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184 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
disorders aggregate in families, and the often-overlapping
clinical presentations of ODD with ADHD and CD
suggest the possibility of shared genetic risks (BaskinSommers, 2016; van Goozen et al., 2022; Waller & Hyde,
2018).
Much of the research on genes and heredity is focused
on specific characteristics and dimensions that are part of
the clinical presentation of ODD and CD. For example,
there are ample data on the heritability of prosociality,
empathy, negative emotionality, fearlessness or daring,
irritability, emotion regulation, aggression, and callousunemotional traits (Brotman et al., 2017; van Goozen
et al., 2022; Wakschlag et al., 2018; Waller & Hyde, 2018).
Polygenic models, with multiple genes having small effects,
have received the most empirical support. As discussed in
other chapters, current research is often focused on models
of vulnerability and differential sensitivity, with compelling
data that gene-by-environment-by-time processes are
essential to understanding the development of externalizing
disorders over time (Overbeek et al., 2020; van Goozen
et al., 2022).
Physiological Factors
Brain im aging and neurodevelopmental st udies have reported
both structural differences and functional impairments.
Individual differences in brain areas and processes include
those related to frontal lobe activation, the amygdala and
limbic system, the hypothalamic-pituitary-adrenal (HPA)
axis, the behavioral inhibition system, neurotransmitters and
hormone systems, and connectivity (Ostrov et al., 2022; Tillem
et al., 2021; van Goozen et al., 2022). Multiple physiological
systems contribute to the risk, including those involving
punishment processing, with underarousal and reduced
distress response; reward processing, with increased focus
on reward; and executive function, with dysregulation of
emotion and cognitive processes (Brotman et al., 2017;
Matthys et al., 2013; Ostrov et al., 2022; van Goozen
et al., 2022).
Physiological (and behavioral) patterns associated with
temperament dimensions are also notable for children
diagnosed with ODD and CD. In general, low fear + high
reward motivation à high approach + low sensitivity to
punishment à ODD and CD symptoms. This sequence
involves multiple G 3 E 3 T and epigenetic processes
(An & Kochanska, 2022; Brotman et al., 2017; Matthys
et al., 2013; Ostrov et al., 2022; van Goozen et al., 2022).
Child and Adolescent Factors
Child and adolescent factors that have an impact on the
development of oppositional defiant disorder, conduct
disorder, aggression, and antisocial behavior include emotion
factors, cognitive factors, and temperament and personality
factors. Among the most common findings are that youth
diagnosed with ODD or CD exhibit deficits in the processing
of negative emotional stimuli (e.g., they do not respond in
typical ways to others’ fear and distress). In addition, high
negative emotionality and difficulties with emotion regulation
are risk factors (Ostrov et al., 2022). Low empathy is another
risk factor, with individual differences in the development
of empathy associated with attachment histories (Stern
& Cassidy, 2018; van Goozen et al., 2022). Irritability,
dysregulated/destructive tantrums, and atypical aggression in
early childhood may be particularly important contributors
to later dysfunction (Brotman et al., 2017; Liu et al., 2018;
Wakschlag et al., 2019).
A number of cognitive factors a re associated with increa sed
risk. These include language deficits and executive function
(EF) difficulties (Bornstein et al., 2018; Pinsonneault
et al., 2022; Wakschlag et al., 2018). Delayed language
skills may contribute to problems with self-regulation,
social adjustment, and academic achievement, each of
which is linked to disruptive disorders. EF difficulties may
also increase the risk for dysregulation and maladaptation.
Youth with ODD and/or CD are more likely to display hot
EF impairments (van Goozen et al., 2022).
Because m any youth w ith ODD and CD a re also diagnosed
with ADHD, it is difficult to tie EF deficits specifically to the
ODD or CD presentation (Crick & Dodge, 1994, 1996). One
comparison of impaired decision making between ADHD
and CD contrasts the inefficient, inconsistent, and impulsive
decision making observed in children and adolescents with
ADHD and the reckless, insensitive to negative outcomes
decision making observed in children and adolescents with
CD (Sonuga-Barke et al., 2016).
Behavior-related risks involve impulsivity and deficits in
effortful control. The negative consequences of impulsivity
are heightened by the presence of characteristics such as
being daring (i.e., the enjoyment of exciting, risky, and
possibly dangerous activities) (Bierman & Sasser, 2014;
Dishion, 2014). Overall, these are youth with fewer
coping skills and resources. Well-developed emotion
regulation skills, EF abilities, and behavioral competence
are protective factors (van Goozen et al., 2022).
Temperament and personality factors are also associated
with increased risk. Investigators have identified challenging,
difficult temperaments as potentially problematic
(Kochanska et al., 2019; Ostrov et al., 2022). Daring and
fearless youth who are highly focused on reward situations
may display a lack of flexible, goal-directed behaviors.
Poorly-timed activity or conflicts with others may lead
to frequent, intense frustration and possible aggression.
Coupled with diminished processing of others’ emotional
responses, these negative cycles increase the risk of ODD
and CD (Brotman et al., 2017; Wakschlag et al., 2018).
