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Chapter 23
Disruptive Behavior
Disorders
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Disruptive Behavior Disorders
• Characterized by persistent patterns of behavior that
involve:
– Anger
– Hostility
– Aggression
• Toward people and/or property
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Types of Disruptive Behavior Disorders
• Intermittent explosive disorder (IED)
• Oppositional defiant disorder (ODD)
• Conduct disorder
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Characterization of Disruptive Behavior
Disorders
• Some practitioners view oppositional defiant disorder and
conduct disorder as a continuum that also includes
antisocial personality disorder.
• Others view oppositional defiant disorder as a more mild
form of conduct disorder.
• Intermittent explosive disorder is often viewed as an
impulse control disorder.
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Intermittent Explosive Disorder (IED)
• Viewed as an impulse control disorder
• Involves aggression toward people and property
• Age of onset: adolescence to young adulthood, but only
diagnosed after 18 years of age
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Characteristics of Intermittent Explosive
Disorder
• Repeated episodes of impulsive, aggressive, violent
behavior and angry verbal outbursts
• Episodes last less than 30 minutes
• May involve physical injury to others, destruction of
property, or injury to self
• May feel guilty and remorseful after the outburst but not
able to refrain from future outbursts
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Characteristics of Intermittent Explosive
Disorder (cont.)
• Occurs more frequently in males ages 13 to 21
• 80% have a comorbid psychiatric disorder:
– Substance abuse
– ADHD
– Oppositional defiant disorder
– Depression
– Conduct disorder
– Anxiety disorder
• Often related to childhood trauma, neglect, or
maltreatment
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Intermittent Explosive Disorder Etiology
• Neurotransmitter imbalance (serotonin)
• Plasma tryptophan depletion
• Frontal lobe dysfunction
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Intermittent Explosive Disorder Treatment
• Psychopharmacology
– Fluoxetine (Prozac)
– Lithium
– Anticonvulsant mood stabilizers
• Cognitive–behavior therapy
• Anger management
• Relaxation techniques
• Avoidance of alcohol and illicit drug use
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Question
• Which of the following is considered a characteristic of
intermittent explosive disorder?
–
A. Episodes of anger lasting greater than 30
minutes
–
B. No feeling of guilt or remorse after episode
–
C. Injury to self, others, or property
–
D. Comorbidity of an autistic disorder
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Answer
•
C. Injury to self, others, or property
• Rationale: Intermittent explosive disorder includes
repeated episodes of violent behavior that include
physical injury to others, property, or self.
– Episodes last less than 30 minutes, and typically the
person experiences guilt/remorse but is unable to
refrain from future outbursts. Autistic disorders are
not an associate comorbidity.
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Oppositional Defiant Disorder (ODD)
• An enduring pattern of uncooperative, defiant,
disobedient, and hostile behavior toward authority
figures without major antisocial violations
• Typically behavior begins in adolescence.
• 25% develop conduct disorder; 10% diagnosed with
antisocial personality disorder as adults.
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Oppositional Defiant Disorder (ODD) (cont.)
• In oppositional defiant disorder, behaviors are more
frequent, intense, and lead to dysfunction in:
– Social
– Academic
– Work
• Impaired problem solving
• ↓ Attention, ↓ flexibility of thinking and decision making
(see Table 23.1.)
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Oppositional Defiant Disorder (ODD) (cont.)
• Occurs more frequently in males (with an ↑ in ♀
occurrence over past few years)
• Children with oppositional defiant disorder have lower
self-concept.
• Lack confidence in social situations
• Little insight into consequences of behavior
• Early onset of ODD is associated with ↑ risk of developing
conduct disorder (30%).
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Oppositional Defiant Disorder Etiology
Believed to be an interaction between:
– Genetics
– Temperament
– Adverse social conditions
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Oppositional Defiant Disorder Treatment
• Parental training models of behavioral interventions:
– Parents learn to ignore maladaptive behaviors.
– Positive behaviors are rewarded.
• Individual therapy with behavioral focus
• Treatment of any psychiatric comorbidities (ADHD,
anxiety, psychosis)
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Question
• Is the following statement true or false?
• Anticonvulsant mood-stabilizing medications are
frequently used to treat oppositional defiant disorder.
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Answer
• False
• Rationale: Oppositional defiant disorder treatment
typically involves behavioral interventions/behavior
therapy.
• Anticonvulsant mood stabilizers are used in treating
intermittent explosive disorder.
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Conduct Disorder
• Persistent antisocial behavior; two subtypes based on
age of onset
– Childhood—onset (before age 10)
– Adolescent—onset (after age 10)
• Classification: mild, moderate, severe
• Etiology: interaction of genetic vulnerability,
environmental adversity, factors such as poor coping
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Conduct Disorder (cont.)
• Risk factors/protective factors
• Treatment:
– Early intervention/prevention; parenting education,
social skills training, family therapy, individual
therapy, medications (in conjunction with treatment)
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Conduct Disorder and Nursing Process
Application
• Assessment
– History: disturbed peer relationships, aggression
toward people or animals, destruction of property,
deceitfulness, theft, truancy, running away, staying
out all night
– General appearance, motor behavior: typical for age
group; may be extreme
– Mood, affect: quiet, reluctant to talk; openly hostile,
angry; disrespectful
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Conduct Disorder and Nursing Process
Application (cont.)
• Assessment (cont.)
– Thought processes, content
– Sensorium, intellectual processes
– Judgment, insight: limited; rule breaking
– Self-concept: tough appearance; low self-esteem
– Roles, relationships: disruptive, possibly violent
– Physiologic, self-care
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Question
• Which of the following would the nurse most likely assess
in a child with a conduct disorder?
–
A. High self-esteem
–
B. Aggression toward animals
–
C. Disorientation
–
D. Lack of rational thinking
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Answer
•
B. Aggression toward animals
• Rationale: A child with conduct disorder will often exhibit
aggression toward people or animals.
– These children have low self-esteem; are oriented;
and are capable of logical, rational thinking.
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Conduct Disorder and Nursing Process
Application (cont.)
• Data analysis/nursing diagnoses:
– Risk for other-directed violence
• Outcome identification:
– No injury to others or damage to property
– Participate in effective problem solving and coping
– Use age-appropriate and acceptable behavior when
interacting with others
– Verbalize age-appropriate statements about self
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Conduct Disorder and Nursing Process
Application (cont.)
• Interventions
– Decreasing violence/increasing compliance with
treatment
• Limit setting with consistent enforcement
• Behavioral contracting; time-out
– Improving coping skills, self-esteem
– Promoting social interaction
– Providing patient, family education
• Evaluation
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Mental Health Promotion
• Parenting classes
• Assist parents to ↓ their own “risky” behaviors
• Child anxiety management
• Parent–child intervention emphasizing coping skills
• Early detection of potential problems (SNAP-IV Teacher
and Parent Rating Scale; see Chapter 22 and Box 22.2)
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Self-Awareness Issues
• Recognize own beliefs about parenting, how they differ
from others.
• Focus on patient’s and family’s strengths, not just
problems/support family.
• Try to have positive impact on patient even when
disability is severe.
• Recognize feelings associated with working with patients
with anger, violence, and aggression issues.
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