These are a group of disorders that are linked by varying difficulties in controlling aggressive behaviors, self-control, and impulses. Typically, the resulting behaviors or actions are considered a threat primarily to others’ safety and/or to societal norms. Some examples of these issues include fighting, destroying property, defiance, stealing, lying, and rule breaking.
These disorders are:
- Oppositional defiant disorder
- Intermittent explosive disorder
- Conduct disorder
- Other specified disruptive, impulse-control and conduct disorder
- Unspecified disruptive, impulse-control, and conduct disorder
Problematic behaviors and issues with self-control associated with these disorders are typically first observed in childhood and can persist into adulthood. In general, disruptive, impulse-control, and conduct disorders tend to be more common in males than females, with the exception of kleptomania.
Behavioral issues are a common reason for referral to psychiatrists or other mental health providers. It is important to note that it can be developmentally appropriate for kids to become disruptive or defiant at times. However, disruptive, impulse, and conduct disorders involve a pattern of much more severe and longer-lasting behaviors then what is developmentally appropriate. For instance, these behaviors are frequent, occur in various settings, and can have significant consequences (including legal repercussions). It is also important to consider that anger and defiance can be manifestations of other disorders.
One difference between disruptive behavioral disorders and many other mental health conditions is that with behavioral disorders, a person's distress is focused outward and directly affects other people. With most other mental health conditions, such as depression and anxiety, a person's distress is generally directed inward toward themselves.
Types of Disorders
Oppositional Defiant Disorder
Oppositional defiant disorder is a common disorder in children and adolescents who are referred to mental health providers for behavioral issues. Individuals with this disorder experience varying levels of dysfunction secondary to oppositionality, vindictiveness, arguments, and aggression.1
Symptoms of oppositional defiant disorder include a pattern of:
- Angry/irritable mood—often loses temper, easily annoyed, often angry and resentful.
- Argumentative/defiant behavior—often argues with authority figures or adults, often refuses to comply with requests or rules, deliberately annoys others, blames others for mistakes or misbehavior.
- Vindictiveness—spiteful or vindictive.
These behaviors are distressing to the individual and alarming to others. Anger, threatening behaviors, and spitefulness cause disruption at school or work and affect relationships with others. Of note, these behaviors do not include aggression towards animals or people, destruction, or theft.2 In other words, there are no violations to others or societal norms.1 Individuals with oppositional defiant disorder, will likely experience conflict with adults and authority figures.
To be diagnosed with Oppositional defiant disorder, the behaviors must occur with at least one individual who is not the person's sibling. Signs of the disorder typically develop during preschool or early elementary school but can also begin in adolescence.3 For children under age 5, the behaviors occur on most days for at least six months. For people 5 and older, the behaviors occur at least once per week for at least six months. The severity of this illness is based on the number of settings in which these behaviors are observed.
The cause of oppositional defiant disorder is not fully understood. However, it is believed that ODD might be secondary to several biological, psychological, and social factors. There are several risks associated with the development of oppositional defiant disorder: having poor frustration tolerance, high levels of emotional reactivity, neglect during childhood, and inconsistent parenting.2 ODD tends to be more common in children who live in poverty and is more common in boys than girls prior to adolescence.3 The prevalence of oppositional defiant disorder is about 3.3%.
Many, but not all, children and adolescents who have been diagnosed with oppositional defiant disorder will later be diagnosed with Conduct Disorder, which is typically considered a more severe behavioral disorder. More information on Conduct Disorder to follow. However, oppositional defiant disorder is not necessarily a chronic condition. About 70% of individuals with oppositional defiant disorder will have resolution of the symptoms by the time they turn 18 years old.3 Furthermore, about 67% of children diagnosed with oppositional defiant disorder will no longer meet diagnostic criteria within a 3 year follow up.1 Of note, adults and adolescents who have been diagnosed with oppositional defiant disorder have a 90% chance of being diagnosed with another mental illness in their lifetime3 - especially anxiety disorders, mood disorders, substance abuse, conduct disorder, antisocial personality disorder, and other personality disorders. Individuals with oppositional defiant disorder, have higher risk of dying by suicide then the general population.3
Oppositional defiant disorder is diagnosed by a psychiatrist or other mental health professional based on information from the individual (child, adolescent, adult) and, for children/adolescents, from parents, teachers and other caregivers. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that it's important for a child to have a comprehensive evaluation to identify any other conditions which may be contributing to problems, such as ADHD, learning disabilities, depression or anxiety.1
Treatment of oppositional defiant disorder often involves a combination of therapy and training for the child, and training for the parents. For children and adolescents, cognitive problem-solving training can teach positive ways to respond to stressful situations. Social skills training helps children and youth learn to interact with other children and adults in a more appropriate, positive way. In some cases, medications might be necessary.