The developmental propensity model integrates research
and clinical findings related to four dimensions of risk:
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negative emotionality, daring, low prosociality, and low
cognitive abilities. Whether measured in toddlerhood
or later childhood, each of these dimensions predicts
the presence of later conduct problems in children and
adolescents (Lahey & Waldman, 2003; Lahey et al., 2018;
Rhee et al., 2016).
The personality characteristic receiving the most
attention is the callous-unemotional construct. CU traits
are associated with significant stability over time and
with more severe and more aggressive conduct disorder
(Bierman & Sasser, 2014; Dishion, 2014; Waller et al.,
2017). Related to callousness is the personality construct
of psychopathy. Several dimensions of psychopathy
have been observed in adolescents: callous-unemotional
traits, impulsivity, and narcissism, with different studies
suggesting various relations among psychopathy, CD,
antisocial personality disorder, and typically developing
personality (Bierman & Sasser, 2014; Dishion, 2014;
Pauletti et al., 2012).
The triarchic model of psychopathy is a three-part
conceptualization to explain an especially problematic
developmental pathway (Patrick et al., 2009; Sica et al.,
2020). The first component is disinhibition, involving
a propensity toward impulse-control problems, a lack of
planfulness, an insistence on immediate gratification,
and deficient behavioral restraint. Disinhibition is “at the
nexus of impulsivity and negative affectivity” (Patrick
et al., 2009, p. 925). The second component is boldness,
involving the capacity to remain calm in stressful
situations, high self-assurance and social efficacy, and a
tolerance for danger. The third component is meanness,
with deficient empathy, a disdain for others, exploitation
of others, and empowerment (refer to Figure 10.3). The
many intersecting research and clinical perspectives
focused on a better understanding of emerging antisocial
behavior are highlighted in the overlap between the
developmental propensity model and the triarchic model
of psychopathy.
Parent and Family Factors
Parent and family factors include parent characteristics (e.g.,
personality, psychopathology, experiences), relationship
variables, and parenting attitudes and practices. Even with
myriad child and environmental factors, the direct and
indirect impact of parents on the developmental pathways
of most cases of ODD and CD cannot be overestimated.
Parental mental health/mental illness is an important factor
to consider. Depression, anxiety, substance use, and antisocial
behaviors in caregivers increase the risk for ODD and CD
(Barry et al., 2018; Dishion, 2014; Gutman et al., 2018).
Parental psychopathology has both direct (e.g., genetic) and
indirect effects (e.g., marital conflict, family dysfunction
and instability, and poor parenting) that affect child and
Etiology 185
Figure 10.3 The triarchic model of
psychopathy
A presentation of hypothesized relations among
constructs of disinhibition, boldness, and meanness
(circles) and influences of difficult temperament and
low fear (arrows) on each construct.
Difficult Temperament
Disinhibition
Meanness
Source: Patrick, Fowles, & Krueger (2009). Triarchic conceptualization of
psychopathology: Developmental origins of disinhibition, boldness, and
meanness.
adolescent adjustment (Baskin-Sommers, 2016; Bornovalova
et al., 2014). Some children and adolescents appear to be
even more harmed than others by marital and family conflict
and chaos (Burt, 2015). Parental incarceration is another
risk factor for disruptive disorders in youth (Bradshaw
et al., 2021).
Negative parenting practices such as harsh, derisive, or
neglectful parenting are powerful influences on adaptation
and maladaptation. Harsh and coercive parenting and
physical punishment increase the risk for ODD and CD
in children and adolescents (Bierman & Sasser, 2014; Burt
et al., 2021). A meta-analysis of over 1400 studies found
that harsh control and psychological control are the most
important predictors of externalizing disorders in youth
(Pinquart, 2017).
Certain developmental transitions may increase the
impact of negative parenting practices. Harsh parenting
during young childhood interferes with the development
of prosociality. This increased impact may be more evident
in young children with greater differential susceptibility
(Trentacosta et al., 2019). Derisive parenting, involving
behaviors that demean or belittle children and
adolescents, leads to dysregulated anger in youth and
other problematic outcomes (Dickson et al., 2019).
Boldness
Low Fear
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186 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
Keep in mind, however, that some aspects of harsh,
controlling, and authoritarian parenting may look
different in various cultural contexts.
One component of harsh parenting, physical punishment,
is especially significant. Physical punishment involves the use
of force to cause pain or discomfort in a child or adolescent
to control or modify behavior (Gershoff et al., 2018). There
is overwhelming evidence, across decades of study, that the
use of physical punishments leads to detrimental outcomes.
Spanking is the most common form of physical discipline
and is observed in many families of many different
backgrounds. Despite frequent use, “the strength and
consistency of the links between physical punishment and
detrimental child outcomes lead to recommendations that
parents should avoid physical punishment, psychologists
should advise and advocate against it, and policymakers
should develop means of educating the public about the
harms of and alternatives to physical punishment” (Gershoff
et al., 2018).
