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Children who exhibit disruptive behaviors such as chronic defiance and provocation of classmates are commonly seen in primary care. Disruptive behaviors put children at greater risk for serious injury and illness, affect a child's success and cause great frustration for parents and teachers.1 Such children often are labeled and dismissed as "bad," reflecting the moral judgments of others. Families commonly feel desperate and vulnerable because of their child's disruptive behaviors. The primary care provider's nonjudgmental approach can foster a more thorough and informative evaluation, helping restore hope to patients and their families.
There are two main disruptive behavior disorders diagnosed in children: oppositional defiant disorder (ODD) and conduct disorder (CD). ODD is a disorder characterized by a "recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures for at least 6 months."2 CD is a more severe form of social oppositionality than ODD, and involves a "pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated."2 Such behaviors include violence, stealing, deception and serious violation of age-related obligations such as attending school, and obeying curfew.
Determination of Normal Behaviors
Because some degree of oppositional and disruptive behavior is developmentally normal in children, determining if the behavior is abnormal requires an overall assessment of the child's developmental stage, the problem behavior's context and the degree of impact on functioning.
The frequency of normal oppositional and defiant behaviors changes predictably throughout development. Child first learn to express anger and frustration by 2 to 6 months of age,3 but they cannot begin to modulate their expression of anger and frustration until about 2 years of age.4 Increased compliance with authority figures progresses with 4- to 5-year-olds being twice as likely to comply with requests than 2- to 3-year-olds.5 In the early elementary school years, children learn how to use improved language skills effectively to manage their frustrations.6 Conflict between child and parent about the child's autonomy rises to a peak in early adolescence, with a natural decline thereafter.7
A disruptive behavior disorder diagnosis before elementary school or during the very early stages of adolescence should only be made if the symptoms clearly go above and beyond those of same...