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To Paula and Linda

About the authors

Walter Matthys, MD, PhD, is Professor of Aggression in Children at Utrecht University, The Netherlands. His clinical work as a child and adolescent psychiatrist is based at the Department of Child and Adolescent Psychiatry, University Medical Centre Utrecht. His research at the Rudolf Magnus Institute of Neuroscience focuses on the neurobiological and psychological characteristics of children and adolescents with aggressive behaviour and disruptive behaviour disorders, and on interventions to prevent and treat these disorders.

John E. Lochman, PhD, ABPP, is Professor and Doddridge Saxon Chairholder in Clinical Psychology at the University of Alabama, where he also directs the Center for Prevention of Youth Behavior Problems. He has served as a Special Professor at Utrecht University. He is Editor-in-Chief of the Journal of Abnormal Child Psychology, serves on the Board of the Society for Prevention Research, and is President of the American Board for Clinical Child and Adolescent Psychology. His research interests encompass risk factors, social cognition and intervention and prevention with aggressive children.

Preface

This book offers a brief but comprehensive overview of empirical knowledge and associated clinical information regarding oppositional defiant disorder (ODD) and conduct disorder (CD) in children aged 3–14 years. Since the amount of research in this subject is vast, we have avoided presenting an extended review of the literature of some areas while neglecting others. Instead, we have given priority to conciseness and clarity in the presentation of a broad array of topics.

The book opens with an introductory chapter on relevant terms. We then present the developmental psychopathology perspective (Chapter 2). The section of the book on aetiology starts with a chapter on basic issues (Chapter 3) followed by two detailed chapters on individual and environmental characteristics (Chapters 4 and 5). We then describe the clinical assessment from a decision-making point of view (Chapter 6). The section on intervention opens with a chapter on general issues (Chapter 7), followed by chapters on behavioural parent training (Chapter 8), cognitive-behavioural therapy (Chapter 9), pharmacotherapy (Chapter 10) and multicomponent interventions (Chapter 11). Finally, issues relating to the delivery of intervention are discussed in Chapter 12.

This synopsis is intended to be a guide for professionals and will be useful for students and researchers as well. Some information, for example on genetics, will serve as background information for clinicians and will be relevant for their accurate general understanding of the initiation, development and maintenance of the disorders. The background aetiological chapters can also help clinicians in understanding subsets of the children they see. Students and beginning researchers will find a quick overview of the whole field, while advanced researchers may find essential information on topics that are not their primary focus of interest and expertise.

For decades, the research fields of ODD and CD (and aggressive and antisocial behaviour) on the one hand and attention deficit/hyperactivity disorder (ADHD) (and hyperactive, impulsive and inattentive behaviour) on the other have been split as if these two groups of disorder and problem behaviour are independent of each other. In fact, however, they often co-occur. The separation of research areas of ODD/CD and ADHD has hampered our understanding of these two groups of related disorders. Fortunately, the last decade has seen an integration of the research fields of these disorders. In this book, we have paid much attention to the relation between these disorders, with respect both to aetiology, assessment and treatment, and to neurobiological factors in ODD and CD, as information on this topic has grown rapidly over the last few years and is essential for an accurate understanding of these disorders.

In reviewing the literature, we pay particular attention to recently published studies and meta-analyses, if available, without neglecting older, high-quality studies. The selection of studies, of course, reflects our own view on the subject. Likewise, we give personal comments on issues. We include our clinical and research experience in the chapters on clinical assessment and interventions. To make the book accessible, we have included a conclusion in the form of summary points at the end of each chapter.

We would like to thank the publisher Wiley-Blackwell for the invitation to write the book and the many people associated with the publisher for their assistance: Carole Millett, Emma Hatfield, Holly Myers, Al Bertrand, Darren Reeds, Anne Bassett, Annie Rose, Carrie Walker and Helen Baxter. We would also like to thank Karen Shield for her assistance in manuscript delivery, and Martin Schmidt, Dennis Schutter, Louk Vanderschuren and Sarah Durston for their detailed comments on earlier drafts of the chapters.

