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174 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
involve the density and diversity of social networks. Over
the years of childhood and early adolescence, the availability
of peers increases with, for instance, entrance into larger
schools and involvement in sports, clubs, extracurricular
lessons, and community activities.
Four extreme-status groups of children have been
described for decades (Coie et al., 1982; Newcomb et al.,
1993). Popular children are those who receive lots of positive
responses and few negative ones. Rejected children receive
many negative responses and few positives. Neglected children
receive few positive or negative responses. Controversial
children have both positive and negative responses.
Although most children are classified as average (not in
any of the extreme groups), the results from many studies
suggest that the extreme classifications are relatively stable.
Youth in various peer groups provide and receive help in
particular ways, with peer group similarity and dissimilarity
influencing the emergence and maintenance of prosociality
across the school years (van Rijsewijk et al., 2016). Overall
classroom prosociality also influences prosociality in young
adolescents (Busching & Krahé, 2020).
Children and adolescents, of course, do not always exhibit
prosociality. “Most individuals engage in antisocial or
aggressive behavior from time to time. Typically developing
children occasionally disobey adults, tell lies, fight, and
intimidate other children” (van Goozen et al., 2022, p. 355).
Disruptive behavior occurs at home, on the playground, in
classrooms, and in many public settings. Disruptive behavior
is often age-expected (such as a 4-year-old’s increasingly
loud and sorrowful protests in Target when Dad says no
to another new toy) and familiar (such as sibling teasing
or arguments that progresses to name-calling, hitting, or
slamming doors).
Research on varieties of antagonistic, rule-breaking, and
aggressive behavior in typically-developing youth provides
a complementary perspective to research on prosociality.
One study of siblings and friends, for example, focused on
prosocial refusals (not sharing or not helping in response
to a request) (Tavassoli et al., 2020). Prosocial refusals are
observed in interactions with both siblings and friends
and provide opportunities to practice and strategize social
decision making in lower-stakes contexts. Prosocial refusals
are more frequent in boys and with siblings (compared
to friends) (Tavassoli et al., 2020). Prosocial refusals may
reflect a lack of motivation to help or share or a prioritization
of one’s own needs or desires over another’s. These types of
social decisions and their consequences likely influence the
development of prosociality in distinctive ways (apart from
parent influences).
Studies of the forms and functions of aggressive behavior
in large-scale, longitudinal studies provide compelling data
about physical (hitting, shoving) versus relational (social
exclusion, spreading gossip) aggression, intentional, goaldirected aggression versus reactive aggression, and sex- and
gender-linked patterns. Both boys and girls exhibit physical
and relational aggression, but the frequency and severity of
aggression differ. Physical aggression is more common and
more intense in boys across childhood and adolescence.
Relational aggression is a fairly common experience for
both girls and boys across race and ethnicity during middle
and high school years. For both boys and girls, individual
differences also need to be taken into account (Aimé et al.,
2017; Casper et al., 2020; Espelage et al., 2018).
Emotion dysregulation is a risk factor for all types of
aggression, and daring behavior is a risk factor for physical
aggression (especially for boys) (Ostrov et al., 2022).
iStock.com/Cathy Yeulet
Peer relationships become an increasingly important influence on prosociality during
childhood and adolescence.
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Developmental Tasks andChallenges Related toProsociality 175
Varied developmental pathways for aggression have been
observed, from declining aggression over time to high-frequency
and stable trajectories (Aimé et al., 2018; Evans et al., 2019).
Individual aggression may be embedded in peer group
aggression. The frequency, severity, and outcomes of aggression
in peer groups are influenced by both individual and group
factors (Jung et al., 2019). When youth have opportunities
to participate in aggression, peer support (or lack of support)
inf luences decision mak ing and behavior (Lansford et al., 2020).
Across China, Colombia, Italy, Jordan, Kenya, the Philippines,
Sweden, Thailand, and the United States, opportunities and
peer support for aggression and delinquent behaviors increase
from early to mid-adolescence. These opportunities to behave
aggressively vary somewhat across cultures but are more strongly
related to differences in adult supervision, family factors, and
available discretionary time (Lansford et al., 2020).
A Developmental Perspective
on Bullying
Across the world, parents, teachers, mental health
professionals, and public health advocates are extremely
concerned about the phenomenon of bullying and the
sometimes tragic consequences for bullied children and
adolescents. A developmental perspective is especially useful
for understanding the prevalence, origins, and outcomes
of bullying and victimization and allows for an informed
discussion of prevention, treatment, and public policy.
Definitions of bullying emphasize negative actions intended
to hurt or harm (e.g., fighting, harassing, excluding) that
are repeated over time and that involve a power differential
between the bully and the victim (Casper, 2021; Zych et al.,
2020). Cyberbullying is an increasingly problematic form
of bullying (Gini et al., 2018; Elbedour et al., 2021). Some
bullying behaviors (e.g., nasty teasing, social exclusion) have
more typical developmental counterparts (e.g., friendly
teasing, refusing to interact with someone for a short while
after a disagreement).
