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Section 16
The Diagnosis of Disruptive Behavior Disorders

CEU Question 16 | CEU Answer Booklet | Table of Contents | Parenting
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Disruptive behavior disorders in children and adolescents can lead to a lifetime of problems. The 2 disruptive behavior disorders identified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) are oppositional defiant disorder and conduct disorder. Although much research has been conducted to learn more about these 2 disorders, little is known about gender differences in the disorders. There is a dearth of specific information regarding girls with disruptive behavior disorders. This article discusses the diagnosis, risk factors, and treatment of oppositional defiant disorder and conduct disorder while incorporating information specific to girls to investigate how disruptive behavior disorders differ for girls.

Disruptive behavior disorders in children and adolescents can lead to a lifetime of social dysfunction, antisocial behavior, and poor adjustment (Kazdin, 1995). The consequences of these behaviors affect not only the children and adolescents who suffer from them, but their families, their peers, and society as a whole. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association [APA], 1994), classified oppositional defiant disorder (ODD) and conduct disorder (CD) as disruptive behavior disorders. A large body of research exists on these disruptive behavior disorders, but most of the documented information has been conducted with all male or predominantly male populations. Atkins, McKay, Talbott, and Arvanitis (1996) stated that CD and ODD in girls "are not well-understood by researchers and are likely to be overlooked by mental health staff' (p. 279). The focus of this article is on diagnosis, diagnostic methods, risk factors, and treatment approaches to girls displaying ODD and CD, despite the relative absence of research on female children and adolescents. (Please note that the terms boy and girl are used to refer to the periods of childhood and adolescence.)

Although ODD occurs with the same frequency in post-pubescent boys and girls, the female population seems to have been practically ignored in the existing studies of this disorder (APA, 1994). Atkins et al. (1996) pointed out that there are two to three times more boys diagnosed with CD than girls. They also reported that this diagnosis is the second most common diagnosis found in girls and has seldom been studied in the female population (Atkins et al., 1996). Zoccolillo, Tremblay, and Vitaro (1996) reported the tragic life circumstances that adolescent girls with CD are likely to face: early and violent death, arrest, substance abuse and dependence, failure to finish high school, and teenage pregnancy. That this disorder is one of the most prevalent in girls and that the consequences can be so devastating demonstrate the need to better understand CD and ODD in girls. We begin this discussion by differentiating, contrasting, and clarifying these two disorders.

Diagnosis of Disruptive Behavior Disorders
To discriminate between ODD and CD, it is important to understand the diagnostic criteria that have been established for each disorder. ODD was first introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; APA, 1980; Angold & Costello, 1996). It has progressed from a required two out of five behaviors in DSM-III to four out of eight behaviors in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; APA, 1987), to the current requirement of four out of eight behaviors in the DSM-IV (Angold & Costello, 1996). Atkins et al. (1996) noted that the deletion of swearing and using abusive language was the major change from DSM-III-R to DSM-IV.

The DSM-IV (APA, 1994) defines conduct disorder as a "repetitive and persistent pattern of behavior in which either the basic rights of others or major age-appropriate societal norms or rules are violated" (p. 85). Although CD is a separate diagnosis from ODD in the DSM-IV, the two disorders are often viewed as having a hierarchical relationship. Atkins et al. (1996) stated that studies have demonstrated that "most children with CD have early histories of ODD, and that there are similar family correlates for CD and ODD" (p. 275). Similarly, a history of CD is commonly found in adults diagnosed with antisocial personality disorder (APA, 1994).

Although CD is certainly the more serious of the two disorders, both disorders pose a considerable challenge to the counselor in both school and agency settings (Bernstein, 1996). In fact, these are among the most difficult clients that counselors in any setting are likely to encounter (Church, 1994), and the possibility of negative outcomes is always present (Kazdin, 1994). In DSM-IV field trials, Frick et al. (1994) were optimistic in their findings that diagnostic criteria may be applicable across gender, although only one third as many girls as boys were represented in the sample. The primary DSM-IV criterion found to have the most diagnostic utility for predicting CD in girls was fighting, even though fighting and cruelty were less frequent in girls than in boys (Frick et al., 1994). It should also be pointed out that a considerable number of adolescent girls who exhibit violence and lack impulse control have been victims of sexual abuse (Gil, 1996).