Parental neglect, permissiveness, and poor monitoring
of adolescents are also noteworthy risk factors, with
links between lack of involvement and monitoring and
disruptive disorders (Bierman & Sasser, 2014). Monitoring
may be more important in high-risk neighborhoods,
where lack of supervision is associated with aggression
and conduct problems (Miller & Tolan, 2018). Parent
involvement, in contrast, may be a protective factor. In one
study of Hispanic families, parent involvement predicted
lower problematic peer affiliation and greater school
connectedness as well as higher levels of prosociality in
youth (Maiya et al., 2020).
Caregiver-child relationships set the stage for various
Lack of parental monitoring is one contributor to adolescent
conduct problems.
types and outcomes of parenting. As summarized earlier
in the chapter, positive caregiver–child relationships
are the basis for children’s willingness to respond
to socialization. When children repeatedly display
irritability, frustration, or misbehavior, parents make
important parenting decisions (such as those related
to positive or negative parenting). The probability of
the sequence from child difficulty to parental negative
control to poor outcomes depends, in part, on the
whether the parent–child relationship is characterized by
insecurity or security. The problematic sequence is less
frequent in children in secure relationships (Kochanska
et al., 2019). For children in insecure relationships,
there may be negative cascades with caregivers and
children “growing increasingly negative, resentful and
adversarial” over time, increasing the risk for disruptive
behavior disorders (Kochanska et al., 2019). Positive
parenting with challenging children is a protective factor
(Perra et al., 2021; van Goozen et al., 2022).
of oppositional defiant disorder, conduct disorder, and
antisocial behavior (Dishion, 2014; Jung et al., 2019).
Various forms of peer difficulties need to be considered,
including difficulty forming and keeping relationships,
aggression and bullying, and peer rejection. Many types of
peer factors contribute to difficulties for youth diagnosed
with various disorders. For example, deficits in social
cognition are likely to negatively influence relationships.
These deficits are observed in children and adolescents who
misinterpret others’ social intentions, who display more
incompetent problem solving during peer conflicts, or who
are inaccurate in predicting the outcomes of their own
negative behaviors.
As described earlier, peer dislike, rejection, and
victimization often begin early and are key predictors of
later problems. The “risk of catching aggressive behavior
from one’s peers” varies depending on individual and
group factors (Jung et al., 2019, p. 8). Susceptibility to peer
Peer Factors
Peers and peer relationships have a notable impact on both
the development and the later improvement or deterioration
influence depends, in part, on status. Highly popular youth
are less influenced by aggressive and antisocial peers than
less popular youth. For other at-risk youth, peer contagion,
deviancy training, and coercion help explain aggressive
David Young-Wolff/Getty Images
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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.
Intervention 187
and antisocial pathways. Gene-by-environment-by-time
processes also play a role, with initial predispositions
playing out in specific peer groups, classrooms, and
neighborhoods (Dishion, 2014; Jung et al., 2019).
Sociocultural Factors
Many studies of larger environmental variables such as SES,
economic instability, and neighborhoods provide context
to the current conceptualizations of ODD and CD. SES is
inversely related to CD, even though the majority of youth
from low-income backgrounds do not exhibit problem
behaviors or disorders (Dishion & Sasser, 2014; Cyr et al.,
2022; Kim & Kochanska, 2021). Combinations of adversity
factors increa se the likelihood of CD. Hypothese s exploring the
social learning of conduct disorder emphasize the transactions
among pervasive poverty, high-crime neighborhoods, poor
parenting, antisocial and aggressive peer groups, exposure
to community violence, and lack of economic resources
(Burt et al., 2016; Chung & Steinberg, 2006; Perra et al.,
2021). Shared sociodemographic adversity helps explain the
cross-generational stability of problem behaviors (van Goozen
et al., 2022). To be clear, CD may result from a range of
causal factors, including many not related to low SES. For
example, there is research that describes the increased risks
for disruptive and externalizing problems in youth from more
affluent backgrounds (Luthar et al., 2013).
Exposure to aggression and antisocial and aggressive
behavior crosses the boundaries and systems in which youth
are embedded, with reciprocal influences from families to
peer groups, to classrooms and schools, and to neighborhoods
(Jung et al., 2019). As summarized in the previous section,
school factors related to discipline and exclusion increase the
risk for externalizing disorders and deteriorating pathways.
Other environmental variables have also been investigated.
In a multi-nation study of risk factors for aggression and
problem behavior, exposure to media violence increased the
likelihood of aggression over and above other risk factors
(Anderson et al., 2017).
Assessment and Diagnosis
Patterns of externalizing behavior are usually observed more
quickly than are patterns of internalizing behavior. Given
the impairments associated with ODD and CD and the
effects of disruptive and externalizing behaviors on families,
teachers, peers, neighborhoods, and society, it is imperative
to identify early and identify correctly. Indeed, early
screening in pediatric clinics and preschools, with ratings
made by parents and teachers, can identify children at risk.
