Disruptive, Impulse-Control, and Conduct Disorders

These are not the ordinary defiance and tempers of childhood. Disruptive, impulse-control, and conduct disorders are persistent, they violate rules and the rights of others, and the patient often cannot control emotion or behavior. The cluster runs from oppositional defiant disorder and intermittent explosive disorder through conduct disorder, antisocial personality disorder, pyromania, and kleptomania, and it can turn violent or aggressive toward people or property.

Description

In DSM-5, oppositional defiant disorder and conduct disorder sit alongside antisocial personality disorder and intermittent explosive disorder, reflecting data that link them clinically and biologically along a developmental spectrum. Antisocial personality disorder concerns violations of others' rights. Intermittent explosive disorder is defined by impulsive aggressive and assaultive behavior out of proportion to the stressor.

• Oppositional defiant disorder (ODD). A childhood disorder of frequent, persistent anger, irritability, arguing, defiance, or vindictiveness toward authority figures.
• Intermittent explosive disorder (IED). Repeated, unforeseen episodes of impulsive, destructive, violent behavior or angry verbal outbursts grossly out of proportion to the situation.
• Conduct disorder (CD). Persistent antisocial behavior in children and adolescents that impairs social, academic, or occupational function. These patients show little empathy, low self-esteem, poor frustration tolerance, and temper outbursts, often with early sexual behavior, drinking, smoking, illegal substance use, and other reckless behavior.
• Antisocial personality disorder (ASPD or APD). A long-term pattern of manipulating, abusing, or violating others' rights without guilt.
• Pyromania. An impulse to set fires, marked by recurrent failure to resist the urge in persons who are not psychotic, cognitively impaired, or antisocial.
• Kleptomania. A rare but serious disorder of recurrent inability to resist urges to steal items the person does not need and that usually have little value.

Statistics and Incidences

Conduct disorder occurs in 2 to 10 percent of the population, with a median prevalence of 4 percent, rising from childhood to adolescence and higher in males than females. Oppositional defiant disorder occurs in 1 to 11 percent of the population, average estimate around 3.3 percent, more prevalent in males at a ratio of about 1.4:1 before adolescence, though this does not consistently carry into adolescence or adulthood. Intermittent explosive disorder occurs in about 2.7 percent of the population and is more prevalent in those younger than 35-40 years. Kleptomania prevalence is estimated at 0.3% to 0.6% in the general population.

Causes

Genetic vulnerability, environmental adversity, and factors such as poor coping interact to produce the disorder.

• Genetics. Genetic risk exists for conduct disorder though no specific marker is identified; it is more common in children with a sibling who has conduct disorder or a parent with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD.
• Biologic. Children with conduct disorder show a lack of autonomic nervous system reactivity, mirroring adults with antisocial personality disorder.
• Environmental. Poor family functioning, marital discord, poor parenting, and a family history of substance abuse and psychiatric problems all link to conduct disorder.

Clinical Manifestations

Oppositional defiant disorder. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, shown by at least 4 symptoms from the categories below during interaction with at least 1 person who is not a sibling.

Angry and irritable mood:

• Often loses temper.
• Often touchy or easily annoyed.
• Often angry and resentful.

Argumentative and defiant behavior:

• Often argues with authority figures, or with adults in children and adolescents.
• Often actively defies or refuses to comply with requests or rules.
• Often deliberately annoys others.
• Often blames others for his or her mistakes or misbehavior.

Vindictiveness:

• Spiteful or vindictive at least twice within the past 6 months.

Intermittent explosive disorder, occurring twice weekly on average for 3 months:

• Verbal aggression
• Temper tantrums
• Tirades
• Verbal arguments or fights
• Physical aggression toward property, animals, or people that does not damage property or cause physical injury
• 3 behavioral outbursts involving damage or destruction of property and/or physical assault causing injury to animals or people within a 12-month period

Conduct disorder. A repetitive, persistent pattern violating the basic rights of others or major age-appropriate norms, shown by at least 3 of the 15 criteria in the past 12 months, with at least 1 in the past 6 months.

Aggression to people and animals:

• Often bullies, threatens, or intimidates others.
• Often initiates physical fights.
• Has used a weapon that can cause serious harm (bat, brick, broken bottle, knife, gun).
• Has been physically cruel to people.
• Has been physically cruel to animals.
• Has stolen while confronting a victim (mugging, purse snatching, extortion, armed robbery).
• Has forced someone into sexual activity.

Destruction of property:

• Has set fires deliberately to cause serious damage.
• Has deliberately destroyed others' property by means other than fire.

Deceitfulness or theft:

• Has broken into someone else's house, building, or car.
• Often lies to obtain goods or favors or to avoid obligations.
• Has stolen items of nontrivial value without confronting a victim (shoplifting, forgery).

Serious violations of rules:

• Often stays out at night despite parental prohibitions, beginning before age 13 years.
• Has run away from home overnight at least twice, or once without returning for a lengthy period.
• Often truant from school, beginning before age 13 years.

Antisocial personality disorder:

• Pervasive poor social conformity, deceitfulness, impulsivity, criminality, and lack of remorse.
• Disregard for right and wrong; persistent lying.
• Being tough, cynical, and rude; using charm or wit to manipulate others for gain or pleasure.
• Arrogance, a sense of superiority, and being extremely opinionated.
• Recurring problems with the law, including criminal behavior, and repeatedly violating others' rights through intimidation and dishonesty.
• Hostility, significant irritability, agitation, aggression, or violence.
• Unnecessary risk-taking or dangerous behavior with no regard for safety.
• Poor or abusive relationships; failure to consider or learn from negative consequences.
• Consistent irresponsibility and repeated failure to meet work or financial obligations.

