Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Overview of Mental Disorders in Children
Disruptive Disorders
Disruptive disorders, such as oppositional defiant disorder and conduct
disorder, are characterized by antisocial behavior and, as such, seem to be a
collection of behaviors rather than a coherent pattern of mental dysfunction.
These behaviors are also frequently found in children who suffer from
attention-deficit/hyper-activity disorder, another disruptive disorder, which is
discussed separately in this chapter. Children who develop the more serious
conduct disorders often show signs of these disorders at an earlier age.
Although it is common for a very young children to snatch something they want
from another child, this kind of behavior may herald a more generally aggressive
behavior and be the first sign of an emerging oppositional defiant or conduct
disorder if it occurs by the ages of 4 or 5 and later. However, not every
oppositional defiant child develops conduct disorder, and the difficult
behaviors associated with these conditions often remit.
Oppositional defiant disorder (ODD) is diagnosed when a child displays a
persistent or consistent pattern of defiance, disobedience, and hostility toward
various authority figures including parents, teachers, and other adults. ODD is
characterized by such problem behaviors as persistent fighting and arguing,
being touchy or easily annoyed, and deliberately annoying or being spiteful or
vindictive to other people. Children with ODD may repeatedly lose their temper,
argue with adults, deliberately refuse to comply with requests or rules of
adults, blame others for their own mistakes, and be repeatedly angry and
resentful. Stubbornness and testing of limits are common. These behaviors cause
significant difficulties with family and friends and at school or work (DSM-IV;
Weiner, 1997). Oppositional defiant disorder is sometimes a precursor of conduct
disorder (DSM-IV).
In different studies, estimates of the prevalence of ODD have ranged from 1 to 6
percent, depending on the population sample and the way the disorder was
evaluated, but not depending on diagnostic criteria. Rates are lower when
impairment criteria are more strict and when information is obtained from
teachers and parents rather than from the children alone (Shaffer et al.,
1996a). Before puberty, the condition is more common in boys, but after puberty
the rates in both genders are equal.
In preschool boys, high reactivity, difficulty being soothed, and high motor
activity may indicate risk for the disorder. Marital discord, disrupted child
care with a succession of different caregivers, and inconsistent, unsupervised
child-rearing may contribute to the condition.
Children or adolescents with conduct disorder behave aggressively by fighting,
bullying, intimidating, physically assaulting, sexually coercing, and/or being
cruel to people or animals. Vandalism with deliberate destruction of property,
for example, setting fires or smashing windows, is common, as are theft;
truancy; and early tobacco, alcohol, and substance use and abuse; and precocious
sexual activity. Girls with a conduct disorder are prone to running away from
home and may become involved in prostitution. The behavior interferes with
performance at school or work, so that individuals with this disorder rarely
perform at the level predicted by their IQ or age. Their relationships with
peers and adults are often poor. They have higher injury rates and are prone to
school expulsion and problems with the law. Sexually transmitted diseases are
common. If they have been removed from home, they may have difficulty staying in
an adoptive or foster family or group home, and this may further complicate
their development. Rates of depression, suicidal thoughts, suicide attempts, and
suicide itself are all higher in children diagnosed with a conduct disorder
(Shaffer et al., 1996b).
The prevalence of conduct disorder in 9- to 17-year-olds in the community varies
from 1 to 4 percent, depending on how the disorder is defined (Shaffer et al.,
1996a). Children with an early onset of the disorder, i.e., onset before age 10,
are predominantly male. The disorder appears to be more common in cities than in
rural areas (DSM-IV). Those with early onset have a worse prognosis and are at
higher risk for adult antisocial personality disorder (DSM-IV; Rutter & Giller,
1984; Hendren & Mullen, 1997). Between a quarter and a half of highly antisocial
children become antisocial adults.
The etiology of conduct disorder is not fully known. Studies of twins and
adopted children suggest that conduct disorder has both biological (including
genetic) and psychosocial components (Hendren & Mullen, 1997). Social risk
factors for conduct disorder include early maternal rejection, separation from
parents with no adequate alternative caregiver available, early
institutionalization, family neglect, abuse or violence, parents’ psychiatric
illness, parental marital discord, large family size, crowding, and poverty (Loeber
& Stouthamer-Loeber, 1986). These factors are thought to lead to a lack of
attachment to the parents or to the family unit and eventually to lack of regard
for the rules and rewards of society (Sampson & Laub, 1993). Physical risk
factors for conduct disorder include neurological damage caused by birth
complications or low birthweight, attention-deficit/hyperactivity disorder,
fearlessness and stimulation-seeking behavior, learning impairments, autonomic
underarousal, and insensitivity to physical pain and punishment. A child with
both social deprivation and any of these neurological conditions is most
susceptible to conduct disorder (Raine et al., 1998).
Since many of the risk factors for conduct disorder emerge in the first years of
life, intervention must begin very early. Recently, screening instruments have
been developed to enable earlier identification of risk factors and signs of
conduct disorder in young children (Feil et al., 1995). Studies have shown a
correlation between the behavior and attributes of 3-year-olds and the
aggressive behavior of these children at ages 11 to 13 (Raine et al., 1998).
Measurements of aggressive behaviors have been shown to be stable over time
(Sampson & Laub, 1993). Training parents of high-risk children how to deal with
the children’s demands may help. Parents may need to be taught to reinforce
appropriate behaviors and not harshly punish transgressing ones, and encouraged
to find ways to increase the strength of the emotional ties between parent and
child. Working with high-risk children on social interaction and providing
academic help to reduce rates of school failure can help prevent some of the
negative educational consequences of conduct disorder (Johnson & Breckenridge,
1982).
Back to the Mental Health: The Surgeon General's Report Table of Contents