This makes early prevention efforts possible (Johnston &
Burke, 2020; Wakschlag et al., 2019). Before ODD or CD
is diagnosed, careful distinctions need to be made between
more common and developmentally expected problems and
more severe psychopathology. Questions focused on atypical
irritability in young children are very important (Smith
et al., 2019; Stringaris et al., 2018). Multiple instruments
and evidence-based assessments, including observations,
parent and teacher ratings, self-reports, and lab tests, are
essential.
Parents, teachers, and children provide data in a variety of
ways and for a variety of purposes. Taking note of the different
settings in which symptoms are displayed—at home or
school, in the clinic, or in the community—is also necessary
(Bierman & Sasser, 2014; Yoder & Williford, 2019). Parent
reports must sometimes be interpreted cautiously, but
parental perspectives on functioning in the home and on
especially problematic behaviors such as aggression can
be very useful. Teacher reports may also provide valuable
information about children, peer groups, and antisocial
behaviors.
Children and adolescents themselves should also be
routinely included in the assessment process. Self-reporting
by children and adolescents about behavioral difficulties
seems an unlikely source of good data. However, young
children and adolescents may provide useful information
about specific problems. Keep in mind as well that although
most adolescents do not refer themselves for treatment,
many with difficulties, particularly peer difficulties, do
want help. From a holistic perspective, it is essential to
explore the child’s or adolescent’s developmental assets
or strengths. This allows for a balanced appreciation of
adaptation/maladaptation and may also provide insight for
treatment planning.
The most salient issues related to differential diagnosis
focus on distinctions among CD, ODD, and ADHD. It
is possible to differentiate CD from each of these other
disorders, but clinicians must understand that ODD, CD,
and ADHD may co-occur, with appropriately separate
diagnoses. In practice, the CD diagnosis often supersedes
the ODD diagnosis. Both may be diagnosed to indicate
that each is salient in a particular environment (e.g., ODD
in school and CD in the neighborhood). CD may also be
comorbid with either anxiety or depression. Questioning
about depression is especially important because the
combination of CD and depression involves a much higher
risk for substance abuse and suicidality; girls are more
likely to display this combination (Capaldi & Kim, 2014;
Wertz et al., 2015).
Intervention
Because oppositional defiant disorder and conduct disorder
are associated with so much distress and dysfunction,
there has been significant work focused on prevention and
treatment for many years. Given the developmental cascades
observed for irritability and antisocial and aggressive
behavior, it may seem as if poor outcomes for struggling
youth are inevitable. There are compelling data, however,
that well-timed, individualized, and comprehensive
interventions for externalizing disorders are both successful
and cost effective (Kaminski & Claussen, 2017; Weisz &
Kazdin, 2017).
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188 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
Box 10.2 Clinical Perspectives
The Early Risers Program
A number of prevention and intervention programs, such as The
Incredible Years and The Triple P Positive Parenting Program,
have been designed to improve the trajectories of children
at risk for developing disruptive behavior disorders (Crosby
et al., 2019; Klimes-Dougan et al., 2018). The Early Risers
program, originally developed at the University of Minnesota
and now implemented in communities across the country,
is a multicomponent, high-intensity intervention program
that targets aggressive elementary school children at risk for
developing significant conduct problems (August et al., 2004;
Bernat et al., 2007). This well-established program, focused
on improving children’s self-regulation skills and parenting
effectiveness, is based on the premise that early, comprehensive
intervention, sustained over time and across settings, can
change the developmental pathway for at-risk children from
one characterized by destructive and maladaptive behavior to
one characterized by resilience and success.
The intervention includes self-regulation and social skills
training; tutoring in reading and math; behavioral group
therapy for aggressive, disruptive, and noncompliant behavior;
and parent support services, including consultation and brief
intervention for acute family problems. Sessions are based in
schools or community centers and emphasize communication,
consistency, and coordination of the intervention approach
throughout the child’s environment (school, community, and
home). The enhanced sense of general competence that the
children develop in the program has been found to improve
their self-image, decision making, and problem-solving skills.
Outcomes for individuals completing five years of continuous
intervention show sustained improvement (Bernat et al., 2007).
Longitudinal follow-up studies have provided strong evidence
for positive and sustained outcomes. The value of early
intervention is that it prevents or minimizes the developmental
cascades that would otherwise lead to externalizing behavior
problems in the later teen years (Hektner et al., 2014).
Research on the Early Risers program has evolved over the
years to emphasize important contemporary questions in
developmental psychopathology. For example, investigators
have studied the differential effectiveness of the Early Risers
program in high- and low-risk youth as determined by their
stress-activation biology (Klimes-Dougan et al., 2018) as well
as response heterogeneity in youth who differ in family risk
profiles (Piehler et al., 2022).