Walter Matthys

John E. Lochman

Foreword

The authors of this important book, Professors Walter Matthys and John E. Lochman, need little by way of introduction; they are known to a wide professional readership for their prolific empirical, clinical and theoretical studies of Disruptive Behavior Disorders (DBD) and other challenging behavior problems of childhood and adolescence. Certain children, as early as two or three years of age, drive their parents to despair by the intensity of their tantrums and aggressive outbursts, the intransigence of their defiance, and the wilfulness of their demands. During the school years teachers struggle to cope with their violation of classroom rules, and the disruption that results from (inter alia) their inattention, hyperactivity, bullying, and cheating. Many go on to an adolescence marked by violence, vandalism, theft, and other delinquent activities. These children, diagnosed early on as presenting Oppositional Defiant Disorder (ODD) and later Conduct Disorder (CD), cause much harm to society. As they grow up they enter, exit and almost invariably return, through the ‘revolving doors’ of mental health, educational, social services, and justice departments. Carers and teachers endure ongoing distress and demoralisation, while the State is forced to raise vast sums of money for damage limitation and repairs, and the costs of assessment and treatment agencies.

Clearly, the need to support families, teachers and workers from the social and mental health professions is urgent, and represents a compelling rationale for the book. The authors state that their aim is to write for professionals, students, and researchers, a concise guide to the aetiology and the assessment of ODD and CD, as well as to evidence-based interventions, and their short and long-term outcomes, Focusing on children aged 3 to 14 years, the book provides in twelve chapters, a overview of aetiology, assessment, prevention and treatment of ODD and CD, with particular attention given to recently published studies and meta-analyses. High quality studies from the past are not neglected. The introductory guides and final point-by-point summaries to each chapter, the provision of technical and conceptual definitions, plus comprehensive referencing, ensure that child and adolescent psychiatrists, clinical psychologists, and trainees, have access to a store of useful empirical information and practice wisdom. There is another group of professionals who also benefit, as they acquire familiarity with subjects which are not necessarily their primary focus of interest and expertise.

The authors explore several theoretical domains that are pertinent in a study of behavioral pathology: psychiatric taxonomy; developmental psychopathology; behavior genetics; pharmacology; neurobiology; conditioning; social learning; and cognitive science. A consistent theme of the book is an insistence on empirical knowledge and evidence-based practice. This philosophy leads to a search for reliable and valid assessment methods, several of which are described and analysed fully. Alongside this inquiry is an exploration of clinically efficacious and effective interventions. Several have been demonstrated to have ‘significant effects’ (a term that is explained) on particular disruptive behavior problems, after treatment and at longer term follow-up. Most of them emerge from areas including cognitive behavior therapy, ecological (systemic) multi-component treatment, behavioral parent training, and psychopharmacotherapy. Multi-component programs may combine psychopharmacotherapy and psychosocial treatments; in general they are most effective if they provide the treatment to both child and parent. With regard to the question of how ‘cost-effective’ (a term also explained) the interventions are, the initial findings are encouraging. Given the popularity of computers and video games for young people, it is not surprising that electronic media have an established role in an increasing number of treatment programs.

What sets this book apart from many others of its genre is the space given to the factors (ranging from macro-level influences of social policy and environmental advantages or disadvantages to microlevel factors such as adverse temperamental and personality traits) which encourage or prove antipathetic to the delivery of successful interventions. Outcomes for evidence-based interventions may often be less promising when they are exposed to the vicissitudes of real-life ‘scenarios’ and settings, such as community agencies, schools and clinics. There are many other potentially adverse contingencies: a recurring difficulty, for example, is the failure of many parents to engage in treatment programs, despite imaginative efforts to promote their attendance at sessions. On the basis of ‘received wisdom’ in some areas it is assumed that there is therapeutic value in the use of a collaborative approach to treatment and the use of booster sessions at the end of treatment sessions. There is, in fact, very little research to guide clinical practice in these areas. Methodological bias in empirical investigations may produce misleading conclusions. For example, constitutional factors such as Attention Deficit Hyperactivity (ADHD) often occur at the same time as DBD. An understanding of the two conditions was hampered by considering them in earlier studies as separate entities. An integration of the research fields in the last decade has produced valuable insights into the nature of both disorders.

