Developmental Pathways to Disruptive, Impulse-Control, and Conduct Disorders

Michelle M. Martel, Michelle M. Martel

• Publisher: Academic Press
• Year: 2018
• ISBN:
  9780128113240
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Developmental Pathways to Disruptive, Impulse-Control, and Conduct Disorders provides essential understanding on how disruptive behavior disorder (DBD) is characterized, its early markers and etiology, and the empirically-based treatment for the disorder. The book covers features and assessment of various DBDs, including oppositional-defiant disorder, conduct disorder, and antisocial personality disorder, the psychological markers of externalizing problems, such as irritability and anger, common elements of effective evidence-based treatments for DBD for behavioral treatments, cognitive therapies, and family and community therapies. A final section discusses new and emerging insights in the prevention and treatment of DBD.

• Provides a critical foundation for understanding how disruptive behavior disorder (DBD) is defined
• Looks at early markers and etiology of DBD
• Goes beyond the surface-level treatment provided by other books, offering in-depth coverage of various DBDs, such as oppositional-defiant disorder and antisocial personality disorder
• Examines the causal factors and developmental pathways implicated in DBD
• Includes cutting-edge insights into the prevention of DBD prior to the emergence of symptoms

Part I

Features and Assessment of Disruptive, Impulse-Control, and Conduct Disorders

Outline

• 1 Disruptive, impulse-control, and conduct disorders
• 2 Oppositional defiant disorder
• 3 Conduct disorder: A neurodevelopmental perspective
• 4 Antisocial–psychopathic personality disorder

1

Disruptive, impulse-control, and conduct disorders

Paul J. Frick^1,2 and Tatiana M. Matlasz¹, ¹Louisiana State University, Baton Rouge, LA, United States, ²Australian Catholic University, Banyo, QLD, Australia

Abstract

This chapter provides a definition of disruptive, impulse-control, and conduct disorders and provides an overview of some key issues in the classification of these disorders in children and adolescents. This chapter then provides an overview of the history of how these disorders have been classified in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This summary is followed by a discussion of key issues involved in the classification of each disorders currently included in this category, with a particular focus on Oppositional Defiant Disorder and Conduct Disorder. Finally, the chapter concludes with a comparison of the approach taken by the DSM with the approach taken by the International Classification of Diseases that is published by the WHO.

Keywords

Disruptive disorders; conduct disorder; oppositional defiant disorder; classification; diagnosis; DSM; ICD

Introduction

Symptoms of the most common mental health disorders have typically been conceptualized as falling into two broad dimensions in both adults (Krueger & Markon, 2006) and children (Lahey, Van Hulle, Singh, Waldman, & Rathouz, 2011). One dimension has been labeled as overcontrolled, distress, or internalizing and it includes symptoms of the emotional disorders such social withdrawal, anxiety, and depression. The second dimension has been labeled as undercontrolled, disinhibited, or externalizing and it includes various impulsive, hyperactive, substance use, disruptive, and aggressive behaviors. These two domains of psychopathology robustly form separate factors across various samples of different age groups supporting distinct patterns of covariation within individuals (i.e., phenotypic correlations; Lahey, Krueger, Rathouz, Waldman, & Zald, 2016). Research has also consistently supported that the specific patterns of behaviors (i.e., disorders) that can be subsumed under these two broad categories share a number of causal factors (Lahey et al., 2016). As a result, systems of classifying mental disorders that attempt to differentiate within these broad categories often result in high levels of co-occurring conditions or “comorbidities,” such as the high rate of co-occurrence between hyperactivity and conduct problems that is found in samples of children and adolescents (Waschbusch, 2002). However, there is also evidence to support the contention that there are some unique causal processes that can lead to different disorders within these broad dimensions, making it important for causal theories to consider both the shared processes that increase risk for all disorders across the broad dimensions of psychopathology, as well as the specific processes that differentiate disorders within these overarching dimensions (Lahey et al., 2016).

The purpose of this book is to focus on these shared and unique causal factors related to the externalizing or disinhibited dimension of psychopathology and, even more specifically, on those disorders that are defined by disruptive behaviors. This specific form of externalizing psychopathology involves behavior that either violates the rights of others or brings the individual into conflict with society norms or authority figures (American Psychiatric Association, 2013). Thus, these disorders all involve potential harm to others. Further, persons who show significant levels of disruptive behavior are at risk for a host of significant problems in adjustment across the lifespan, including emotional, social, educational, occupational, and legal problems (Odgers et al., 2008). Given the harm to others and substantial risk for both current and future impairment in multiple life domains for persons who show significant disruptive behavior, it is not surprising that major systems for classifying mental disorders have all included syndromes or disorders defined by these behaviors.

Key issues in classifying disruptive behavior disorders

A brief history of classifying disruptive behavior disorders

One method for defining syndromes and disorders within this category has been based on factor analyses of items from rating scales that assess behavior problems in children and that define syndromes based on their observed pattern covariation across age, sex, and culture (Achenbach, Ivanova, & Rescorla, 2017). When this method is used with items defining the full range of externalizing behaviors, the findings consistently suggest that inattention and hyperactivity typically form separate dimensions from the disruptive behaviors (Rescorla et al., 2016). Further, the disruptive behaviors often factor into those that are (1) covert in nature and involve major violation of societal norms but do not involve a physical or verbal confrontation with a victim (e.g., theft, truancy, vandalism, substance use) or (2) overt in nature and involve verbal (e.g., defiant, angry, or oppositional behavior) or physical aggression (e.g., fighting, bullying, threats for harm) directed toward others (Burt, 2012; Frick et al., 1993). Importantly, this method for classifying disruptive behaviors explicitly endorses a dimensional approach for classifying people by defining a disruptive disorder as being a level of disruptive behavior that is past what is considered normative (e.g., 98th percentile) for the person’s age and sex (Achenbach et al., 2017).