Barriers to effective treatment and positive outcomes
include poor collaboration between agencies and schools,
transportation difficulties, and high staff turnover; these
factors must be accounted for and addressed in the planning
and treatment stages (August et al., 2006). Predictors of more
effective implementation of the Early Risers program include
the use of Web-based technologies to monitor adherence to the
treatment protocol (Lee et al., 2008) and specific clinician
characteristics such as confidence in the program,
conscientiousness, and flexible coping skills (Klimes-Dougan
et al., 2009). In addition, successful wide-scale implementation
is clearly enhanced by including comprehensive implementation
support, such as school-based family advocates, in the design
and implementation of the Early Risers program (Bloomquist
et al., 2013). The Early Risers program is included in the U.S.
Department of Health and Human Services list of effective,
evidence-based interventions for disruptive behavior disorders.
Comprehensive interventions such as the Incredible
Years program, the Fast Track model, and the Early Risers
program include several components and take into account
both child-treatment compatibility and adult-treatment
compatibility (Bierman et al., 2020; Sorensen et al., 2016;
refer to Box 10.2). Interventions are most likely to be useful
when there is a reasonable match between the clinical
presentation and various treatment components. Examples
of such matches include children’s social skills deficits paired
with cognitive-behavioral techniques, poor parenting skills
paired with parent training and support, and damaged
parent–child relationships paired with family therapy. Given
the complexity of etiological models, interventions that target
parenting and interventions that target youth difficulties may
be timed and combined in various ways to improve outcomes
(van Goozen et al., 2022; refer to Figure 10.4).
Youth Treatments
Given the difficulties observed in children and adolescents
struggling with externalizing disorders, it is not surprising
that wi llingness to par ticipate in treatment must be addressed .
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Adolescents especially may be reluctant to become engaged
in psychotherapy. It is essential, then, to quickly address the
motivation for change and personal responsibility for change.
For example, in designing treatments, clinicians may want
to allow an adolescent some responsibility for goal setting
and decisions about discipline and rule breaking (Dishion,
2014; Kazdin, 2018). These efforts may foster motivation,
attendance, and treatment adherence.
Child and adolescent treatments target emotional,
cognitive, and behavioral difficulties, including selfregulation, decision-making difficulties, and limited
coping skills (Modecki et al., 2017). Cognitive-behavior
approaches such as cognitive problem-solving skills training
are evidence-based treatments focused on informationprocessing, executive function impairments, problematic
peer relationships, and parent conflict. Cognitive problemsolving skills training demonstrates significant reduction in
problematic behaviors and increases in prosociality (Kazdin,
2018). Other treatments have focused on emotion skills and
empathy training to help youth most likely to persist in
aggressive and antisocial behavior (van Goozen et al., 2022).
Intervention 189
Figure 10.4 A model of antisocial pathways and the timing of parent and child interventions
Self-regulation
(physiological, emotional,
and cognitive mechanisms)
Behavioral outcomesFamilial influences
Genetic factors
Early childhood adversity
Early behavioral problems
Parent training
interventions
Source: van Goozen, Langley, & Hobson (2022). Childhood antisocial behavior: A neurodevelopmental problem. Used with permission of Annual Reviews
©2022 permission conveyed through Copyright Clearance Center, Inc.
Interventions that target irritability and emotion
dysregulation have also received empirical support (Brotman
et al., 2017; Waxmonsky et al., 2021). The focus of these
interventions is on emotion recognition, reactivity, and
regulation. Significant improvements in irritability (as well as
conduct problems) have been observed for modular approaches
such as MATCH (Modular Approach to Therapy for Children
with Anxiety, Depression, Trauma, or Conduct Problems),
where therapists are able to select appropriate modules (from
a larger set of modules) matched to the child’s or adolescent’s
clinical presentation (Evans et al., 2020). Youth themselves
reported faster and greater symptom reduction. “It seems
possible that youths—who may be brought into treatment
without understanding why, or even against their will—
respond better to a flexible, multiproblem, highly personalized”
treatment (Evans et al., 2020, p. 263).
Parent Treatments
For decades, most of the interventions focused on parent
training—particularly behaviorally oriented parent training,
frequently referred to as parent management training (PMT).
There is overwhelming support for the role of this training
in the treatment of externalizing disorders in children and
adolescents (Kaminski & Claussen, 2017; Weisz & Kazdin,
2017). The goals of PMT, across all variations of PMT, involve
decreasing coercive interactions, increasing positive parenting,
Neurobiological deficits
Antisocial behavior
problems
Impaired emotion and
executive functioning
Self-regulation
interventions
Time
and increasing compliant behavior and prosociality. The
Oregon model is based on social interaction learning processes
and includes two mechanisms for change. The first is focused on
interactions within the family, primarily negative reinforcement
provided to children for oppositional and antisocial behavior.
The second is focused on the social environment outside the
home, primarily peer situations (Patterson et al., 2010).
Parent– Child Interaction Therapy (PCIT) is an evidencebased, developmentally informed intervention for children
with disruptive behavior problems and their parents. PCIT
recognizes that the parent–child relationship provides
a powerful context for understanding and changing
behavioral patterns in young children (Funderburk &
Eyberg, 2011). Using a variety of techniques, the parent
and therapist collaborate to understand the nature and
effects of the parent’s behavior on the child, to discover
and practice new ways of interacting with the child, and
to acknowledge both the problematic aspects of parents’
behaviors and their capacity to modify those behaviors to
change the child’s behavior and experience of the world.