In conclusion: I have had only sufficient space to comment on a fraction of the book I read in its entirety. Professors Matthys and Lochman have, in my opinion, written an outstanding review of an extensive, and at times difficult, clinical literature. By skilful organisation and thoughtful defining of terms and concepts, they have produced a pleasurable read without sacrificing intellectual rigor. They have stuck throughout to a clear set of aims and objectives. Whereas psychotherapy with children and adolescents has traditionally involved the application of many empirically unsupported methods, the authors have committed themselves to evidence based studies of childhood interventions – a basis essential for effective and thus ethical clinical practice.

Martin Herbert

Professor Emeritus, Exeter University

1

Behaviours and disorders

All children refuse to comply at some time or other. And a lot of children occasionally get involved in fights. Also, various children lie at times. Although these behaviours are inappropriate, from a clinical point of view they need not be of great concern if they occur infrequently and in an isolated manner. When, however, these behaviours occur in a cluster and repeatedly in a particular child, there is reason to be worried. In this chapter, we first look at the various types of socially inappropriate, disruptive behaviour that have been discerned, and then consider related clusters of behaviours or diagnostic categories that have been distinguished. Finally, we discuss appropriate behaviours that may be underdeveloped in children with maladjustment.

Disruptive behaviours

Oppositional behaviour

Oppositional behaviour or non-compliance is behaviour in which a child resists a caregiver. A range of oppositional behaviours may be discerned, from passive to active forms of non-compliance (Kochanska & Aksan, 1995). Thus, children may ignore a parental direction, which is an example of passive non-compliance, but they may also directly refuse a parental command, which is a form of mildly active non-compliance. In addition, children may angrily reject parental commands or prohibitions, which is a form of severe non-compliance or defiance. In preschool children, moreover, a distinction needs to be made between normative non-compliance and clinically significant noncompliance or oppositionality (Wakschlag & Danis, 2004). Normative noncompliance reflects the young child’s self-assertion and is driven by the desire to do something autonomously (Wakschlag & Danis, 2004). Normative or self-assertive non-compliance is generally short-lived, whereas clinically significant non-compliance is more intransigent (Wakschlag & Danis, 2004).

Aggressive behaviour

Aggression is behaviour deliberately aimed at harming people (Parke & Slaby, 1983). Hitting other children is an example of physical aggression. There are, however, other forms of aggression. Words also may harm people, either as a possible precursor of physical aggression such as in verbal threats, or as a means to denigrate or provoke another child. This occurs, for example, when children call each other names. Relational aggression is another form of aggressive behaviour that has been investigated in recent years (Crick & Grotpeter, 1995). It is defined as damaging interpersonal relationships or feelings of inclusion. Malicious gossiping and threatening to withdraw friendship are examples of relational aggression. In this book, when we use the term ‘aggression’, we understand this as physical or verbal aggression. When relational aggression is discussed, this is made explicit.

Among these various forms of aggressive behaviour, the distinction has been made between reactive and proactive aggression (for reviews, see Dodge, 1991; Kempes et al., 2005; Vitaro et al., 2006). Reactive aggression is an impulsive aggressive response to a frustration, a perceived threat or a provocation. On the other hand, proactive aggression is controlled aggressive behaviour that anticipates a reward. Reactive aggression also has been called defensive or ‘hot-blooded’ aggression, whereas proactive aggression has been called instrumental or ‘cold-blooded’ aggression.