Bullying is a globally pervasive problem in families,
schools, and neighborhoods. In schools, bullying is observed
at all grade levels, including kindergarten (Pepler et al.,
2008; Zych et al., 2020), with the roots of some forms of
bullying interactions observed even earlier in development
(Godleski et al., 2015; Troy & Sroufe, 1987). Both boys
and girls bully, and both boys and girls are victims,
although girls are more likely to be victimized (Casper
et al., 2020; Zych et al., 2020). LGBTQ+ youth, youth who
experience mental health difficulties, and those who are
from marginalized racial or ethnic groups are more likely to
be bullied (Abreu & Kenny, 2018; Fu et al., 2021). Crosscountry estimates of the prevalence of bullying vary widely,
with cross-country differences related to the definitions and
recognition of forms of bullying (Modecki et al., 2014). The
rates are highest in early adolescence (the middle school
years) (Bettencourt et al., 2022). Specific forms of bullying
change over time, with more bias-based aggression related to
emerging sexuality and sexual and gender identity in middle
school and high school (Abreu & Kenny, 2018; Hatchel
et al., 2020; Pepler et al., 2006).
Both stability and change are observed in bullying
trajectories (Zych et al., 2020). Although many youth
who are victimized do not bully others, youth who are
victimized sometimes display aggression. Youth who bully
others are sometimes themselves victimized, and youth
who are uninvolved in bullying can at times display or
receive aggression. Episodic bullying is more frequent than
persistent bullying. It is important to note the relatively
high prevalence of youth who are neither bullies nor victims
(56% at age 11, 65% at age 17) (Zych et al., 2020).
Bullies are a mixed group of children and adolescents.
Researchers have identified a number of factors that are
associated with being a bully. Both poor social skills
and well-developed social skills have been described
(Arsenio & Lemerise, 2001; Crick & Dodge, 1994).
Other research has focused on deficits in empathy
and in the internalization of values (van Noorden
et al., 2015). Differences related to sex and race/ethnicity
are sometimes observed (Bettencourt et al., 2022; Haltigan
& Vaillancourt, 2018). Motivations for bullying are
complex and include status, psychological gratification,
and material rewards. Increased risk for bullying is also
associated with environmental factors such as child
maltreatment, lack of adult monitoring (relevant for
both bullies and victims), parent antagonism, domestic
violence, and hostile neighborhood interactions (Bowes
et al., 2009). School factors such as teacher attitudes,
degree of supervision, school ethos, and school policies are
also important (Elbedour et al., 2020).
Poor outcomes related to bullying include short- and
long-term consequences related to psychological, physical,
and social adjustment (Gini et al., 2018; Troop-Gordon
et al., 2015). Higher rates of internalizing and externalizing
symptoms, including self-harm and suicidality, are observed,
iStock.com/SolStock
Bullying behavior, including threatening and harassing
more vulnerable classmates, is increasingly recognized as
a serious problem requiring school- and community-based
prevention and intervention.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
176 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
as well as reduced academic achievement. Improvements
over time have been noted (Schoeler et al., 2018). Improved
outcomes over time are also observed in studies of bullying
and peer victimization in low-income countries (Nguyen
et al., 2019).
Anti-bullying programs have been adopted in most
states in the United States and around the world. The U.S.
Department of Education has listed 16 components of
legislation and ranks states’ laws and policies accordingly.
Intervention and prevention programs are effective,
although there is an urgent need for better implementation
of available resources (Bradshaw, 2015; Gaffney et al., 2019;
Kull et al., 2016). The research to date suggests that both
universal and individual (victim-oriented) interventions are
necessary, targeting schools, families, and communities.
Well-timed interventions (e.g., in late elementary school
before the transition to larger schools) and interventions
that focus on increasing adult supervision in “hot spots”
such as cafeterias, playgrounds, and restrooms are more
useful (Lansford et al., 2020). Adult support (from parents,
teachers, school psychologists, and school counselors) is
critical (Elbedour et al., 2020; Johnson et al., 2018; TroopGordon, 2015).
Oppositional Defiant Disorder
Oppositional defiant disorder (ODD) is a sustained
pattern of anger, irritability, and defiant or vindictive
behavior. The disorder is differentiated from the more severe
conduct disorder, involving the violation of social norms
and rules as well as the rights of others. The following two
cases describe common ODD presentations.
The Case of Ava
Ava is a six-year-old child who exhibits noncompliance,
frequent temper tantrums, and physical aggression at
home and at school. These aggressive behaviors include
throwing objects, biting, punching, and kicking. Her
mother, a single parent, reported that Ava’s difficulties
began at age 3 and emerged during a period of multiple
life changes, including moving to a new home and
enrolling in a different school. Because of the disruptive
behaviors, Ava was asked to leave several day care centers
before starting kindergarten. In addition to being
frustrated with Ava, Ava’s mother is upset with herself
because she has no idea how to handle Ava’s increasingly
loud and obnoxious interactions with her and with her
siblings at home and in public. She is concerned that,
despite Ava’s enjoyment of all things related to nature
and interest in science, Ava’s disrespectful attitude and
behaviors in school will lead to teachers labeling her a
troublemaker. Her mother is also worried that Ava’s peers
are beginning to avoid or reject her on the playground
and in the neighborhood.
