What are disruptive behaviour disorders?

Most of the children who receive psychiatric care are in therapy because of disruptive behaviours. Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are the best examples of diagnoses of clinically disruptive behavioural patterns. Early identification and treatment of children with disruptive behaviour disorders is crucial. There are great differences in the frequency, intensity and kind of symptoms that mark the onset of the disorder. Almost all children with CD also have an ODD diagnosis. Comorbid ADHD is also very prevalent among children with disruptive behaviour disorders.

What factors increase the risk of developing a disruptive behaviour disorder?

Several different environmental as well as genetic factors can contribute to the risk of developing a disruptive behaviour disorder.

The clearest case of an environmental exposure that predisposes to DBDs is exposure to active maternal smoking during pregnancy. Children from economically disadvantaged neighborhoods manifest DBDs more often, a phenomenon that is referred to as the neighborhood effect. Neighborhood disadvantage is also associated with exposure to neighborhood violence, which independently increases DBD risk. Children exposed to chronic violence also have faulty processing of interpersonal cues, with more negative and hostile attributions about others’ behavior, leading to increased aggression. There are indirect associations between family income and children’s behavioral problems mediated by maternal depression and parental stress: Exposure to maternal depression during infancy increases preschool children’s likelihood of developing DBDs, likely mediated by the effects of disengaged, harsh, or overly permissive parenting. Parental stress is another environmental risk factor for developing a disruptive behaviour disorder. 

Positive parenting techniques include close monitoring of the child, positive reinforcement, and regular engagement. These techniques are associated with decreased DBD risk, and are taught in parent management training programs used for prevention and treatment of preschool ODD and CD.  

Disruptive behaviour disorders cluster in families with ADHD, CD, ODD and depression. Recent studies have also investigated genetic polymorphisms that may predispose to DBDs through interaction with childhood adversity. Polymorphisms in the 5-hy- droxy-tryptamine transporter–linked polymorphic region (5HTTLPR) and monoamine oxidase A (MAOA) gene are the most intensely investigated. The S allele results in decreased production of serotonin transporters, and thus decreased serotonin clearance from the synaptic cleft. Although not all research supports this finding, some 5HTTLPR studies found that the S allele increases vulnerability to externalizing disorders in the context of childhood adversity.

What brain abnormalities are associated with disruptive behaviour disorders?

Disruptive behaviour disorders are accompanied with certain structural and functional abnormalities in the brain. There has not been executed a lot of research towards the brain structural and functional abnormalities in children with a disruptive behaviour disorder. However, it was established that children with ODD and CD have smaller bilateral amygdalae and insulae, as well as decreased brain activity in these areas on functional MRI. Decreased volume in the right striatum, left medial and superior frontal gyrus, and left precuneus were also found. Children with comborbid ADHD and ODD display decreased response inhibition and working memory. Children with a disruptive behaviour disorder also display more risk-taking behaviours. This behaviour is associated with decreased orbitofrontal cortex reactivity to reward in these children.

How can psychologists assess a disruptive behaviour disorder?

The Achenbach System of Empirically Based Assessment (ASEBA) is one of the most comprehensive report forms for assessment of DBDs, and there is a version for children 1.5 to 5 years of age. In addition to an ODD Diagnostic and Statistical Manual of Mental Disorders (DSM)–oriented scale and emotionally reactive and aggressive behavior syndrome scales, the ASEBA also screens for comorbid conditions. The Disruptive Behavior Diagnostic Observation Schedule is an observational method of assessing preschool disruptive behavior. 

How are disruptive behaviour disorders treated within psychotherapy?

Psychosocial interventions are the first-line treatments for preschool DBDs. Examples are Parent Management Training-Oregon Model, parent-child interaction therapy and the IY program.

• The Parent Management Training-Oregon Model (PMTO) focuses on training caregivers rather than focusing on the child directly. In the PMTO model, children’s disruptive behaviours result in part from parents’ unintentional reinforcement of children’s use of coercive methods to obtain what they want. The program involves a concerted effort to reshape parenting techniques, paring down reliance on coercion and focusing instead on positive reinforcement for prosocial behaviour.

• Parent-child interaction therapy (PCIT) is a dyadic therapy method focusing on the ways in which parent-child interactions can improve parents’ and children’s abilities to regulate strong emotions. Parents learn ways to engage positively with their children via praise and reflection, and how to ignore negative behaviors

• In the Incredible Years (IY) program, therapists observe parent-child interactions through a 1-way mirror, then discuss observed maladaptive interactional styles. In later sessions, therapists coach parents through interactions with their children, delivering instructions via earpiece.