When considering aggression, one may distinguish differences in the underlying motivation (or the ‘whys’ of aggressive behaviour) from differences in the various forms of aggression (the ‘whats’ of aggressive behaviour) (Little et al., 2003). Thus, the distinction between reactive and proactive aggression (the ‘whys’) may be applied both to physical, verbal and relational aggression (the ‘whats’). One example of verbal reactive aggression in children is to get angry and swear at adults when corrected. One example of physical reactive aggression is to strike back when teased by a peer. A child threatening another child in order to get his or her own way is an example of verbal proactive aggression. To incite other children to act against a child whom he or she dislikes is an example of proactive relational aggression. Although reactive aggression and proactive aggression are highly correlated, correlations drop dramatically after the distinction has been made between the form and the motivation of aggression (Polman et al., 2007).

Antisocial and delinquent behaviour

Antisocial behaviour is defined as behaviour by which basic norms, rights and rules are violated. Thus, when children lie they violate the norm of speaking the truth, when they steal they violate the right of the protection of one’s property, and when they are truant they violate a rule. ‘Antisocial behaviour’ is often used as a general term for the various inappropriate behaviours such as oppositional and aggressive behaviour. When children repeatedly resist in response to requests, instructions or corrections given by adults, they indeed violate the norm to be obedient to their parents or teachers. And when children beat their peer, they violate their peer’s right of physical integrity.

When antisocial behaviours are legal violations, they are called delinquent behaviours. Depending on the age of the child, behaviours such as theft, running away, truancy from school and setting fires are considered to be delinquent. Legislation between countries, and among states within countries, largely varies, so that the same behaviour, for example drinking alcohol, is considered as illegal in one country or state but not in another.

Psychopathic features and callous-unemotional traits

There is one other term that is relevant here–psychopathy. Psychopathy refers to personality characteristics such as an absence of empathy, an absence of guilt, an absence of anxiety, shallow emotions and the inability to form and sustain lasting relationships (Cleckley, 1976; Hare, 1993). Thus, psychopathy does not refer to a specific set of behaviours but to underlying characteristics of individuals.

The construct of psychopathy in adults consists of various dimensions. The dimensions that have been found to be useful in children and adolescents are callous-unemotional traits (for a review, see Frick & White, 2008) and narcissism (Barry et al., 2007). The affective factor of psychopathy – the callous-unemotional trait – consists of lack of guilt, lack of empathy and callous use of others for one’s own gain, and has been found to have moderate stability in longitudinal research (Pardini et al., 2007; Barry et al., 2009).

Disruptive behaviours

The above discussed inappropriate behaviours also are called disruptive behaviours. These behaviours not only disrupt child–child interactions and child–adult interactions, but when these behaviours occur frequently, the relations between children and the relations between children and adults are disrupted as well. ‘Externalizing behaviour’ is another general term for these inappropriate behaviours (Achenbach & Edelbrock, 1978). It is used to distinguish these behaviours from overcontrolled or internalizing behaviours such as withdrawal and anxious behaviours.

There are, however, more behaviours that are disruptive than the ones discussed above. Impulsive behaviours such as interrupting others and having difficulty in waiting a turn indeed are clearly disruptive. Hyperactive behaviour such as running about in the living room or leaving one’s seat in the classroom and during meals at home, are troublesome as well. Finally, attention problems such as difficulty in sustaining attention may occur unnoticed, but other behaviours related to attention problems, such as not following through on instructions, are quite upsetting.

Diagnostic categories

Disruptive behaviours may occur either infrequently or in isolation in individual children, and in these cases the behaviours can then be considered as ‘normative’. However, they may also occur as clusters. These clusters of co-occurring patterns of inappropriate behaviours or syndromes form the basis of the psychiatric categories from the classification systems of the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994), or its revised form DSM-IV-TR (American Psychiatric Association, 2000), and the International classification of diseases, 10th revision (ICD-10; World Health Organization, 1996). Although these syndromes originate from hypotheses about co-varying symptoms or behaviours derived from observations of patients by clinicians, factor analytic studies of child and adolescent problem behaviour support how these behaviours are associated to each other (see later in this chapter).