The Case of Liam
Liam is an 11-year-old referred for a diagnostic assessment
by his mother and father because of his “horrible” behavior
and school difficulties. Liam is in sixth grade. His parents
describe him as disrespectful, disobedient, and spiteful. At
times, they are taken aback by his loud and threatening
behavior, especially when it is directed at his younger
brother. Grounding Liam and withholding money and
other privileges has had little impact, even though there
are times when he seems distressed by his own actions.
Liam has been suspended twice this school year for
disruptive behavior, including yelling at a teacher. His few
close friends are increasingly frustrated with his meanspirited teasing and his blaming them for some recent
classroom misbehavior. Academically, Liam is struggling
to keep his grades high enough to pass, although he had
little trouble in school prior to this year.
Both Ava and Liam exhibit mixes of typical and atypical
behaviors that require closer study. Developmentally, Ava
displays disruptive behaviors that are more frequent and more
intense than expected. Indeed, her repeated dismissals from
day care settings suggest clinically significant disturbance.
Liam displays externalizing behaviors that complicate his
everyday life and ruin family activities. For both Ava and
Liam, the transition to new school situations that require
additional self-control has been more problematic than for
most of their peers. Both Ava and Liam meet the diagnostic
criteria for oppositional defiant disorder (refer to Table 10.1).
Early descriptions of oppositional defiant disorder mainly
focused on its role as a preceding or milder expression of
conduct disorder. Researchers and clinicians have since come
to conceptualize ODD as a distinctive pattern of distress
and dysfunction associated with significant impairment.
Dimensional approaches help to explain the disorder and its
various clinical presentations (Burke et al., 2021; van Goozen
et al., 2022). Four dimensions, overlapping and extending the
DSM-5-TR criteria, underlie oppositional defiant disorder
(Burke et al., 2021; Wakschlag et al., 2010): oppositionality,
irritability, aggression, and callous-unemotional traits.
iStock.com/jegesvarga
Negativistic, hostile, and defiant behaviors are the core
features of oppositional defiant disorder.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Conduct Disorder 177
Table 10.1 Oppositional Defiant Disorder:
Summary of DSM-5-TR Diagnostic Criteria
A. Pattern of angry/irritable mood, argumentative/
defiant behavior, or vindictiveness lasting at
least six months; four or more symptoms from
list below, exhibited during interactions with
individuals other than siblings.
Angry/Irritable Mood
1. Often loses temper
2. Often easily annoyed
3. Often angry and resentful
Argumentative/Defiant Behavior
1. Often argues with authority figures
2. Often defies or refuses to comply with
requests from authority figures or rules
3. Often blames others for mistakes or
misbehavior
Vindictiveness
1. Spiteful or vindictive at least twice within the
past six months
B. The disturbance in behavior is associated with
distress in the individual or others or impairment
Oppositionality includes noncompliance (refusals to follow
directives or rules), stubbornness, and argumentative and
defiant behaviors, often displayed in combination with
negative attitudes. Irritability involves chronic anger,
frustration, or cranky moods. Irritability also includes loss of
temper and temper tantrums. Aggression is reflected in overt
verbal, physical, or relational behaviors intended to harm
others. Callous-unemotional traits include vindictiveness, low
concern for others, a lack of empathy, and a lack of remorse
or guilt. Callous-unemotional traits are also referred to as
limited prosocial emotions.
Irritability is the focus of a lot of research and clinical
attention and is a common parent concern. Most typicallydeveloping young children display some irritability, such as
when they experience brief or mild bad moods or have tantrums
during transitions from a well-liked activity (playing outside
with friends, watching a favorite video) to a disliked activity
(completing homework, getting ready for bed) or in response
to parent limit-setting. Atypical irritability involves responding
to frustration and blocked goals across a range of contexts
and situations with anger, distress, and tantrums. Frequent,
dysregulated, destructive, and long-lasting irritability is clinically
meaningful (Wakschlag et al., 2018; Wiggins et al., 2018).
Irritability is a transdiagnostic symptom. It is a key component
of most clinical presentations of ODD, and it is also a core
characteristic of disruptive mood dysregulation disorder (refer to
Chapter 12) (Wakschlag et al., 2018; Wiggins et al., 2018).
Oppositional defiant disorder has been identified in many
different cultures and countries. Prevalence in populations
varies somewhat, but overall estimates are approximately
3% (Canino et al., 2010; Robins, 1999). Rates of ODD are
higher in children younger than 12 years of age. Almost
all investigations of ODD report that it is more common
in boys, but the sex difference is less than the male:female
differences observed in ADHD and conduct disorder
(Demmer et al., 2017). ODD is frequently discussed in
tandem with conduct disorder, and there is notable overlap
in risk factors, etiology, and clinical presentation.
Conduct Disorder
The Case of Mateo
Mateo is a 14-year-old referred for evaluation by his father
and school principal due to concerns about escalating
behavior problems, school difficulties, and suspected
substance abuse. He gets in trouble at school nearly every
week, sometimes for disobeying school rules, sometimes for
rude comments to teachers, and occasionally for fighting
with other students. Recently, Mateo was suspended for
stealing a cell phone and money from another student’s
locker. He was also suspended last year, when he punched
and kicked a younger student who accidentally ran into
him in the hallway. Although Mateo is not involved in
any school teams or organizations and most other students
avoid him, he does have a small group of friends who have
also been in considerable trouble. Some of them have been
arrested for property-related criminal behavior.