There is a primary difference in the way boys and girls present symptoms of disruptive behavior disorders. Externally directed behaviors, generally associated with boys, are acts that are harmful to others or the environment, such as stealing, lying, fighting, and destructiveness. Behaviors that are internally focused are more common in girls and include anxiety, shyness, withdrawal, hypersensitivity, and physical complaints (Kazdin, 1995). Unlike the overt acts that boys tend to exhibit with greater frequency, the covert behaviors usually occur without the awareness of adult caretakers (McMahon & Wells, 1998). Webster-Stratton (1996) reported that girls exhibit internalizing problems "at least twice as frequently as boys in the adolescent years" (p. 541). Because girls' behaviors are often not as overtly aggressive as those of boys, it is likely that boys would be noticed and referred more frequently than would girls. This may account for the finding that girls referred for conduct problems have more severe behavior problems (Webster-Stratton, 1996). It seems that emphasis needs to be placed on identifying these less noticeable, nonaggressive behaviors early to prevent problems from escalating. Zoccolillo argued that this information suggests a need for gender-specific criteria in diagnosing children with conduct problems, including a "lower threshold of aggressive behavior" for girls (as cited in Webster-Stratton, 1996, p. 549).

One critical difference in the symptoms presented by boys and girls with disruptive behavior disorders is the prevalence of comorbid disorders. Girls are more likely to be diagnosed as having one or more comorbid disorders, including attention deficit-hyperactivity disorder, anxiety, depressive disorders, somatization disorder, substance use disorders, antisocial personality disorder, and academic underachievement (McMahon & Wells, 1998). This difference underscores the need for increased attention to early detection of behavior disorders in girls. Another interesting difference between the sexes is related to the purpose or motive for aggressive behaviors. In researching aggression in boys and girls, Atkins and Stoff (1993) reported that boys have higher rates of hostile aggression, which is intended to inflict pain on the victim with little or no benefit to the aggressor. Instrumental aggression rates, however, were similar between the two sexes. Instrumental aggression provides some advantage to the aggressor that is not related to the discomfort of the victim.

A factor to consider when examining the differences in gender symptom presentation is the perceptions of significant others including parents, teachers, and peers. The expectations of these people may account for some of the differences noted between the sexes. For example, behaviors deemed appropriate for one sex may be considered dysfunctional for the other. It is difficult to speculate on the degree to which differences in symptomatology are created by typical adult expectations. This is simply because there is little information regarding the effects of parenting styles on girls with conduct problems; most parenting research has been conducted with boys (Webster-Stratton, 1996). One difference in parental expectations noted was that fathers tolerated physical aggression in boys but perceived problems with the internalizing behaviors of girls, which the mothers and teachers (98% of whom were female) did not view as problematic (Webster-Stratton, 1996). It might be speculated, then, that adults more easily tolerate behaviors from children of the same respective sex. Combine this with the fact that fathers are more involved with their sons than with their daughters (Webster-Stratton, 1996), an interesting possibility emerges concerning same-sex observations and amount of contact.

One reason that girls are not identified with problem behaviors as often could be that fathers, the parent who observes problems in the internalizing behaviors of girls, spend less time with their daughters. However, mothers may overlook their daughters' behaviors as problematic, and, because they are often the primary caregiver, conduct problems go undetected in girls. Another significant finding related to gender differences and parent expectations was the disciplinary actions taken with children. Physical punishment is used more often on boys than on girls in studies of normative, nonrisk samples (Webster-Stratton, 1996). On the other hand, girls are treated with more warmth and less aggression. This raises the issue of whether boys' greater externalizing behavior is related to the aggressive treatment they receive more often than girls do.