The disruptive behaviours are distinguished from other disorders such as pervasive developmental disorders in DSM-IV-TR. Indeed, the former group of disorders is described under the general heading ‘Attention deficit and disruptive behaviour disorders’. These disorders consist of: (1) attention deficit/hyperactivity disorder (ADHD), with characteristic features of hyperactive behaviour, impulsive behaviour and attention problems; and (2) the two disruptive behaviour disorders (DBDs) – oppositional defiant disorder (ODD) and conduct disorder (CD) – with characteristic features of oppositional, aggressive and antisocial behaviour. It is generally accepted that ODD and CD are different age-related manifestations of the same condition, with ODD already occurring in young children and CD occurring more often in older children and adolescents (Loeber et al., 2000). Therefore, in this book for purposes of brevity ODD and CD are often referred to as the DBDs.

Although the subject of this book is the DBDs, we also will pay attention to ADHD. The DBDs and ADHD are related to each other with respect to their symptoms, and these disorders also often co-occur or are comorbid. Indeed, the odds ratio of DBD–ADHD comorbidity in a meta-analysis of community based samples was 10.7 (Angold et al., 1999). Or to put it in another way, about 50% of children and adolescents with a DBD have comorbid ADHD, and vice versa (Kutcher et al., 2004). In the assessment of children who are referred because of disruptive behaviour problems, clinicians therefore need to consider whether the child’s inappropriate behaviours or symptoms are part of a DBD or of ADHD, or whether both disorders can be diagnosed. As we will describe in later chapters, the treatment of DBDs

Box 1.1 Symptoms of oppositional defiant disorder

comorbid with ADHD is different from the treatment of DBDs without ADHD comorbidity.

Oppositional defiant disorder

In DSM-IV-TR, ODD is defined as ‘a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviour toward authority figures’. An overview of ODD symptoms is given in Box 1.1. Whereas DSM-IV-TR differentiates the various symptoms of CD into distinct groups such as ‘Aggression to people and animals’ and ‘Serious violations of rules’ (see Box 1.2, below), subgroups of symptoms are not formally identified for ODD.

However, in our view, a close consideration of the eight symptoms or criteria of ODD shows that they are very heterogeneous as well. Indeed, two symptoms are clearly oppositional and defiant in nature: ‘Actively defies or refuses to comply with adults’ requests or rules’ and ‘Argues with adults’. There are two symptoms of emotional dysregulation: one is mild (‘Is touchy or easily annoyed by others’) and one is more severe (‘Loses temper’). There is one emotional symptom, and it is specifically about anger: ‘Is angry and resentful’. There is one symptom of provocativeness: ‘Deliberately annoys people’. And, finally, there are two symptoms of hostility: one is mild (‘Blames others for his or her mistakes or misbehaviour’) and one is severe (‘Is spiteful or vindictive’).

Thus, among the eight symptoms of ODD, there are only two oppositional and defiant symptoms. Consequently, a child may be diagnosed with ODD without showing any clear oppositional or defiant behaviour. Furthermore, the issue of heterogeneity of symptoms of ODD is important as inconsistencies in results of studies might be caused by differences between sample characteristics. The heterogeneity of samples is even increased when subjects with CD also are included, which is often the case.

Importantly, DSM-IV-TR specifies that manifestations of ODD are almost invariably present at home and need not be present at school or in the

Box 1.2 Symptoms of conduct disorder

Aggression to people and animals

1. Bullies, threatens or intimidates others

2. Initiates physical fights

3. Uses a weapon

4. Is physically cruel to people

5. Is physically cruel to animals

6. Steals while confronting a victim

7. Forces someone into sexual activity

Destruction of property

1. Sets fires

2. Destroys others’ property

Deceitfulness or theft

1. Breaks into someone’s house or car

2. Lies to obtain goods or favours, or to avoid obligations

3. Steals without confronting a victim

Serious violations of rules

1. Stays out at night

2. Runs away from home

3. Truants from school

community. The opposite symptom pattern, however, such as the presence of four symptoms at school but none at home, does not preclude ODD. Thus, according to DSM-IV-TR, symptoms need not be present in more than one setting.