Mateo’s problems at school are compounded by defiant,
reactive, and disruptive behavior at home, dating all the
way back to his preschool years. When younger, Mateo
was hard to manage at home and at school, and by middle
school, his father felt that he had very little control over
him. Now his father tends to steer clear of Mateo and is
grateful for the occasional periods of uneasy truces.
The Case of Riley
Riley is a 15-year-old referred for evaluation at the
suggestion of her pediatrician. She is in the tenth grade
and currently failing most of her classes. She skips school
several times a week and hangs out with a group of
older teens who have dropped out of high school. Riley
has been stealing money from her parents and has also
been arrested twice for shoplifting. She has recently
come home intoxicated, and her parents have found drug
paraphernalia in her room.
This is not how life has always been for Riley. Riley’s
parents report a relatively uneventful childhood. They
began to be concerned about her, however, during eighth
grade. At the time, Riley dropped out of sports and her
grades fell dramatically. Eventually, Riley was diagnosed
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
178 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
with depression, participated briefly in therapy, and began
taking an antidepressant. Although her mood and behavior
improved somewhat, she continued to struggle throughout
the year. After a period of social isolation, she began to hang
out with a group of girls who prided themselves on their
alienation from mainstream school and family experiences.
Conduct disorder (CD) involves a persistent pattern
of very problematic behavior in which there are serious
violations of social norms and rules. As described in
DSM-5-TR (refer to Table 10.2), these violations include
Table 10.2 Conduct Disorder: Summary
of DSM-5-TR Diagnostic Criteria
A. Repetitive and persistent pattern of behavior
in which the rights of other or age-appropriate
societal norms or rules are violated as
manifested by at least three of the following:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon that can cause serious
physical harm to others
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting victim
7. Has forced someone into sexual activity
Destruction of Property
1. Has deliberately engaged in fire setting
2. Has deliberately destroyed others’
property
Deceitfulness or Theft
1. Has broken into someone else’s house,
building, or car
2. Often lies to obtain goods or favors or to avoid
obligations
3. Has stolen items of nontrivial value without
confronting victim
Serious Violations of Rules
1. Often stays out at night despite parental
prohibitions
2. Has run away from home overnight at least
twice
3. Is often truant from school, before age of 13
years
B. Disturbance in behavior causes clinically
significant impairment in social, academic, or
occupational functioning
aggression or mistreatment directed toward people or
animals, property destruction, deceitfulness or theft,
and other serious rule violations. In addition to these
behavioral criteria, children and adolescents who receive
a diagnosis of conduct disorder are evaluated with respect
to callous-unemotional traits or limited prosocial
emotions. These characteristics (also included in the
previous section on ODD) include insensitivity to others,
lack of empathy, lack of guilt or remorse, and shallow/
deficient emotion. Estimates of the prevalence of CD in
youth range between 2% and 4% (Canino et al., 2010;
Wakschlag et al., 2018). Between 25% and 35% of youth
diagnosed with CD display callous-unemotional traits
(Wakschlag et al., 2018).
Conduct disorder is characterized by heterogeneity, with
varied clinical presentations (van Goozen et al., 2022).
There are two subtypes of CD: early-onset pathway and
adolescent-onset pathway. With onset in childhood, the
individual diagnosed with conduct disorder has a long
history of negative personal and interpersonal behaviors,
and the behaviors deteriorate over time. With onset in
adolescence, the individual’s problem behavior emerges
more abruptly. Adolescent-onset CD is much more common
than early-onset CD, and males outnumber females in both
presentations. Although much of the CD research has
focused on adolescent-onset and early-onset pathways, a
third pathway has been identified. This childhood-limited
pathway involves problem behaviors that emerge early in
development but diminish over time. Fewer youth display
this specific pathway (Bevilacqua et al., 2018; Cyr et al.,
2022). It is important to note that some youth do not fall
neatly into any of these categories. For many, CD unfolds
over time, with some of the disruptive behaviors appearing
early and others appearing later (Bierman & Sasser, 2014;
Gutman et al., 2018).
Early-onset, adolescent-onset, and childhood-limited
conduct disorder differ not only in their timing, but also in
their symptom patterns, severity, and outcomes. Moffitt’s
(2003; Moffitt et al., 2008) theory of CD describes a life-
course persistent (LCP) trajectory, similar to early-onset CD,
and an adolescence-limited (AL) trajectory. The AL form of CD
is somewhat less problematic over time than the LCP form,
although there is still evidence of significant impairment
in daily functioning and a risk for poor outcomes. LCP
individuals are more likely to have a history of ODD and
a family history of antisocial behavior and are more likely
to display aggression and have worse outcomes than AL
individuals.
There are notable sex differences in clinical presentation
(Konrad et al., 2022). Girls are more likely to be diagnosed
with adolescent-onset CD (compared to early-onset CD).
