23.7 Conduct Disorder, Oppositional Defiant Disorder, and Disruptive Mood Dysregulation

Conduct Disorder

When a child shows An ongoing pattern of aggression toward others with serious violations of rules and social norms at home, at school, and with peers is called conduct disorder (CD). These rule violations may involve breaking the law and result in arrest (CDC, 2021f). Adults with antisocial conduct disorder typically show symptoms of CD before age fifteen (Mayo Clinic, 2023b). Examples of CD behaviors are as follows (CDC, 2021f):

• breaking serious rules, such as running away, staying out all night, or skipping school
• being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals
• lying, stealing, or purposefully damaging other people’s property

Children who exhibit these serious behaviors should receive a comprehensive evaluation and treatment by a mental health professional. Some signs of behavior problems, such as not following rules in school, can be related to learning disorders that require additional assessment and interventions. Without treatment, many children with conduct disorder are likely to have ongoing problems resulting in the inability to adapt to the demands of adulthood (American Academy of Child & Adolescent Psychiatry, 2018).

Conduct disorder may have onset in childhood or adolescence. Symptoms can begin as early as preschool, but usually more serious symptoms appear when a child reaches middle school to age eighteen (American Psychiatric Association, 2021b). It is more common in males than in females. Conduct disorder occurs in 2 to 10 percent of children in the United States (Cleveland Clinic, 2022a). Conduct disorder is not diagnosed after age eighteen, so an adult who has the symptoms of conduct disorder may be diagnosed with antisocial personality disorder.

The exact cause of conduct disorder is unknown. It is believed to be a combination of genetic and environmental factors (Cleveland Clinic, 2022a). Genetic and biological factors include traumatic brain injury and seizures, higher than normal levels of testosterone, and inheriting the traits of conduct disorder. Environmental factors include lack of structure in the home environment, exposure to domestic violence, low socioeconomic status, drugs and crime in the child’s neighborhood, and parents who have substance use problems or conduct disorder behaviors.

Diagnosis is made after a child or adolescent is fully assessed by a mental health professional after the individual exhibits three or more of the following symptoms in the past twelve months and at least one symptom in the past six months: “seriously violating their parents’ rules, lying or stealing, destruction of property, and aggression toward people and/or animals” (Cleveland Clinic, 2022a, “How is conduct order diagnosed?” section).

Oppositional Defiant Disorder

A behavioral condition in which the child has symptoms of being uncooperative, defiant, and may be hostile toward people in authority is called oppositional defiant disorder (ODD) (Cleveland Clinic, 2022b). Most children will display this type of behavior at some point in their early years, but if this behavior lasts longer than six months, then the child may be diagnosed with ODD. About 30 percent of children with ODD go on to develop the more serious behavioral symptoms of conduct disorder. This disorder can be treated with CBT, family therapy, and peer group therapy (Cleveland Clinic, 2022b). Although medications are not typically used, there have been studies conducted showing that medications, such as guanfacine, may have some benefit at decreasing symptoms (Newcorn et al., 2020).

Disruptive Mood Dysregulation Disorder

Another behavioral disorder seen in children is disruptive mood dysregulation disorder (DMDD) in which children experience chronic, intense, angry outbursts. This disorder may be a comorbidity with autism and other neurodevelopmental disorders. To diagnose DMDD, symptoms need to be present before the child turns ten years old and must disrupt their daily lives (Cleveland Clinic, 2022c). Psychotherapy is a first-line treatment for this disorder tried prior to considering the use of any medications. There is not specific FDA-approved medication for DMDD, but medications may be prescribed to manage certain symptoms—stimulants to decrease irritability, antidepressants for mood, and atypical antipsychotic medications to treat aggression (Cleveland Clinic, 2022c).

Medications

Medication is not a first-line treatment for conduct disorder. If the child/adolescent is experiencing explosive anger, then the health-care provider may suggest that the individual take risperidone (Risperdal). Risperidone is an antipsychotic medication that has been FDA-approved to help children with autism spectrum disorder. It may be used off-label for short periods of time in children/adolescents with conduct disorder (Miller, 2023).