Pyromania:

• Multiple episodes of deliberate, purposeful fire setting and failure to resist the impulse on more than one occasion.
• Watching fires in their communities and setting off false fire alarms.
• Fascination with or attraction to fire and its contexts (paraphernalia, uses, consequences).
• Pleasure, gratification, or relief when setting fires or witnessing their aftermath.
• Fire setting not done for monetary gain, ideology, concealing crime, anger or vengeance, improved circumstances, delusion or hallucination, or impaired judgment.
• Not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Kleptomania:

• Failure to resist powerful urges to steal items not needed.
• Rising tension, anxiety, or arousal before the theft.
• Pleasure, relief, or gratification during the theft.
• Guilt, remorse, self-loathing, shame, or fear of arrest afterward.
• Return of the urges and repetition of the cycle.
• Stealing not done to express anger or vengeance and not in response to a delusion or hallucination.
• Not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Medical Management

Because conduct problems carry many comorbidities, treatment usually combines medication, parenting skills, family therapy, and school consultation.

• Preschool. Programs such as Head Start lower rates of delinquent behavior and conduct disorder through parental education on normal growth and development, child stimulation, and parental support during crises.
• School age. Treatment targets the child, family, and school: parenting education, social skills training for peer relationships, and efforts to improve academic performance and compliance with authority.
• Adolescents. Adolescents rely more on peers than parents, so treatment includes individual therapy.

Pharmacologic Management

Stimulants effectively control inattention, impulsivity, and hyperactivity in the short term.

• Stimulants. First choice, given a relatively safe side-effect profile. When misuse or diversion is a risk, choose less abusable agents such as Daytrana (methylphenidate in patch form) or Vyvanse (lisdexamfetamine), which is oral but bound to lysine and requires stomach acid to activate.
• Anticonvulsants. Second-line for nonspecific aggression.
• Lithium. Lithium and methylphenidate reduced aggressiveness in one set of studies, but later followup research could not replicate lithium's effect.

Nursing Management

Nursing Assessment

• History. Disturbed peer relationships, aggression toward people and animals, destruction of property, deceitfulness or theft, and serious rule violations.
• General appearance and motor behavior. Typically normal for age but may be somewhat extreme.
• Mood and affect. Quiet and reluctant or openly hostile and angry, usually disrespectful toward parents, nurses, or any authority.
• Judgment and insight. Limited for the developmental stage; the client breaks rules with no regard for consequences.
• Roles and relationships. Disruptive and sometimes violent, especially with authority.

Nursing Diagnosis

• Risk for other-directed violence related to aggression toward people or animals.
• Noncompliance related to resentment of authority.
• Ineffective coping related to low self-esteem.
• Impaired social interaction related to hostility toward authority.
• Chronic low self-esteem related to lack of self-worth.

Nursing Care Planning and Goals

The client will not hurt others or damage property, will participate in treatment, will use effective problem-solving and coping skills, will use age-appropriate and acceptable behaviors with others, and will voice positive, age-appropriate statements about self.

Nursing Interventions

• Decrease violence, increase compliance. Set limits on unacceptable behavior at the start. For limits to work, the consequences must matter to the client, such as recreation time they value.
• Improve coping and self-esteem. Accept the client as a worthwhile person even when behavior is not. Set limits matter-of-factly, without judgmental statements.
• Promote social interaction. Name what is inappropriate (profanity, name-calling) and what is appropriate; positive feedback tells the client they are meeting expectations.
• Involve the family. Teach parents age-appropriate activities and expectations: reasonable curfews, household responsibilities, and acceptable behavior at home.

Evaluation

Goals are met when the client does not hurt others or damage property, participates in treatment, uses effective problem-solving and coping skills, behaves in age-appropriate ways with others, and voices positive, age-appropriate statements about self.

Documentation Guidelines

Document individual findings (contributing factors, interactions, social exchanges, specific behaviors); cultural and religious beliefs and expectations; the plan of care; the teaching plan; responses to interventions and teaching; and progress toward outcomes.

Pediatric Considerations

• Conduct disorder usually begins in ages 6-10 and does not show before age 10. The hallmark is behavior that grossly violates social norms (animal torture, stealing, truancy), with high risk for criminal behavior, antisocial personality disorder, and substance abuse in adulthood.
• Oppositional defiant disorder usually begins at age 8 with defiant, negative behavior (anger) that does not violate social norms. These children are argumentative and resentful, especially toward authority. Many develop conduct disorder in adulthood, and remission rates are high.

Nursing care tips for children with ADHD and conduct disorders:

• Build a trusting relationship with child and family by conveying acceptance.
• Give clear behavioral guidelines, including consequences for disruptive and manipulative behavior.
• Talk with the child about making acceptable choices.
• Teach effective problem-solving skills and have the child demonstrate them back.
• Identify abusive communication (threats, sarcasm, disparaging comments) and encourage the child to stop.
• Teach constructive ways to release negative feelings and express anger appropriately.
• Help the child accept responsibility for behavior rather than blaming others, becoming defensive, or wanting revenge.
• Use role-playing to practice handling stress and build confidence with difficult situations.
• Teach parents how to handle the child's demands, including reinforcing appropriate behavior and bonding more strongly with the child.