Peer expectations could also be a cause for differences in diagnosis. It is possible that because girls are expected to be more sensitive or withdrawn in approaching adolescence, friends fail to notice when this characteristic has become indicative of a behavior disorder. It could also be speculated that because girls with behavior disorders exhibit more covert behaviors, their friends fail to notice even a potential problem. From the viewpoint of the general society, stressors associated with budding female sexual identity during adolescence can also contribute to problem behaviors (J. B. Miller, 1986; Pipher, 1994). These stressors can include problems with body image, eating, sexual activity, and similar issues.

Although little is known about the differences in diagnosing boys and girls with disruptive behavior disorders, there are several factors of which mental health professionals and educators should become aware. There is a "discontinuity in girls' aggression and defiance" that makes it necessary to obtain assessments from several raters (Atkins et al., 1996, p. 279).

Atkins et al. addressed the generalization that girls with conduct problems tend to self-direct their .anger and remain nonconfrontational by pointing out that two groups of girls with more aggressive conduct problems exist: a small group with "aggressive behavior that is as severe and persistent as boys," and a larger group that "exhibits subtle social aggression, ostracism of others, and defiance" (p. 279). Although early identification is considered to be important for boys with disruptive behavior disorders, it is equally important for girls. Early identification is pertinent in preventing the behaviors from escalating to the more dramatic level (Zoccolillo et al., 1996). To facilitate the process of diagnosing behavior disorders a review of relevant instruments and assessments follows.

Specific Methods of Diagnosing Behavior Disorders
In diagnosing disruptive behavior disorders in children and adolescents, it is important to consider the child's behavior in general and--in an interactional context--his or her associated characteristics and disorders (i.e., temperament, ADHD) and familial and extrafamilial factors (McMahon & Wells, 1998). There are various methods used in the diagnostic process that takes these factors into account. Interviews, behavior rating scales, and behavior observations are among the most common tools used. Kazdin (1995) suggested using institutional and societal records in addition to other methods selected. Although there are advantages and disadvantages to each method, Kazdin emphasized the importance of using various methods in an assessment battery. The use of multiple assessments would certainly decrease the chances of misdiagnosis and would provide a more thorough evaluation of clients with these disorders. It would also give a view of the client taking multiple perspectives into account.

In determining the presence of a disruptive behavior disorder, the counselor may choose to interview the child, the parents, and the teacher. When the child is younger than 10, the individual interview is not considered to be useful because young children are often not able to reliably report their own behavioral symptoms (McMahon & Wells, 1998). With older children, however, these interviews can be very helpful in assessing the individual's perceptions of his or her behavior. Furthermore, in consideration of girls' high rate of internalizing behavior, it should be noted that they may be better at reporting internalizing disorders than other disorders (Hart, Lahey, Loeber, & Hanson, 1994). McMahon and Wells encouraged including the teacher interview when the child's behavior was affecting school performance. The parent interview is critical in determining interactions between parents and children that could be problematic. One recommended interview format developed by McConaughy and Achenbach is the Semi-Structured Clinical Interview for Children and Adolescents (McMahon & Wells, 1998), which "employs a protocol of open-ended questions to assess a variety of areas of children's functioning" (p. 122).

One of the few studies on diagnostic methods that actually included almost the same number of female participants as male participants was the Diagnostic Interview Schedule for Children, Version 2.3 (DISC-2.3; Schwab-Stone et al., 1996). Although gender differences were not analyzed in this study, this team of researchers nevertheless reported that an adult informant is necessary for a reasonable assessment of the disorder because it requires "reporting on the child's negative impact on the social environment" (p. 886). Children are not likely to correctly identify the ways in which their behavior negatively affects those around them. CD diagnosis seems to be less subjective with the DISC 2.3 because the behaviors are usually factual matters not relying on self-reports, such as legal or school records (Schwab-Stone et al., 1996).