The prevalence of ODD, i.e. the percentage of cases at a given point in time, varies considerably between studies, with a median of 3.2 (Lahey et al., 1999). Although gender differences for ODD are quite inconsistent across studies, most data suggest either somewhat higher rates in boys than in girls or no gender difference (Loeber et al., 2000).

Conduct disorder

In DSM-IV-TR, CD is characterized as a ‘repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated’. Four groups of behaviours are distinguished: (1) aggressive conduct that causes or threatens physical harm to people or animals; (2) non-aggressive conduct that causes property loss or damage; (3) deceitfulness or theft; and (4) serious violations of rules (Box 1.2). Although the symptoms of ODD are all within the capacity of preschool children to perform, some of the symptoms of CD, such as forcible sexual activity, use of weapons and breaking into houses, are not (Wakschlag et al., 2007).

DSM-IV-TR distinguishes two types of CD: the childhood-onset type with the onset of at least one symptom prior to age 10 years, and the adolescent-onset type, with an absence of any symptom prior to age 10 years. The distinction between these two types is supported by various studies (Moffitt, 1993; Lahey et al., 1998; for a review, see Moffitt, 2003; see also Chapter 2). This childhood-onset group has been shown to have relatively poorer outcomes when compared with the adolescence-onset group. Because of this outcome, the childhood-onset type has also been called the life-persistent CD subtype (Moffitt, 2003).

Some longitudinal studies suggest that, among the children with early-onset CD, some lack the continuity of conduct problems from childhood to adulthood; these children have therefore been termed ‘childhood-limited conduct problem group’ (Moffitt, 2003). However, to date there is not enough evidence to further divide the childhood-onset type into a life-course-persistent versus a childhood-limited group (Moffitt et al., 2008).

ODD and CD are both related to and different from each other. The association between these disorders needs to be considered from a developmental point of view. Longitudinal studies give the opportunity not only to prospectively follow children (follow-forward studies), but also to examine earlier diagnoses in adolescents who meet the criteria of disorders (follow-back studies). With regard to the relation between ODD and CD, follow-forward studies have shown that most children with ODD do not develop CD, whereas follow-back studies have shown that most children with CD had prior ODD (for a discussion of this issue, see Moffitt et al., 2008, and Chapter 2). Importantly, most children who meet the criteria for childhood-onset CD also meet criteria for ODD (for a review, see Lahey et al., 1992). Therefore, the rules of DSM-IV-TR specify that ODD is to be excluded if CD is present.

The prevalence of CD varies considerably between studies, with a median of 2.0; CD is more common in boys than in girls (Lahey et al., 1999).

Other relevant disorders

Other diagnostic categories are relevant here for two reasons. First, some characteristic behaviours of these disorders are similar to symptoms of ODD and CD. For example, ‘Does not seem to listen when spoken to directly’ is a criterion of inattention in ADHD but is related to refusing to comply with adults’ requests, which is a symptom of ODD. Also, a depressed mood, characteristic of a dysthymic disorder, in children may manifest as irritability. This expression of irritability may be related to the ODD symptom ‘Is angry and resentful’. Second, some disorders often co-occur with ODD and CD. The most prevalent comorbid disorder of the DBDs is ADHD (Angold et al., 1999). This comorbidity is highly important both with respect to the aetiology of the DBDs (see Chapters 3 and 4), the assessment (see Chapter 6) and the treatment of the DBDs (see Chapters 8–11).

DSM-IV-TR provides lists for two types of ADHD symptom: inattention and hyperactivity/impulsivity. Thus, three ADHD subtypes are distinguished: predominantly inattentive (I), predominantly hyperactive-impulsive (HI), and combined (C). An overview of ADHD symptoms is given in Box 1.3.