Treatment Settings, Family Therapy

Starting treatment early for CD is important. For younger children, research indicates the most effective treatment is behavior therapy training for parents where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behavior. For school-age children and teens, a combination of behavior therapy training that includes the child, the family, and the school is most effective (American Academy of Child & Adolescent Psychiatry, 2018).

Behavioral interventions for the classroom help children and adolescents succeed academically. Behavioral classroom management is a teacher-led approach that encourages a student’s positive behaviors in the classroom through a reward system or a daily report card and discourages their negative behaviors. Organizational training teaches children and adolescents time management, planning skills, and ways to keep school materials organized to optimize student learning and reduce distractions (CDC, 2021f).

Behavioral interventions reward desired behaviors and reduce maladaptive coping behaviors. Most child and adolescent treatment settings use structured programs to motivate and reward age-appropriate behaviors. For example, the point or star system may be used where the child receives points or stars for desired behaviors, and then specific privileges are awarded based on the points or stars earned each day.

The basis of family therapy is to decrease negative interactional patterns between family members. The parents of children with conduct disorders often place blame on their children for everything else that is not going well in the family environment (Helimaki et al., 2020). Developing a working relationship with the different family members can be a challenge for the therapist as the layers of relationships all influence family dynamics. One point that Helimaki et al. (2020) make is that it is important to be sure that if the child is present in sessions with the parents that the child is not left out of the conversation or just a passive participant who is listening to what is being said about them.

Nurse’s Role

There are several evidence-based strategies that nurses can teach parents and caregivers to help manage behaviors of children and adolescents with conduct disorder, such as time-out and special time (Hilt & Nussbaum, 2016). As part of parent management training (PMT), the intervention of time-out may be effective for emotional regulation when used consistently in a therapeutic manner (Roach et al., 2022). Such consistency increases the child’s feeling of security as opposed to dysfunctional forms of discipline. Roach et al. (2022) acknowledge the need for further research in this area. Time-out is a strategy for shaping a child’s behavior through selective and temporary removal of the child’s access to desired attention, activities, or other reinforcements following a behavioral transgression. This strategy works for children who experience regular positive praise and attention from their parents or caregivers because they feel motivated to maintain that positive regard. The length of time should be about one minute for each year of age, but adjustments need to be made based on the child’s developmental level. For example, children with developmental delays should have shorter durations (Hilt & Nussbaum, 2016). Tips for caregivers implementing time-outs include the following (Hilt & Nussbaum, 2016):

• Set consistent limits to avoid confusion.
• Focus on changing priority misbehaviors rather than everything at once.
• After setting a time-out, decline further verbal engagement until a “time-in.”
• Ensure time-outs occur immediately after misbehavior rather than being delayed.
• Follow through if using warnings (e.g., “I’m going to count to three . . . ”).
• State when the time-out is over. Setting a timer can be helpful.
• When the time-out finishes, congratulate the child on regaining personal control and then look for the next positive behavior to praise.
• Give far more positive attention than negative attention.

Special time is a strategy for a caregiver and a young child to establish the enjoyment of each other’s company. It is also referred to as “child-directed play” because it emphasizes that caregivers follow the child’s lead. Tips for caregivers implementing special time include the following (Hilt & Nussbaum, 2016):

• Commit to setting aside a regular time for “special time.” Daily is best, but two to three times a week consistently also works.
• Select the time of day and label it as “our special time.” Choose a time short enough that it can happen reliably, usually 15 to 30 minutes. Ensure that this time happens no matter how good or bad the day’s behaviors were.
• Allow the child to select the activity, which must be something you do not actively dislike or does not involve spending money or completing a chore.
• Follow the child’s lead during play, resisting the urge to tell them what to do.
• End on time; a timer may be helpful. Remind the child when the next special time will be.
• If the child refuses at first, explain you will just sit with them during the “special time.”
• Expect greater success if you set your own special times for yourself, too.