Considering Disruptive Behaviors

Problems with oppositional, aggressive, and disruptive behaviors have long been of concern to mental health professionals; they continue to be among the most common problems in children referred for mental health intervention (1). Such behaviors are the source of much distress to the child as well as to the family and society, can be associated with a host of other difficulties (1), and, as the classic work of Robins and colleagues has shown (2, 3), are highly persistent. Despite the clear importance of these difficulties, their classification has been somewhat controversial, with the international (ICD) and American (DSM) systems taking somewhat different, if overlapping, approaches (4). DSM-IV draws a distinction between conduct disorder and oppositional defiant disorder, whereas ICD-10 defines conduct disorder as an amalgam of the two DSM-IV disorders. Further difficulties are raised by the complex question of comorbidity—the strong association of problems in conduct with attentional and other problems (5). Two articles in this issue address aspects of disruptive behavior disorders in children.

The review article by Keenan and Wakschlag is concerned with whether valid diagnoses of disruptive behavior disorders can be made in preschool children. They note that such problems are common reasons for referral to mental health clinics in this age group, and yet, somewhat paradoxically, there has been some controversy about how validly these diagnoses can be made in these children. This controversy reflects several factors, including a concern for premature (and possibly inappropriate) labeling, difficulties in dealing with developmental aspects of disruptive behavior, and potential difficulties in the applicability of the DSM-IV criteria for conditions that, in some respects, are clearly more oriented toward older children and adolescents. Keenan and Wakschlag propose a developmental approach and suggest that the degree of interference with normal developmental functioning can help distinguish the clinical condition of oppositional defiant disorder from more normative developmental issues involving oppositionality and increasing autonomy. For conduct disorder, some of the same developmental considerations apply. For example, learning to deal with aggression and its expression is a normative developmental task. A second issue in validity of the conduct disorder diagnosis is the idea that a child with the disorder must understand and thus knowingly violate societal rules. As the authors note, otherwise typically developing children have some basic understanding of rule violation as early as 3 years of age. On the other hand, studies of moral development suggest that major changes in this area occur throughout childhood. For preschool children, there is at least some evidence for the validity of these conditions, although interpretation of the data is compromised to some extent by the relative dearth of studies, the difficulties in diagnosis (e.g., given the orientation of the DSM-IV criteria to somewhat older children), and the tendency to lump oppositional defiant disorder and conduct disorder together in research and clinical reports. It is important to note that early-onset conduct problems may be even more persistent than later-onset ones (6, 7). Keenan and Wakschlag suggest that issues of assessment in children in this age group need to be carefully considered, particularly since young children with conduct problems seem to be at greater risk for persistent and more widespread difficulties (6). Similarly, additional work (8) has supported the effectiveness of an array of intervention techniques, including parent-focused, youth-focused, and system-based interventions, thus making early identification even more relevant.

In the second of this issue’s articles on disruptive behavior disorders, Wakefield and colleagues address a somewhat different problem—whether the diagnostic criteria for conduct disorder should consider social context. Their study found that, in a contrived experimental situation, mental health professional can incorporate consideration of social context into their clinical judgment of conduct disorder. This issue is important given DSM-IV’s text discussion of conduct disorder, which states that a diagnosis of the disorder should not be made if the symptoms are simply a reaction to a negative environment. As Wakefield and colleagues point out, the actual DSM-IV criteria for conduct disorder do not incorporate this exclusion. Thus clinicians who rely solely on the criteria to make a diagnosis (i.e., who fail to read the text) may not take special circumstances into account. The authors note the long history of concern about this problem. I am also reminded of a colleague, the late Dr. Donald Cohen, who, during a meeting of the DSM-IV childhood disorders work group, suggested only half facetiously that the word “THINK” be printed in large, boldface type at the head of each page of DSM-IV! As Wakefield and colleagues report, clinicians’ judgment that a child needs treatment as a result of a disordered environment does not necessarily imply that the child has a disorder.

These two articles highlight the advances made in understanding conduct disorder and other disruptive behavior disorders, as well as the significant issues that remain to be addressed. These issues include continuity over time (e.g., with adult disorders), the nature of risk and protective factors, and our understanding of causal factors, including theoretical models for the pathogenesis of these conditions. As Hill (1) suggested, there is a considerable need to broaden our conceptual/theoretical understanding. The articles by Keenan and Wakschlag and Wakefield and colleagues in this issue help further this goal.