Also important is comorbidity with other disorders and developmental conditions, including mood disorders (Angold et al., 1999) such as dysthymic disorder, anxiety disorders (Angold et al., 1999) such as separation anxiety disorder, learning disorders and academic underachievement (Frick et al.,

Box 1.3 Symptoms of attention deficit/hyperactivity disorder

Inattention

1. Fails to give close attention to details or makes careless mistakes

2. Has difficulty sustaining attention

3. Does not seem to listen

4. Does not follow through on instructions and fails to finish schoolwork or chores

5. Has difficulty organizing tasks and activities

6. Avoids, dislikes or is reluctant to engage in tasks that require sustained attention

7. Loses things

8. Is easily distracted

9. Is forgetful in daily activities

Hyperactivity

1. Fidgets

2. Leaves his or her seat

3. Runs about or climbs

4. Has difficulty playing or engaging in leisure activities quietly

5. Is ‘on the go’

6. Talks excessively

Impulsivity

1. Blurts out answers

2. Has difficulty waiting a turn

3. Interrupts or intrudes on others

1991; Hinshaw et al., 1993), communication disorders and borderline intelligence. We will pay attention to these comorbid disorders and conditions when discussing the assessment (see Chapter 6) and treatment of the DBDs (see Chapters 8–11).

DSM-IV and ICD-10

Besides DSM-IV-TR, the ICD-10 (1996) of the World Health Organization is used in many countries. It should be noted, however, that little research has been conducted into ICD-10-defined disruptive behaviour problems. Over the years, differences between both systems have diminished, but important distinctions still remain. First, ODD is not a distinct category in ICD-10 but is instead a subtype of CD, along with the socialized and unsocialized subtypes of CD. Second, hyperkinetic disorder in ICD-10 is quite different from ADHD in DSM-IV-TR. Hyperkinetic disorder requires symptoms in three domains (hyperactivity, impulsivity, inattention), whereas DSM-IV-TR distinguishes various subtypes depending on the occurrence of symptoms of inattention and hyperactivity/impulsivity. Thus, hyperkinetic disorder is a narrower concept than ADHD. Third, one of the subtypes of hyperkinetic disorder is hyperkinetic conduct disorder. Thus, in contrast to DSM-IV, in ICD-10 the co-occurrence of CD (of which ODD is a subtype) with hyperkinetic disorder is not considered a comorbidity but a subtype of hyperkinetic disorder, i.e. hyperkinetic conduct disorder.

Factor analytic studies support the distinction that DSM makes between ODD, CD, ADHD and other disorders. Factor analysis is one statistical technique that can search for patterns in co-variation among a group of behaviours. Using exploratory and confirmatory factor analyses with data from various questionnaires in population and clinically referred samples, Hartman et al. (2001) investigated the internal construct validity of a DSM-IV-based model of ADHD (inattention, hyperactivity/impulsivity), ODD, CD, generalized anxiety and depression. The factorial structure of these syndromes was supported by the data. However, the DSM-IV model did not meet the absolute standard of adequate model fit, leaving substantial room for improvement. Findings from another study support the four-factor DSM-IV model (ODD, CD, hyperactivity/impulsivity, inattention) of the DSM-IV-TR ‘Attention deficit and disruptive behaviour disorders’ (Lahey et al., 2008a). In addition, this model fitted better with the data than models based on ICD-10 and the Child Behavior Checklist (Achenbach, 1991).

Socially appropriate behaviours

It is also important to pay attention to appropriate behaviours, because children with DBDs may not have these behaviours in their repertoire. There are a number of social behaviour skills that children use to cope adequately with everyday problem situations. These skills include entering a group, starting a conversation, asking questions and listening to others. Other socially appropriate behaviours such as showing interest, comforting, sharing, helping and donating are more clearly prosocial in that they are intended to benefit other persons (Eisenberg & Fabes, 1998). Empathy is related to prosocial behaviour (Eisenberg & Miller, 1987). Empathy is defined as the understanding of, and sharing in, another’s. emotional state (Hoffmann, 2000). Strictly speaking, empathy is not behaviour. Instead, it is an emotion. Empathy involves a matching of emotions between the child and the other person, i.e. feeling with another person.

Summary points