Girls with adolescent-onset CD are more similar to boys
with early-onset CD than boys with adolescent-onset
CD. Girls are less likely than boys to exhibit physical
aggression and property destruction but are more likely to
commit serious rule violations (Konrad et al., 2022). CD
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Developmental Course 179
is observed across all SES groups; the diagnosis is more
common in youth from lower-SES backgrounds (Bierman
& Sasser, 2014).
Because aggression is common in both typical and
atypical development, it makes sense to step back and
consider again the forms and functions of aggression
and the ways in which aggression predicts later antisocial
outcomes (Aimé et al., 2018; Dishion, 2014; Evans
et al., 2019). Aggression involves behaviors that are
carried out with an immediate goal of causing harm to
another. Instrumental aggression is aggression that is
premeditated or planned. In most cases, instrumental
aggre ssion is a means to a part icular end. A bully who w recks
another child’s science project to impress delinquent peers
exhibits instrumental aggression. Reactive aggression
is aggression that occurs in response to a provocation. It is
angrier and more impulsive. A child who is tripped on
the soccer field displays reactive aggression by shoving
the offending player on the opposing team. Although
this instrumental–reactive distinction is useful in many
ways, it is important to remember that aggression often
has multiple motives and multiple goals. These include
attempts to reestablish self-esteem or public image,
attempts to express grievances, or attempts to obtain
benefits such as money or information.
The whats of aggression have to do with whether
aggression is overt or covert (Card et al., 2008). Overt
aggression (also called direct aggression) involves harmful
physical behaviors or overt behaviors such as name-calling.
Overt aggression is more often associated with low levels of
prosocial behavior, emotional dysregulation, externalizing
problems, and poor peer relationships. Covert aggression
(also called indirect aggression) may include the externalizing
behaviors observed in CD, such as property damage or
theft. It may also involve behaviors that harm the target by
rejection or exclusion (relational aggression) or alternative
strategies (such as manipulation) employed when the costs
of overt aggression are high. Covert aggression is associated
with higher levels of prosocial behavior and internalizing
problems.
Ongoing research emphasizes the need to better
understand the callous-unemotional construct. CU is a
dimensional construct and may be seen in low concern
for others, not caring about another’s feelings, continuing
to do something that upsets another person, enjoying
making others angry or afraid, and doing things to
embarrass or humiliate others (Wakschlag et al., 2018).
In contrast to irritability, which is present in some form
in most typically developing children, CU traits are not
normative. Indeed, concern for others and the capacity
to follow social norms is observed very early in life and
continues across the lifespan (Frick et al., 2014; Wakschlag
et al., 2018). Conduct disorder accompanied by CU (or
limited prosocial emotions) is associated with more
serious disorder and worse outcomes (Bierman & Sasser,
2014; Frick et al., 2014). Combinations of CU (or limited
prosocial emotions) and severe irritability are associated
with aggression and greater impairment (Waschbusch
et al., 2019).
Developmental Course
There are several predictable pathways for children with
early externali zing and disruptive disorders. For oppositional
defiant disorder, it is important to keep in mind the
continuous nature of oppositional and disruptive behaviors
(the connections between t ypically a nd atypically de veloping
children). However, early patterns of disruptive difficulties
are frequently and strongly associated with later patterns
of difficulties, and children with clinically significant
disorders do not grow out of their problems (Wakschlag
et al., 2019). For conduct disorder, the historical framework
for understanding developmental pathways is provided
by Lee Robins’s (1966) classic book, Deviant Children
Grown Up. Robins documented the potential stability of
conduct disorder, finding that many troubled children
and adolescents display antisocial personalities, along with
other types of psychopathologies, as adults. However, he
also observed the possibility of positive change and better
outcomes in some individuals. Robins’s findings have
been replicated many, many times in other longitudinal
studies; the stability of conduct-disordered behavior,
especially related to aggression and callous-unemotional
characteristics, is abundantly clear across individuals and
across generations.
Oppositional Defiant Disorder
As with all disorders, there are many developmental
pathways for children diagnosed with oppositional
defiant disorder. One developmental pathway is for ODD
to continue without much improvement or deterioration,
resulting in years of conflict, hostility, and distress.
Without intervention, this pathway is the most common.
An important factor that contributes to stability is age of
onset. Many beh avior problems and heightened irr itabil ity
are identifiable in 3- and 4-year-olds, and early onset is
associated with persistent patterns of difficulty (Burke
et al., 2021; Wakschlag et al., 2018). Severity of symptoms
is another factor to consider. For both girls and boys, the
more severe the ODD symptoms, the more stable the
disorder (Bierman & Sasser, 2014; Boylan et al., 2017).
In addition to the overall ODD presentation, it is
important to pay attention to separate ODD dimensions
because irritability and behavior problems have distinctive
trajectories and outcomes (Burke et al., 2021; Wakschlag
et al., 2018). Oppositional behavior symptoms may increase
over time and are associated with externalizing disorders,
including ADHD and CD. Irritability trajectories may be
stable, improving, or deteriorating. For children with ODD
who also display callous-unemotional traits, outcomes are
more problematic (Burke et al., 2021).