Together, the parent and therapist work to create specific
improvements in the child’s behavior as well as a broader
foundation of security and satisfaction in the parent–child
relationship upon which the child can organize a more
adaptive and competent developmental trajectory (Yates
et al., 2011).
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190 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
All parent-focused interventions, of course, should be
designed and implemented with family a nd cultural variation
in mind. Family and cultural strengths should be identified
and built upon. The selection of specific interventions
might focus on parental warmth or accessibility of online,
father-inclusive parenting programs (Booker et al., 2020;
Piotrowska et al., 2020).
In addition to treatment components that focus on parents’
interactions with their children, some parents will require other
types of individual and family-based supports. The treatment
of parent psychopathology is especially important. Equally
important are interventions designed to facilitate access to
treatment for parents and families with multiple adversities
that make participation and engagement more difficult.
System-focused, Peer, and School
Programs
The research is clear that intensive, multimodal approaches
work best. One example of such an approach is multisystemic
therapy, based on Henggeler’s research (Henggeler & Lee,
2003; Weisz, 2004). The mechanisms and direction of change
in multisystemic therapy include the following: adherence
to treatment model → improved family relationships →
decreased delinquent associations → decreased delinquent
behavior. Good outcomes and persistent improvements have
been repeatedly demonstrated with multisystemic therapy
(Kazdin & Weisz, 2017; Butler et al., 2011). The benefits of
multi-domain interventions are that achievements in specific
domains can mitigate risks in other domains. In other words,
risks associated with adverse neighborhood contexts can be
lessened by positive parenting. Risks related to harsh and
inconsistent parenting can be lessened by success at school. And
risks due to difficult early school experiences can be lessened by
parents who communicate and support their children (Bierman
et al., 2020; Dodge et al., 2008).
Peer groups for conduct-disordered youth are common.
One important caveat about treatments that involve groups
of conduct-disordered children and adolescents relates to
peer contagion and deviancy training (previously discussed
in the section on developmental course). Peer contagion
and deviancy training involve sharing information about
conduct problems, including additional and varied
problem behaviors, drugs, weapons, and the immediate
and powerful reinforcement of aggressive and antisocial
behaviors (Dishion, 2014). Thinking back to descriptions
of the role of antisocial peers in eliciting and maintaining
conduct-disordered behavior, it is not hard to imagine the
likely effects of including these peers in treatment settings.
A lot of research and clinical experience suggests that the
positive impact of treatment is lessened, with worse outcomes
for those participating in peer groups (Dodge et al., 2006;
Jung et al., 2019). To support children and adolescents with
conduct disorders, prevention and treatment programs
must be reworked to focus on adults (parents and teachers)
and nondeviant peers, and changes must be made across
disciplines and in mental health clinics, educational and
school settings, the juvenile justice system, and community
organizations (Dodge et al., 2006).
School-based programs are very important for some
youth and have demonstrated success in reducing coercive
and antisocial behaviors (Modecki et al., 2017; WebsterStratton et al., 2008). Community interventions designed
to promote effective discipline techniques and decrease
parent–child conflicts supplement individual, family, and
school plans.
Prevention
In the hopes of minimizing future treatment needs,
prevention efforts focus on reducing the rates and/or severity
of ODD, CD, and antisocial behavior. Universal, targeted,
and individual strategies have been pursued. Children who
display high-risk emotions and behaviors can be identified
early in pediatric clinics, prior to a full-blown clinical
presentation. Targeting early dysregulated irritability
improves mental health outcomes for many children and
adolescents (Wakschlag et al., 2019).
Positive youth development programs, designed to foster
adolescent–adult relationships, are associated with longterm positive outcomes (Lerner et al., 2011). As described in
Chapter 2, a mentoring program focused on youth of color
in high-stress communities identified specific internal and
external characteristics that decreased problem behaviors
and increased well-being (Onyeka et al., 2021).
Family-based parenting programs focused on parent
warmth and management skills may be provided to
parents at multiple points across children’s development.
Positive Discipline in Everyday Parenting (PDEP), for
example, a punitive-violence prevention program, has four
components: “1) shifting parents goals from immediate
child compliance to long-term learning; 2) strengthening
parents’ understanding of the importance of simultaneously
providing warmth (physical and emotional security)
and structure (scaffolding of children’s learning) in all
situations; 3) increasing parents’ knowledge of children’s
neurobiological, emotional, and behavioral development
from birth to adolescence; and 4) helping parents integrate
these components to develop problem-solving strategies
to replace physical and emotional punishment” (Durrant
et al., 2017, p. 524). PDEP is associated with improved
parent–child relationships and improved youth behavior.
From its inception, PDEP developers sought information
from parents of various backgrounds to provide culturallyrelevant and useful programming. PDEP is used by parents
in 30 countries (Durrant et al., 2017).