Parent management training can help parents learn skills and techniques to respond to challenging behavior and help their children with positive behavior. The training focuses on providing supportive supervision and immediate, consistent discipline for problem behavior. According to ACAAP, one-time or short programs that try to scare or coerce children and adolescents into behaving, such as tough-love or boot camps, are not effective and may even be harmful.1
If you're concerned about your child's behavior, talk to your child's doctor or a mental health professional, such as a child psychiatrist or psychologist or a child behavioral specialist.
Conduct disorder involves severe behaviors that violate the rights of others or societal norms. Behaviors may involve aggression towards others, animals, and/or destruction of property all of which could result in legal consequences.4 As stated in the oppositional defiant disorder section, many (but not all) children and adolescents with oppositional defiant disorder will eventually meet diagnostic criteria for conduct disorder. However, not all individuals who are diagnosed with Conduct Disorder were first diagnosed with ODD.5
Symptoms of conduct disorder include varying patterns of:
- Aggression to people and animals (bullies, intimidates others, initiates fights, use of weapons, cruelty to others, cruelty to animals, stolen while confronting a victim, raped others).
- Destruction of property (deliberate fire setting, vandalization).
- Deceitfulness or theft (broken into properties, manipulates others, stolen).
- Serious violations of rules (runs away from home, truant from school, stays out at night).
Per the DSM-5, these behaviors can first be observed in pre-school. However, the more significant symptoms tend to appear between middle childhood and middle adolescents. It is rare for these symptoms to first appear after the age of 16. Conduct disorder is only diagnosed in children and youth up to 18 years of age. Adults with similar symptoms may be diagnosed with antisocial personality disorder. Early treatment can help prevent problems from continuing into adulthood.
There are multiple risk factors for the development of conduct disorder, including: harsh parenting styles, exposure to physical or sexual abuse during childhood, unstable upbringing, maternal substance use during pregnancy, parental substance use and criminal activity, and poverty.5
These behaviors cause significant dysfunction in multiple settings such as at home, in school, in relationships, and in occupational settings. However, people with conduct disorder may deny or downplay their behaviors. Conduct disorder is generally considered more serious than ODD. It can be associated with criminal behaviors, dropping out of high school, and substance abuse. About 40% of individuals who meet diagnostic criteria for conduct disorder, will later meet diagnostic criteria for 5antisocial personality disorder.4 The prevalence of conduct disorder is between 1.5% and 3.4%. It tends to be more common in males. About 16-20% of youth with conduct disorder also have ADHD.5 Of note, youth that have both ADHD and Conduct Disorder have higher risk of substance use.
Therapy can help children learn to change their thinking and control angry feelings. Treatment may include parent management training and family therapy, such as Functional Family Therapy. Functional Family Therapy helps families understand the disorder and related problems, teaches positive parenting skills and helps build family relationships. It can help families apply positive changes to other problem areas and situations.
Intermittent Explosive Disorder
Intermittent explosive disorder is a disorder associated with frequent impulsive anger outbursts or aggression—such as temper tantrums, verbal arguments, and fights.2 The observed behaviors result in physical assaults towards others or animals, property destruction, or verbal assaults.6 The aggressive outbursts:
- Are out of proportion to the event or incident that triggered them.
- Are impulsive.
- Cause much distress for the person.
- Cause problems at work or home.
It is important to note that these aggressive behaviors are not planned, they are impulsive and anger based.7 They happen rapidly after being provoked and typically do not last longer than 30 minutes.2 These outbursts must be associated with subjective distress or social or occupational dysfunction.7 Affected individuals tend to have poor life satisfaction and lower quality of life.7
In order to meet diagnostic criteria, affected individuals must be at least 6 years old or the developmental equivalent.2 However, this disorder is usually first observed in late childhood or adolescence.2 The one-year prevalence is 2.7% and lifetime prevalence is 7%.8
Many risk factors have been identified with the development of Intermittent Explosive Disorder, such as: being male, young, unemployed, single, having lower levels of education, and being victim of physical or sexual violence.6 Intermittent explosive disorder is associated with anxiety and bipolar disorders.6 Individuals with this disorder have higher risks of developing substance use disorders than those without it.7
Treatment typically involves cognitive behavioral therapy focusing on changing thoughts related to anger and aggression and developing relaxation and coping skills. Sometimes, depending on a person's age and symptoms, medication may be helpful.
While fire setting can be a common issue among young individuals and a cause of significant destruction in the United States, it is different from pyromania which is a rare disorder that involves repeated impulses or strong desires to set intentional fires.9 Fire setting is typically motivated by curiosity and tends to occur in unsupervised children with access to lighters and matches.9 Individuals with pyromania, on the other hand, are fascinated by fire and its uses. Affected individuals engage in repeated and deliberate fire setting that is not motivated by external reasons.10 They experience strong urges to engage in dangerous fire setting. They also experience internal tension prior to setting fires that is followed by pleasure after fires are lit. These individuals set fires to release built-up inner emotional tension, not for any type of material gain or revenge.
