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Adolescent Medicine Update: Disruptive Behavior Disorders: What's Normal--What's Not?

Adolescent Medicine Update: Disruptive Behavior Disorders: What's Normal--What's Not?

"Chris" is a 14-year-old boy who has been suspended from school 4 times this year for arguing with his teachers. When asked about the suspensions, he admits that he loses his temper easily but is quick to blame other students or his teachers for "unfair" treatment.

His mother adds that Chris has always been "a handful" at home and at school--often going out of his way to annoy family members as well as peers. School has been a particular source of stress and, over the past year, he has become more argumentative about completing his homework. Chris is furious with his mother--last month she confiscated his Game Boy after he intentionally tore up his younger sister's homework during an argument.

"Jason," age 17, currently lives in a residential treatment facility for emotionally troubled teenagers. His "file" indicates that as early as the third grade, Jason was labeled as the class bully and often initiated physical fights with peers. During middle school (age 12) he began skipping school and "roaming the streets" at night while using marijuana and alcohol. He was once confronted by a store clerk as he tried to steal a pair of sneakers. In retaliation he spray-painted obscenities across the clerk's car and tossed a brick through the windshield.

When he was 15, Jason attacked a woman with a broken bottle and took her car keys. He was subsequently arrested after her car was traced by the police and he was court-ordered into a locked residential treatment facility.

These vignettes reflect the real-life stories of two of my patients, both of whom were admitted to a residential treatment facility for emotionally disturbed teenagers. Their stories are typical of adolescents who have disruptive behavior disorders. Most providers recognize that these adolescents are profoundly troubled but are frustrated that they do not have the time or knowledge to help them. For primary care pediatricians, the goal is to recognize behaviors that are out of the realm of normal, and to refer patients in the hope of curtailing the development and severity of disruptive behavior disorders.

Here I focus on oppositional defiant disorder (ODD) and conduct disorder (CD)--the principal disruptive behavior disorders. I describe assessments that a general pediatrician can perform as part of a preliminary evaluation and review some of the treatment options.

DEFINING THE PROBLEM

Disruptive behavior disorders are occasionally referred to as "externalizing disorders" because they commonly affect the world around the person rather than manifesting as internal psychic distress.

The DSM IV-TR criteria for ODD and CD are listed in Tables 1 and 2.1 Familiarity with these criteria can help you recognize a patient whose behavior is not normal.

Oppositional defiant disorder. "Chris"--the adolescent described in the first scenario--demonstrates most features of ODD. According to the DSM-IV, ODD affects 2% to 16% of the population.1 Those most often affected come from troubled families or have at least 1 parent with a history of a mood disorder, ODD, CD, substance use disorder, attention deficit disorder (ADD), or antisocial personality disorder.

ODD generally presents by early adolescence. Limited studies suggest that earlier emergence predicts a more severe course. Oppositional and defiant behavior can manifest in specific situations (such as around only teachers, parents, or law enforcement officers) or it can be seen as pervasive (around all authority figures).

Several features distinguish ODD from normal adolescent rebellious behavior. ODD behaviors tend to occur with regular frequency and lead to more serious social and occupational consequences than does simple adolescent "acting out." Such behaviors usually begin well before puberty and are present for at least 6 months. Therefore, a teen who suddenly begins to demonstrate some short-lived mild oppositional behavior would probably not meet true criteria for ODD.

Conduct disorder. "Jason's" history, as outlined in the second vignette, suggests that he has CD. CD is a distinct disorder from ODD, but it often develops in teens who have a preexisting untreated ODD. The key feature that distinguishes CD from ODD involves the violation of either the basic rights of others or societal norms and rules. The disorder is graded (mild, moderate, severe) based on the frequency and/or the severity of these violations.

CD presents much more commonly in males than in females. Between 1% and 10% of the overall population may be affected. Risk factors include having a parent with CD, ADD, mood disorders, or antisocial personality disorder.1

CD can present during childhood or adolescence. Its severity is predicted by a younger initial presentation and a longer duration of symptoms.

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