Prevention-oriented school programs also contribute to
reducing risk. One example of a universal measure that
has been effective in decreasing disruptive behaviors in
the classroom is the school-based part of the Fast Track
intervention (Bierman et al., 2020). Socioemotional
learning curricula provide skills training that reduces
2019). School approaches to problem behaviors vary in
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Intervention 191
their emphasis on punishment and other behavior change
strategies. Positive discipline approaches are increasingly
observed, with a focus on positive reinforcement instead
of punishment, proactive plans instead of reactive
Key Terms
Prosociality (172)
Prosocial behaviors (172)
Prosocial motivation (172)
Conscientiousness (173)
Conscience (173)
Bullying (175)
Oppositional defiant disorder (ODD)
(176)
Conduct disorder (CD) (178)
Chapter Summary
●
Prosociality includes prosocial behaviors and prosocial
motivations. Developmental tasks and challenges related
to prosociality include the emergence of conscientiousness
and conscience, the influence of caregivers and peers, and
displays of antisocial and aggressive behaviors.
●
The social context for the development of prosociality is
anchored in the parent–child relationship, especially in
early development, and then widens over time to include
peer and other social relationships. This broadening social
context can serve as either a protective or risk factor in
relation to the development of disruptive behavior problems.
●
Bullying, observed across the globe, is characterized by
negative actions intended to cause harm, that are repeated
over time, and that involve a power differential between
bully and victim. Types of bullying, characteristics of
bullies, and trajectories of bullying and victimization are
the focus of research studies.
●
Oppositional defiant disorder (ODD) is characterized by
a sustained pattern of negativistic, hostile, and defiant
behavior. Irritability and impaired social cognition are
also common symptoms of ODD.
●
Although most children diagnosed with ODD do not go
on to develop more severe forms of the disorder, ODD does
significantly increase the risk for later conduct disorder.
responses, and collaborative programs (Oxley & Holden,
2021). Programs designed to prevent bullying are also
incorporated in school curricula in many countries and
cultures.
Callous-unemotional traits (178)
Limited prosocial emotions (178)
Early-onset pathway (178)
Adolescent-onset pathway (178)
Childhood-limited pathway (178)
Aggression (179)
Instrumental aggression (179)
Reactive aggression (179)
Coercion model (181)
Peer contagion (183)
●
Conduct disorder (CD) is differentiated from ODD by
the severity of the externalizing behaviors and the degree
of impairment associated with the disorder.
●
Conduct disorders are further differentiated by patterns
of externalizing behaviors and whether the onset of the
disorder occurs during childhood or adolescence.
●
Callous-unemotional characteristics, such as a lack of
empathy or remorse, are associated with greater continuity
and severity of problems throughout development.
●
A number of etiological risk factors may contribute to the
development of ODD and CD, including characteristics
of the child (such as temperament), quality of parenting,
genetics, peer factors, and environmental factors.
●
Because externalizing symptoms are usually identified
more easily and earlier by observers, early diagnosis and
intervention efforts are especially relevant for both ODD
and CD.
●
Differential diagnosis often focuses on the commonalities
and distinctions among ODD, CD, and ADHD. In
addition, both ODD and CD may be comorbid with
other internalizing or externalizing disorders.
●
Intervention approaches that a re intensive, comprehensive,
multimodal, and implemented early have been found to
be most effective.
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11
Anxiety Disorders, ObsessiveCompulsive Disorder, and Somatic
Symptom Disorders
Chapter Outline
Developmental Tasks and Challenges Related to
Emotion Experiences, Fears, and Worries 193
Anxiety Disorders 194
The Case of Lakshmi: Separation Anxiety Disorder
The Case of Jack: Phobic Disorder
The Case of Rory: Social Anxiety Disorder
The Case of Charlotte: Generalized Anxiety Disorder
The Case of Asher: Generalized Anxiety Disorder with Autism
Spectrum Disorder
The Case of Brynn: Panic Disorder
Obsessive-Compulsive Disorder 200
The Case of Daniel
Somatic Symptom Disorders 202
The Case of Isabella
Developmental Course 203
Learning Objectives
1. Summarize the multiple factors that influence the
experience of fears and worries in typically-developing
children and adolescents.
2. Summarize the core symptoms and developmental course of
separation anxiety disorder.
3. Summarize the core symptoms and developmental course of
phobic disorder.
4. Summarize the core symptoms and developmental course of
generalized anxiety disorder.
5. Summarize the core symptoms and developmental course of
panic disorder.
6. Summarize the core symptoms and developmental course of
obsessive-compulsive disorder.
Continuity and Course of Anxiety Disorders
Continuity and Course of Obsessive-Compulsive Disorder
Box 11.1 Clinical Perspectives: Loneliness across Childhood
and Adolescence
Continuity and Course of Somatic Symptom Disorders
Etiology 205
Genes and Heredity
Physiological Factors
Child Factors
Parent Factors
Environmental Factors
Assessment and Diagnosis 208
Intervention 209
Pharmacological Treatment
Psychological Treatment
7. Summarize the core symptoms and developmental course of
somatic symptom disorders.