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180 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
100%
Low Aggression
Moderate Aggression
HH: High Anger High Aggression
Addressing irritability and dysregulation as soon as
possible is important. “Although not all irritable young
children develop mental health problems, enduring patterns
of early irritability exponentially increase the risk that
they will” (Wakschlag et al., 2019, p. 541). This pattern
of increasing likelihood of disorder in the presence of
irritability, temper loss, and dysregulation was also discussed
in Chapter 5 (refer back to Figure 5.5) in connection with
temperament risk factors. Comparisons of developmental
pathways following a “watch and wait” strategy versus
identification and intervention for early irritability and
dysregulation shows the potential for improved outcomes
for numerous children.
Exploring the roles of anger and aggression in early
development provides useful information about the emergence
and maintenance of ODD. In one community study, three
groups of very young children were identified: low anger/low
aggression (LL), high anger/moderate aggression (HM), and
Figure 10.1 Prevalence of angry/aggressive categories by
child age
high anger/high aggression (HH) (refer to Figure 10.1). Early
differences in anger and aggression demonstrated stability
over time, with some transitions from the HM to HH group
and some from the HH group to the HM group. Note that
while not all young children displayed anger or aggression,
displays of anger become more common over the early years
of life (Perra et al., 2021).
Sex/gender also plays an important role. Beginning in
preschool, boys exhibit more disruptive behaviors with more
negative impact. Combinations of other factors, such as early
temperamental difficulties, poor self-regulation, aggression,
low SES, and a diagnosis of attention-deficit/hyperactivity
disorder (ADHD) also appear to influence gender-specific
pathways (Owens & Hinshaw, 2016).
Parent, family, and peer factors influence the ways
in which ODD plays out over time. Adult patience and
tolerance for oppositional behavior varies widely; similar
child anger or misbehavior may evoke very different
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Infancy Toddlerhood Early Childhood
LL: Low Anger -
HM: High Anger -
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Source: Perra, Paine, & Hay (2021). Continuity and change in anger and aggressiveness from infancy to
childhood: The protective effects of positive parenting.
Developmental Course 181
responses in different individuals (Bierman & Sasser, 2014;
Perra et al., 2021). In addition, most parents deal with
oppositional, coercive, and defiant behavior once in a while
or for limited stretches of time. Parents of children with
ODD manage chronic conflict much more frequently, and
this may be overwhelming (Dishion, 2014). The sex of the
child may come into play as well, with parents responding
differently to early anger and misbehavior in boys versus
girls (Perra et al., 2021). Negative parenting, involving
either hostility and harsh discipline or inadequate discipline,
is associated with poorer outcomes. Conversely, parental
warmth, coupled with active monitoring of children’s
activities, is associated with better outcomes (Perra et al.,
2021; Vanderbilt-Adriance et al., 2015).
The case of Ava provides several examples of the inf luence
of parents and parenting on the course of ODD. Ava’s
mother recalls how many times she has felt embarrassed
over the last year as Ava has misbehaved loudly in the
grocery store, the discount store, and the entrance lobby
of her school. She is positive that other parents believe that
she is either unfit or stupid, and these concerns have led her
to withdraw from many of her regular social activities. Her
parents have tried to help with babysitting and financial
support, but they have also repeatedly criticized her for not
being strict enough with Ava. At this point, Ava’s mother
is discouraged and ready to give up on Ava to focus on her
other children.
The coercion model described by Gerald Patterson
and his colleagues is a developmental model that provides
another framework for understanding developmental
pathways related to oppositional defiant disorder and other
externalizing disorders. In this model, often referred to as
the Oregon model (named for the state in which much of
the research was conducted), the primary focus is on social
interaction learning and patterns of parental characteristics
that lead to negative parent–child interactions (Patterson
et al., 2010; Dishion, 2014). These patterns include: (1)
inconsistent discipline, with parents only sometimes
enforcing limits and rules; (2) irritable, explosive discipline,
with parents enforcing limits and rules in harsh and angry
ways; (3) inflexible, rigid discipline, with parents enforcing
limits and rules without regard to individual child attributes
or special circumstances; and/or (4) low supervision and
involvement.
The basic assumption of the coercion model is that
parents and children struggle for control over a number
of everyday tasks and activities and that maladaptive
parenting leads to children’s externalizing behavior. The
coercion model specifically examines a conditioning
sequence in which children are inadvertently reinforced
for their problematic behaviors (Patterson et al., 2002).
If parents are ineffective and rigid, children’s initial
misbehavior and disobedience (which may be typical
and not always a major concern) escalates. The child’s
escalating opposition is met by the parent’s increasingly
punitive responses, again and again and again. Over time,
children’s externalizing behaviors generalize to other
settings. In school settings, for example, oppositional
behavior leads to struggles with teachers and an increased
risk for academic failure. In peer settings, the child’s
negative behaviors lead to rejection by their typically
developing, more prosocial peers. This rejection leads
to increased association with other deviant peers and
increasingly antisocial behavior.