Behavior Rating Scales
Behavior rating scales are among the most popular diagnostic measures for children with disruptive behavior disorders. Either adults or children can complete these rating scales. McMahon and Wells (1998) reviewed and recommended several scales (based on psychometric properties) considered to be most appropriate for clinical and research purposes with children who have behavior disorders. One such scale is the Child Behavior Checklist (Achenbach & Edelbrock, 1985; as cited in McMahon & Wells, 1998) by Edelbrock and Achenbach, which consists of parallel forms for parents, teachers, youth, and other observers. Another suggested scale is the Eyberg Child Behavior Inventory by Eyberg (as cited in McMahon & Wells, 1998), which focuses on the specific aspects of conduct problems. A third scale, suggested by McMahon and Ester (as cited in McMahon & Wells, 1998), is the Self-Report Delinquency Scale, considered to be one of the most widely used self-report measures in youth ages 11 to 19. An additional scale, which may be used for diagnostic purposes, is the Conners Teacher Rating Scale (L. S. Miller et al., 1995).

Another method of diagnosis that is relevant to school personnel is the New York Teacher Rating Scale, a 90-symptom standardized behavior scale devised for teachers to identify students with "defiant, aggressive, and antisocial behavior" (L. S. Miller et al., 1995). As L. S. Miller et al. noted, teachers are able to observe children in a "critical functional setting" (la. 367), so an instrument of this nature is highly practical. This method would also be ideal for use in public schools because it is inexpensive and is not time-intensive.

Behavior Observations
Although rating scales are valuable for providing information to teachers and mental health personnel, there are advantages to direct observation by the counselor who will be working with the identified child. A checklist completed by the counselor provides very objective information, not allowing for "individual insights" into a child's particular prognosis that may inject bias into the assessment process. McMahon and Wells (1998) noted a twofold purpose of behavior observations: determining maladaptive interaction patterns between the child and the parent or teacher, and assessing changes in these interactions for treatment functions. Behavior observation formats that were suggested for their psychometric properties are the Behavioral Coding System, the Dyadic Parent-Child Interaction Coding System II, and the Interpersonal Process Code (McMahon & Wells, 1998). Both the Behavioral Coding System and the Interpersonal Process Code have been adapted for school use as well.

Another observation method for gathering information useful in diagnosis and in treatment is diagnostic peer groups. Trad (1992) noted that the material gathered in such a group is used to "validate and/or supplement the material gathered about the child from conventional sources" (p. 115); that is, it should not be considered as a replacement but as an adjunct to other methods. For young children at risk of disruptive behavior disorders, a natural environment in which children are interacting with others could provide a wealth of information about them. Not only can details pertaining to diagnosis be obtained, but the data collected may also determine which children would be successful in group therapy (Trad, 1992).

One method that encompasses various screening tools is the Multiple-Gate Screening developed by August, Realmuto, Crosby, and MacDonald (1995). This three-gate procedure is used to identify children at a high risk for behavior disorders. It includes a 10-item teacher scale and a 10-item parent scale regarding the child's disruptive behavior and a 15-item parent scale about discipline in the family (August et al., 1995). This screening procedure's most unique feature is that it was designed to identify students in suburban communities who would be eligible for early intervention programs. This type of identification procedure would be ideal for application in school communities because it is relatively brief and simple. It could give counselors, teachers, and instructional support teams an early indicator of students who could benefit from school-supported intervention programs.

Not only must diagnosticians evaluate children and adolescents solely to determine whether or not they have a disruptive behavior disorder, they must also attend to the severity of the disorder. One measure specifically designed to determine level of severity is a pictorial instrument (Ernst, Godfrey, Silva, Pouget, & Welkowitz, 1994) consisting of 350 pictures drawn to represent criteria for psychotic, mood, anxiety, and disruptive disorders in childhood as specified in the DSM-III-R. Such an instrument is more applicable to patients with severe psychiatric disorders and would not be used as it exists now for school settings (Ernst et al., 1994). However, a similar instrument designed for populations with less severe disorders might be quite useful for ODD and CD and warrants the attention of test constructors.
- Kann, Traci & Fred Hanna; Disruptive behavior disorders in children and adolescents: how girls differ from boys; Journal of Counseling & Development; Summer 2000; Vol. 78; Issue 3.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #2
The preceding section contained information about the diagnosis of disruptive behavior disorders.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
According to Kann & Hanna, what is the benefit in using peer groups to gather information useful in diagnosing and treating a child with a disruptive behavior disorder? Record the letter of the correct answer the CEU Answer Booklet.

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The article above contains foundational information. Articles below contain optional updates.
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