Anger Management for Young Men: From the Boston Children's Hospital Young Men's Health Site
• Anger Management for Young Women: From the Center for Young Women's Health at Boston Children's Hospital
• Boston Children's Hospital Guide to Healthy Relationships