The developmental cascade from challenging
temperament and misbehavior to power-assertive control
by parents (both mother-child and father-child dyads)
is more likely to be observed in families experiencing
greater adversities such as economic disadvantage and
increased stress (Kim & Kochanska, 2021; Lavigne et al.,
2016). Positive parenting, including a focus on emotions
and parental support for child self-regulation, interrupts
the cascade sequence. Caregiver emotional warmth and
responsiveness decreases child anger and problematic
behavior (with fewer opportunities for harsh parenting)
(Perra et al., 2021; Zhang et al., 2020). Positive parenting
also provides repeated modeling of prosocial behavior and
strategies for regulation of distress and frustration. In the
absence of positive parenting, children’s experiences of
harsh parenting may be buffered by warm relationships
with teachers and positive peer relationships (Roubinov
et al., 2020).
Another possible pathway for children with ODD is
progression to conduct disorder (Bierman & Sasser, 2014;
Perra et al., 2021). A diagnosis of ODD is a stronger
predictor of CD for boys, and lower SES and higher levels
of parent hostility also increase the risk of a later diagnosis
of CD (Bierman & Sasser, 2014). The combination of ODD
and ADHD is of special concern, with youth displaying
increasingly problematic disruptive behaviors, aggression,
and delinquency (Burke & Loeber, 2015; Burke et al., 2005;
Lahey et al., 2004). One of the most maladaptive pathways
is from ODD to CD to antisocial personality disorder,
with increases in aggression, violence, and substance abuse
along the way (Dishion, 2014). It is important to emphasize,
however, that with age, fewer and fewer individuals are
diagnosed with the increasingly severe and persistent
disorders.
For many individuals diagnosed in childhood, ODD
symptoms persist into adulthood. In adults, problems
related to irritability, being easily annoyed, and angry are
more common. Behavior symptoms such as defiance and
noncompliance decrease over time (Burke et al., 2021). As
noted previously, comorbidity with other disorders (diagnosed
in childhood and also later in life) is a concern. Common
co-occurring disorders include depression, anxiety, substance
use disorder, and suicidality (Burke et al., 2021).
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182 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
40
CBCL Externalizing Raw Scores
Group 1 (MD; 38.81%)
HS = High stable; K = Kindergarten.
Conduct Disorder
Conduct disorder presents with multiple combinations
of symptoms, multiple pathways, and multiple outcomes
(Wakschlag et al., 2018). With adolescent-onset CD, the
externalizing problems may reflect, for many youth, an
attempt to display maturity and adult status in maladaptive
ways. Behaving in ways that defy or disregard social norms
and that are encouraged or rewarded by antisocial peer
groups leads to impairment in most domains of functioning
(Bevilacqua et al., 2018; Moffitt, 2003; Moffitt et al., 2008).
For many adolescents with CD, however, this is a temporary
phenomenon. For others, this is the beginning of an ongoing
or deteriorating pathway involving other disorders such as
substance abuse and other negative outcomes such as school
dropout (Bierman & Sasser, 2014).
With early-onset CD, stable externalizing trajectories
are already evident in the early school years (Bierman
& Sasser, 2014; Dishion, 2014). Sex/gender-specific
trajectories are also observed. For children who exhibit
problematic behaviors by age 3, more girls show declines
in aggressive behavior over childhood. Boys are more likely
to display persistent problematic behaviors (Gutman et al.,
2018).
Overall, there is a hierarchy of risk associated with each
developmental pathway. Youth diagnosed with early-onset
CD exhibit higher rates of poor outcomes across various
domains (psychological, physical, social, employment).
Youth diagnosed with adolescent-onset CD are at
intermediate risk, followed by youth diagnosed with the
childhood-limited pathway (Bevilacqua et al., 2018; Cyr
et al., 2022). Figure 10.2 presents the stability of conduct
problems in at-risk youth from kindergarten through
grade 7. The figure includes a group of children displaying
highly stable conduct problems over time (22%), a group
displaying moderate conduct problems early that improve
over time (39%), a group displaying very high levels of
antisocial behavior early that increase over time (4%), and a
group displaying low initial levels that continue to decline
(36%) (Cyr et al., 2022).
As described earlier, youth with CD who also exhibit
callous-unemotional traits are at increased risk for especially
maladaptive pathways. CU can be identified early and is
moderately stable over childhood and adolescence (Waller &
Hyde, 2017). Very young children’s limited prosocial emotions
and problematic behaviors predict conduct disorder symptoms
in adolescence (Wakschlag et al., 2018). CU predicts a range
of negative outcomes, including high and rising aggression
over time, social and academic impairment, and involvement
in criminality (Castagna et al., 2022). It is important,
however, to emphasize that ongoing concerns related to CU
do not mean that developmental psychopathologists are able
to identify “preschool psychopaths” or that early displays of
CU traits are inevitably linked to later disorder (Waller &
Hyde, 2017).