Some known risk factors for pyromania are male gender, substance use, victim of abuse, being fascinated with fires, and having mental illness.11 The prevalence of pyromania is about 1% in the United States.9 It is associated with personality disorders or traits (especially antisocial personality disorder or antisocial behaviors), conduct disorder, and substance use disorders.9
Treatment of pyromania usually involves cognitive behavioral therapy and education. The therapy can help people become more aware of the feelings of tension and find ways to cope. Every child should be taught about the dangers of playing with fire and possible consequences.9
Kleptomania is a rare disorder that involves involuntary, impulsive, and irresistible stealing of objects that are not needed for personal or other forms of use. This is different from shoplifting in that shoplifters steal for some form of gain and often plan out their actions.21 However, individuals with Kleptomania do not need what they have stolen. They often give away, return, hide, or hoard the stolen objects.13 People with kleptomania know what they are doing is wrong but cannot control the impulse to steal, leading to hasty and poorly thought-out stealing.12 They experience internal tension before stealing that is then relieved after the theft. While they experience pleasure or gratification from stealing, they tend to have guilt or sadness afterwards.13 Many people with this disorder may try to stop stealing but feel guilt and shame about their inability to do so.13 Unfortunately, many may be apprehended or jailed for these behaviors.13
This disorder tends to appear in adolescence. However, its onset can vary significantly between childhood and old age.13 The prevalence of this disorder is not known, but it is believed to be a generally uncommon diagnosis12 that may be more common in females and psychiatric patients.13 Many with this disorder also have substance use disorders, mood disorders, and first-degree relatives with substance use disorders and OCD.13 Symptoms tend to be more severe when patients also experience anorexia nervosa, bulimia nervosa, and obsessive-compulsive disorder.12 The disorder can be chronic if not treated.13 Treatment for this disorder varies between medications and therapy.
- Attention-deficit/hyperactivity disorder
- Autism spectrum disorder
- Disruptive mood dysregulation disorder
- Social communication disorder
- Steiner H, Remsing L; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jan;46(1):126-141. doi: 10.1097/01.chi.0000246060.62706.af. PMID: 17195736
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 2013.
- Riley M, Ahmed S, Locke A. Common Questions About Oppositional Defiant Disorder. Am Fam Physician. 2016 Apr 1;93(7):586-91. PMID: 27035043.
- Steiner H, Dunne JE. Summary of the practice parameters for the assessment and treatment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry. 1997 Oct;36(10):1482-5. doi: 10.1097/00004583-199710000-00037. PMID: 9334562.
- Lillig M. Conduct Disorder: Recognition and Management. Am Fam Physician. 2018 Nov 15;98(10):584-592. PMID: 30365289.
- Scott, K. M., de Vries, Y. A., Aguilar-Gaxiola, S., et al. World Mental Health Surveys collaborators (2020). Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment, and suicidality. Epidemiology and psychiatric sciences, 29, e138. https://doi.org/10.1017/S2045796020000517
- Rynar L, Coccaro EF. Psychosocial impairment in DSM-5 intermittent explosive disorder. Psychiatry Res. 2018 Jun; 264:91-95. doi: 10.1016/j.psychres.2018.03.077. Epub 2018 Mar 30. PMID: 29627702; PMCID: PMC5983894.
- Fanning JR, Coleman M, Lee R, Coccaro EF. Subtypes of aggression in intermittent explosive disorder. J Psychiatr Res. 2019 Feb; 109:164-172. doi: 10.1016/j.jpsychires.2018.10.013. Epub 2018 Oct 19. PMID: 30551023; PMCID: PMC6699742.
- Merrick J, Howell Bowling C, Omar HA. Fire setting in childhood and adolescence. Front Public Health. 2013 Oct 8;1:40. doi: 10.3389/fpubh.2013.00040. PMID: 24350209; PMCID: PMC3859988.
- Blum AW, Odlaug BL, Grant JE. Cognitive inflexibility in a young woman with pyromania. J Behav Addict. 2018 Mar 1;7(1):189-191. doi: 10.1556/2006.7.2018.09. Epub 2018 Feb 21. PMID: 29464963; PMCID: PMC6035016.
- Peters B, Freeman B. Juvenile Fire setting. Child Adolesc Psychiatry Clin N Am. 2016 Jan;25(1):99-106. doi: 10.1016/j.chc.2015.08.009. Epub 2015 Oct 21. PMID: 26593122.
- Grant JE, Chamberlain SR. Symptom severity and its clinical correlates in kleptomania. Ann Clin Psychiatry. 2018 May;30(2):97-101. PMID: 29697710; PMCID: PMC5935224.
- Grant JE. Understanding and treating kleptomania: new models and new treatments. Isr J Psychiatry Relat Sci. 2006;43(2):81-7. PMID: 16910369.
Rana Elmaghraby, M.D.
Stephanie Garayalde, M.D.