7.15 Behavior Disorders

Children sometimes argue or act angry or defiant around adults. However, a behavior disorder is diagnosed in children if the child demonstrates disruptive behaviors that are uncommon for the child’s age, persist over time, or are severe. Two types of behavior disorders are oppositional defiant disorder and conduct disorder.^[1]

Oppositional Defiant Disorder

All children have oppositional behaviors from time to time, particularly when they are feeling tired, hungry, stressed, or upset. They may argue, talk back, disobey, and defy parents, teachers, or other adults. Oppositional behavior is considered a normal part of development for children two to three years of age and early adolescents. However, uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age or when it significantly affects a person’s social, family, and academic life. Oppositional defiant disorder (ODD) is diagnosed by a mental health professional based on a pattern of angry/irritable mood, argumentative/defiant behaviors, or vindictiveness lasting at least six months.^[2]

Assessment (Recognizing Cues)

Nurses assess for ODD behaviors, including the following^[3]:

• Often being angry, losing one’s temper, or being easily annoyed
• Often arguing with authority figures, or for children and adolescents arguing with adults
• Often actively defies or refuse to comply with requests from authority figures or rules
• Often deliberately annoys others
• Often blames others for their mistakes or misbehavior
• Has been spiteful or vindictive at least twice in the past six months

Severity is determined by the number of settings in which the behavior occurs, such as home, school, work, and peers. Mild cases are present in one setting, moderate cases in two settings, and severe cases are present in three or more settings.^[4]

ODD in Children and Adolescents

For children younger than five years, the behavior occurs on most days for at least six months. For children five years or older, the behavior occurs at least once a week for at least six months. Other factors are also considered, such as developmental level, gender, and culture.^[5]

Treatment

Treatment of ODD includes the following:

• Parent behavioral management training to help parents manage the child’s behavior
• Individual psychotherapy to develop effective anger management skills
• Family psychotherapy to improve communication and mutual understanding
• Cognitive behavioral therapy and other psychotherapies to decrease negativity and enhance effective problem-solving
• Social skills training to increase flexibility and improve frustration tolerance with peers

Medications may be prescribed to control distressing symptoms of ODD, as well as symptoms of coexisting conditions such as ADHD, anxiety, and mood disorders.

Nursing Interventions

Parents of children diagnosed with ODD need support and understanding. Nurses can teach parents to help their child with ODD in the following ways:

• Provide praise and positive reinforcement when the client shows flexibility or cooperation. Discipline will not work without positive interactions also occurring.
• Take a time-out or break if conflict with your child is progressively getting worse instead of better. This sets a good example for the child, and if the child decides to take a time-out to prevent overreacting, they should receive support for doing so.
• Prioritize battles because the child with ODD has trouble avoiding power struggles. Parents should prioritize the things they want their child to do and communicate calmly. Parents should refrain from shouting back when the child shouts.
• Set reasonable, age-appropriate limits and consequences and enforce consistently.
• Collaborate and obtain support from other adults working with your child (e.g., teachers and coaches).
• Manage stress with stress management and positive coping strategies such as participating in mindfulness, meditation, or yoga; using humor and jokes; seeking spiritual or religious pursuits; breathing exercises; and seeking social support. Maintain personal interests so managing your child with ODD doesn’t take all your time and energy. Use respite care and other breaks as needed. Read more about stress management techniques and positive coping strategies in the “Applying the Nursing Process to Promote Healthy Coping” in the “Mental Health Concepts” chapter.

Conduct Disorder

Conduct disorder (CD) is diagnosed by a mental health professional when a client shows an ongoing pattern of behavior in which the basic rights of others or societal norms or rules are violated. Categories of behaviors include aggression to people and animals, destruction of property, deceitfulness or theft, or serious violations of rules.

Assessment (Recognizing Cues)

Nurses assess for and document examples of CD behaviors such as the following^[6]:

• Bullying, threatening, or intimidating others
• Initiating physical fights
• Using a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife or gun)
• Being physically cruel to people or animals
• Stealing while confronting a victim (e.g. mugging, purse snatching, armed robbery)
• Forcing someone into sexual activity
• Deliberately setting fires with the intention of causing serious damage
• Deliberately destroying other people’s property
• Breaking into someone’s house, building, or car
• Lying to obtain goods or favors or to avoid obligations
• Shoplifting
• Staying out all night despite parental prohibitions, beginning before age 13
• Running away from home overnight
• Truant from school, beginning before age 13

Health care providers also determine if the individual exhibits limited prosocial emotions, such as lack of remorse or guilt, lack of empathy, unconcern about performance, and shallow or insincere emotions (e.g., emotions can be turned “on” or “off” quickly to manipulate or intimidate others).^[7]

CD in Children and Adolescents

There are three major types of CD called childhood-onset (i.e., symptoms occur prior to age 10), adolescent-onset (no symptoms occur before age 10), or unspecified onset.^[8]

Children who exhibit serious behaviors suggestive of conduct disorder should be referred to a mental health professional for comprehensive evaluation and treatment. Some behavior problems at school can also be related to learning disorders that require additional assessment and interventions at school. Without treatment, many children with conduct disorder have ongoing problems and the inability to adapt to the demands of adulthood that often result in incarceration.

Treatment

Early treatment for CD is important. For younger children, research indicates the most effective treatment is behavior therapy training for parents where a therapist helps parents learn effective ways to strengthen the parent-child relationship and respond to the child’s behavior. For school-age children and teens, a combination of behavior therapy training that includes the child, the family, and teachers at school is most effective.