Family and peer factors contribute to deteriorating
or improving pathways. In studies of parent behavior
and youth outcomes in nine countries, parental anger
and hostility, harsh discipline, and family conflict are
associated with adolescent externalizing and internalizing
symptoms (Di Giunta et al., 2020). Beyond individual
Figure 10.2 A comparison of pathways for youth diagnosed with conduct disorder
Source: Cyr, Zheng, & McMahon (2022). A long-term look at “early starters”: Predicting adult psychosocial outcomes from childhood conduct
problem trajectories.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
35
30
25
20
15
10
5
0
K 1 2 3 4 5 6
Predicted developmental trajectories of childhood
conduct problems. Note. MD = Moderate decreasing;
LD = Low decreasing; EHI = Extremely high increasing;
Group 2 (LD; 35.49%)
Group 3 (EHI; 3.71%)
Group 4 (HS; 21.99%)
7
Etiology 183
outcomes, disruptive behaviors impact family functioning
and sibling adjustment (Datchev & Woke, 2020). Many
parents of conduct-disordered youth appear to become
disengaged over time, with less monitoring of their
children’s behaviors and activities (Dishion, 2014; Hafen
& Laursen, 2009).
For many youth with CD, peer relationships with
other youth with conduct problems play an increasingly
important role. “Because interacting with aggressive and
antisocial children is unpleasant for less aggressive children
and adolescents, individuals with higher levels of aggression
tend to be unpopular in regular class communities. This
leads them to affiliate with others who behave in a similarly
aggressive and antisocial fashion” (Jung et al., 2019,
p. 8). Social rejection combined with academic difficulties
or failure increases the likelihood of these affiliations.
Friendships with acting-out and aggressive peers do not
substitute for friendships with more typically developing
adolescents. The quality of the relationships is different, and
being part of an aggressive and antisocial group exacerbates
one’s own aggressive and antisocial tendencies (Centifanti
et al., 2017; Jung et al., 2019).
Peer contagion involves exposure, learning, and
reinforcement of various antisocial and aggressive behaviors.
This social contagion, often called deviancy training,
depends in part on the variability of aggressive behavior
within peer groups. Individuals with CD are more likely to
display higher levels of aggression over time when aggression
is exhibited by most peer group members (compared to
when aggression is displayed by relatively few peer group
members) (Jung et al., 2019). Studies of aggressive and
delinquent pathways show that, controlling for early
aggression, opportunities and peer support for problem
behavior predict ongoing aggression and delinquency in
adolescent youth (Jung et al., 2019).
The timi ng of peer diff iculties is i mportant. Adolescence,
for example, is a period of heightened vulnerability
to peer influence (both prosocial and less prosocial)
(Gilettaa et al., 2021; Laursen & Veenstra, 2021). Peer
influence increases during early adolescence and beyond,
with influence demonstrated by increased social
orientation, sensitivity to social comparison and status,
and increased conformity to peer groups. The scope of
peer influence includes individual attitudes and behaviors,
interpersonal well-being, academic achievement, and
(most important for this chapter) conduct problems and
antisocial outcomes (Giletta et al., 2021; Laursen &
Veenstra, 2021).
Children and adolescents who display conduct problems
often display those problems in school settings, and
school factors related to exclusion and punitive discipline
influence CD trajectories. There is abundant evidence
that suspension and expulsion of students from preschools,
elementary schools, middle schools, and high schools has
a disproportionate impact on youth from marginalized
backgrounds (Chen et al., 2021). Although conduct
problems must be addressed, there is an overwhelming
need for more expertise and support in schools to support
youth who struggle with behavior and learning (Bottiani et
al., 2018; Center on the Developing Child, 2011). Students
who miss school and receive punishments are also at risk
for academic impairments and failures. The ability to enroll
in high school courses and complete them may provide an
incentive and reward for staying on track academically,
increasing the odds that conduct problems will diminish
(Jabbari & Johnson, 2020).
Developmental cascade models focused on conduct
disorder and antisocial behavior have emphasized the
multiple underlying patterns and pathways of CD. With
early-onset CD, for example, research has suggested the
following: a difficult and vulnerable child experiences
inadequate or dysfunctional parenting that leads to
disruptions in conscience development and socialization.
Poor socialization leads to problematic relationships in
and out of the home and negative impacts on a variety
of psychological and social domains. Other research on
developmental cascade models has emphasized the crossdomain, spreading effects observed over time in youth
with externalizing behaviors. In these studies, researchers
have documented difficulties with social information
processing, academic difficulties, peer rejection, and
aggression, with cascading effects from externalizing to
internalizing problems over time (Bevilacqua et al., 2018;
Cyr et al., 2022; Dishion, 2014).
Long-term negative impact is observed in mental and
physical health domains. Females diagnosed with CD
display higher rates of depression, anxiety, substance use
disorder, and PTSD. Males exhibit higher rates of ADHD
(which usually precedes the CD). Antisocial personality
disorder and criminality are also seen in some older
adolescents and adults previously diagnosed with CD
(Bevilacqua et al., 2018; Cyr et al., 2022; Konrad et al.,
2022).
Etiology
To explain the diversity of clinical presentations and
pathways for oppositional defiant disorder and conduct
disorder, etiological models must take into account genetics
and physiology, child factors, parent and family factors, peer
factors, and other sociocultural factors. In addition, these
models provide a way to explore links among factors and
integrate findings across domains of functioning, time, and
outcomes.
Genes and Heredity
With respect to the role of genetic factors, the picture
is complicated, with evidence for genetic, shared, and
nonshared environmental influences on oppositional
defiant disorder, conduct disorder, and antisocial behavior.
Researchers have repeatedly observed that externalizing
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.