Our youth now love luxury. They have bad manners and contempt for authority and disrespect for their elders. Children nowadays are tyrants.
—Socrates
The words attributed to Socrates resonate with the perspectives of many contemporary parents and clinicians.1 The endurance of the concern suggests something fundamental about the psychopathology of deviant, disruptive behavior of youth. Yet clinicians struggle to understand its origins, to help parents control their children, and to help the children control themselves. Clinically, this manifests in failed pharmacological treatments, incompleted courses of individual therapy, problems in engaging families in treatment, and controversies over which therapy is most effective.
Disruptive behavior, more frequently seen in males, is clinically significant behavior that interrupts the interpersonal context of the adolescent. Adolescents who display disruptive behavior have not acquired the ability to self-regulate affect and behavior, a prerequisite to social adaptation. This This deficit in self-regulation is shaped by biological vulnerability (eg, temperament, genetics) and by the regulating, developmental influence of family function.2,3
DSMV-IV-TR designates a category of disruptive behavior disorders that includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, and a not-otherwise-specified (NOS) category. The phenotype can be described through such categorization, but these maladaptive behaviors cut across diagnoses. Are disruptive behaviors part of a disease process or a problem in adaptation and adolescent development? This question has recently been addressed by McHugh,4 who looked at all DSM-IV diagnostic categories and concluded that some fit the disease model (eg, autism, schizophrenia, dementia) while others are best described as problems in behavior and adaptation (eg, conduct disorder, posttraumatic stress disorder [PTSD]).
This concept is best illustrated through the controversial topic of pediatric bipolar disorder that for many has become synonymous with deficiencies in self-regulation. While there is no debate regarding the existence of bipolar disorder in youths, especially adolescents, the recent increase in the frequency of the diagnosis remains unexplained. The concern of some is that in current usage the neuropsychiatric disorder of bipolar disorder now includes developmentally mediated deficits in self-regulation. Why is this important? Routinely, bipolar disor-der leads to an initial consideration of medication, while an emphasis on developmentally mediated disruptiveness indicates psychosocial mechanisms and treatments. A lack of diagnostic clarity can be associated with inadequate treatment response when medications are used to treat developmental or family relationship problems and when psychosocial interventions are used for biologically mediated symptoms.
Components of disruptive behavior
Disruptive behavior is a component of numerous disorders, yet a disease model fails to fully explain such behavior. Descriptive diagnostic statements inform clinicians what youth do. Yet they do not clarify why the behavior occurs nor do they map out treatments to manage the behavior. For that, one must turn to the emerging field of developmental psychopathology and the influence of family function on self-regulation.
Problematic externalizing behaviors, including lying, stealing, vandalism, truancy, arson, promiscuity, defiance toward authority, disinhibition (severe impulsivity), and aggression (threatening, bullying, fighting, rape), are some of the most common reasons for consulting a child and adolescent psychiatrist. The disruptive behavior may also be problematic for those outside the family, such as schoolmates and teachers.
The psychiatric assessment of children with disruptive behavior takes place within the traditional evaluation format, with special areas of investigation for the disruptive adolescent (Table 1). Gathering thorough psychiatric and medical histories of both the adolescent and his or her family is the first step in making a treatment decision. Other assessments can include a neuropsychological/psychological assessment, brain imaging (MRI, CT), or electroencephalography.
Those affected by the adolescent’s disruptiveness (parents, schoolmates, extended family) provide essential information, such as age of onset, type of behavior (eg, aggressive), and precipitating factors. This allows the clinician to assess the interactional component: Who is affected? Where does disruption occur? When does it typically occur?
Observing the interaction between the parent(s) and adolescent is essential. Harshness, inconsistency, or indulgence on the part of a parent can significantly influence the child’s behavior. A mental status examination that assesses intellectual ability and communication skills, aggressive/ homicidal ideation, paranoia or other psychotic symptoms, and capacity for empathy should also be part of the evaluation.