8. Integrate and explain how genetics, physiological factors,
child factors, and parent factors contribute to the emergence
and maintenance of anxiety disorders.
9. Integrate and explain how etiological factors, including
genetics, physiological factors, child factors, and parent
factors, contribute to the emergence and maintenance of
obsessive-compulsive disorders.
10. Summarize the key components of a comprehensive
assessment for anxiety disorders, obsessive-compulsive
disorder, and somatic symptom disorders.
192
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Developmental Tasks and Challenges Related to Emotion Experiences, Fears, and Worries 193
Learning Objectives (continued)
11. Summarize the evidence-based child treatments for anxiety
disorders, obsessive-compulsive disorder, and somatic
symptom disorders.
12. Summarize the evidence-based parent treatments for anxiety
disorders, obsessive-compulsive disorder, and somatic
symptom disorders.
In a world that can be realistically frightening (with
adversity, violence, and natural disasters) and unpredictably
threatening (with germs, spiders, or pain), many children
and adolescents are diagnosed with anxiety-based disorders.
Anxiety disorders provide a useful illustration of the
distinction between childhood problems and clinically
significant disorders. Many children struggle with fears and
worries that have a real, negative impact on daily functioning.
For some children, taking a bath is a sudsy disaster because
they are afraid of the water or of going down the drain.
For other children, thunderstorms ruin a family’s evening.
Parents and mental health professionals need to take into
account a variety of factors, including developmental
context, the specific stimuli that elicit fear, and the degree
of impairment, as they recognize, diagnose, and respond to
children’s anxiety-related problems and disorders.
In the opening sections of previous chapters, there are
summaries of temperament, the regulation of emotion and
behavior, and executive function. Each of those summaries
includes information that is also useful for understanding
the development and course of anxiety disorders. In this
section, we provide additional detail related to the overall
experience of emotion and the relations among emotion,
cognition, and behavior to help explain similarities and
differences between typical and atypical development.
Developmental Tasks and Challenges Related to Emotion Experiences, Fears, and Worries
Children and adolescents feel, express, and regulate a variety
of emotions. Development and individual differences
influence what stimuli and situations elicit emotion, how
emotional experiences play out over time, the complexity
of emotion knowledge, and the variety and effectiveness of
emotion regulation strategies (Buss et al., 2019). Emotions
are characterized by valence (positive vs. negative), intensity,
and behavioral activation patterns (approach vs. avoidance).
Positive emotions include joy, contentment, and gratitude.
Negative emotions include fear, anger, and sadness.
Although positive and negative emotions are observed in
infants, the capacity to experience and share a range of
emotions develops over time. Sociocultural variables such
as emotion values and beliefs also play a role in emotion
experience and well-being (Senft et al., 2022).
Arousal, intensity, and duration of emotion are integral
components of emotional experiences and may influence
unpleasant or undesirable outcomes. Emotion regulation
(ER) involves monitoring, moderating, and enduring
emotions. The regulation of negative, intense, or longlasting emotions takes many forms, including emotionfocused strategies, cognitive strategies, and behavioral
strategies. As noted in Chapter 8, ER overlaps the construct
of coping. Frequently-observed coping strategies are emotion
expression, emotion suppression, distraction, avoidance,
acceptance, and cognitive reappraisal (Compas et al., 2017).
When ER or coping is constrained, compromised, or
ineffective, distress tolerance comes into play. Distress
tolerance is the capacity to withstand negative emotional
and/or other aversive states. Both perceived capacity (one’s
belief in one’s ability to endure distress) and behavioral
capacity (one’s actual responses to distress) contribute
to distress tolerance. A variety of self-regulation and
experiential processes, including tolerance of uncertainty
and tolerance of negative emotion, contribute to individual
differences in levels of distress tolerance (Zvolensky et al.,
2010; refer to Figure 11.1).
Almost all typically-developing children and adolescents
experience and manage negative emotions in their everyday
lives. Children and adolescents display a mix of successful
and unsuccessful ER and coping depending on specific
situations (at home with parents, in school with friends), type
of emotional experience (intense fear, less-intense anger),
and emotion-related goals (persist in a stressful situation or
avoid negative affect). With age and experience, strategies
become more differentiated and organized, and individual
differences in youths’ emotion-related goals, capacity for
ER, and coping outcomes become increasingly apparent
(Compas et al., 2017; Lennarz et al., 2019; Zimmermann
& Iwanski, 2014).
Difficult and painful emotions–such as anxiety–often
provide meaningful information about oneself, one’s
relationships, and one’s surroundings. Wariness in the
presence of strangers or on an unfamiliar bike path, or
apprehension before an exam or a recital provides children
and adolescents with important information about the
possibility of harm or the need to prepare for challenging
activities. When emotion signals are perceived and
cognitive and behavioral adjustments are made, anxiety
usually diminishes quickly. Youth who experience little or
no anxiety may fail to plan for demanding tasks or place
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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.