A second approach, and perhaps the dominant method for classifying externalizing disorders for both research and practice, has been the criteria published by the American Psychiatric Association in the Diagnosis and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013). This system for classification was developed with the primary goal of defining persons in need of treatment, and thus emphasized distinctions between disordered and nondisordered individuals based largely on the level of impairment caused by the behavior (Kupfer, Kuhl, & Regier, 2013). Thus, in this approach, the primary consideration of whether a person was considered to show a disruptive behavior disorder was based more on whether the level of behavior caused impairments in the person’s social, educational, or occupational adjustment rather than on whether the level was beyond a level that would be expected based on normative data.

Importantly, the distinctions within the externalizing disorders that have been made in the recent editions of the DSM have been at least partly based on the typical patterns of covariation among symptoms (Frick & Nigg, 2012). That is, the major externalizing disorders in childhood included in the most recent revisions of the DSM are Attention-deficit Hyperactivity Disorder (ADHD) defined by impairing levels of inattention, disorganization, impulsivity, and hyperactivity; Oppositional Defiant Disorder (ODD) defined by impairing levels of angry, defiant, and vindictive behaviors; and Conduct Disorder (CD) defined by impairing levels of behavior that violate the rights of others (aggression) or that violate important age-appropriate norms (destruction of property, deceitfulness or theft, serious violation of rules; American Psychiatric Association, 2013). Although these disorders have consistently been included in the DSM, the way that they have been conceptualized in terms of their relation to each other and to other forms of psychopathology has changed in recent editions of the manual.

Prior to the most recent edition of the DSM, ADHD, ODD, and CD were grouped together within a class of disorders labelled Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (American Psychiatric Association, 1980, 1987, 1994, 2000). Besides these externalizing disorders, this section of the manual included diverse diagnoses such as Mental Retardation, Learning Disorders, Eating Disorders, Pervasive Developmental Disorders, and Tic Disorders. Thus, this grouping was not based on any consideration of shared etiology or any evidence for the frequency of co-occurrence among the symptoms of the disorders but was solely based on the presumed typical timing of onset. This method of grouping externalizing disorders changed in the DSM-5 based on several overarching goals for this edition of the manual (Kupfer et al., 2013).

First, one goal of the DSM-5 was to improve the manual’s attention to important developmental considerations in the diagnostic criteria (Frick & Nigg, 2012). Specifically, the new edition of the manual had as its goal to promote a lifespan view of mental disorders, whereby continuities and changes in manifestations across development are considered for all disorders (Kupfer et al., 2013). Thus, a chapter grouping disorders based on timing of onset was not consistent with such a goal. Specifically, it ignored the fact that many disorders not included in this category often first manifested in childhood and adolescence, such as specific phobia (Kessler et al., 2007). Further, it minimized the importance of certain disorders included in this section when making diagnoses in adults, such as ADHD (Barkley, Murphy, & Fischer, 2010). Finally, it ignored the continuity in symptoms across certain disorders, most notably by placing two disorders both largely defined by antisocial behavior, CD and Antisocial Personality Disorder (APD), into two separate categories.

Second, DSM-5 had as a goal the aim of fostering a more dimensional approach to diagnosis. One way it attempted to do this was to organize disorders in ways that take into account common dimensions, such as shared risk factors or common symptom clusters (Frick & Nigg, 2012). For example, as noted above, there are rather extensive data to suggest that the symptoms of ODD, CD, and ADHD cluster around an overarching externalizing dimension that seems to share substantial genetic influences that are potentially reflective of shared problems in self-control (Lahey et al., 2011; Markon & Krueger, 2005). Thus, in the DSM-IV (American Psychiatric Association, 1994), these disorders were subdivided within the disorders first diagnosed in childhood in a category labelled, “Attention-Deficit and Disruptive Behavior Disorders.” However, there is also evidence to suggest that some symptoms of ADHD, especially the inattention symptoms, cluster strongly with autistic symptoms, motor coordination, and reading problems (Frick & Nigg, 2012). Further, in terms of etiology, ADHD is associated with early appearing alterations or immaturities in neural development (Frick & Nigg, 2012). Thus, in terms of high levels of co-occurrence and their shared problems in self-control, ADHD could be placed with the disruptive behavior disorders, such as ODD and CD. However, in terms of high levels of co-occurrence and shared associations with alterations in neurological development, it could be placed with other neurodevelopmental disorders, such as learning disorders, motor disorders, and autistic spectrum disorders. The DSM-5 adopted the latter conceptualization, and thus ADHD was placed in the chapter entitled, “Neurodevelopmental Disorders,” which has as their defining features that they manifest early in development and produce impairments in personal, social, academic, and occupational functioning (American Psychiatric Association, 2013). In contrast, ODD and CD were placed into a separate category of the Disruptive, Impulse-Control, and Conduct Disorders, which are defined by problems in the self-control of emotions and/or behaviors (American Psychiatric Association, 2013).

It is important to note that this grouping of the externalizing disorders is open t...