Oppositional Disorder and Conduct Disorder
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Introduction
This topic includes both ODD and CD.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
There are social, parental, and individual factors that increase risk for ODD and CD.
Social
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Parental
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Individual
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Pathophysiology
Kids with conduct disorder often find each other, and collusion can make things worse.
Signs and Symptoms
- ODD
- Conduct Disorder
Oppositional Defiant Disorder
Negative, hostile, defiant behaviour for at least six months, during which 4 or more are present more frequently than is typical for others of similar age and development:
- loses temper
- argues with adults
- actively defies or refuses to comply with adults' requests or rules
- deliberately annoys people
- blames others for his/her mistakes or misbehaviour
- touchy or easily annoyed by others
- angry and resentful
- spiteful or vindictive
Clinically significant impairment in the social, academic, or occupational setting
Does not occur exclusively during Mood or Psychotic disorders
Does not meet criteria for Conduct Disorder or Antisocial Personality Disorder (if over 18)
Conduct Disorder
A) A repetitive and persistent pattern of behaviour in which the basic rights of others, or major age-appropriate social norms or rules, are violated, as manifest by the presence of three or more of the following criteria in the past 12 months, with at least once criterion present in the past 6 months:
Aggression to people and animals
- bullies, threatens, or intimidates others
- initiates physical fights
- has used a weapon that can cause serious physical harm to others
- has been physically cruel to people
- has been physically cruel to animals
- has stolen while confronting a victim
- has forced someone into secual activity
Destruction of property
- has deliberately engaged in fire setting with the intention of causing serious damage
- has deliberately destroyed other's property in other ways
Deceitfulness or theft
- has broken into someone else's house, building, or car
- loes to obtain goods or faviurs, or to avoid obligations
- has stolen items of value without confronting a victim
Serious violations of rules
- stays out at night despite parental prohibitions, beginning before age 13
- has run away from home overnight at least twice while living in parental or surrogate home (or once for a lengthy time)
- is often truant from school, beginning before age 13
B) There needs to be significant impairment in social, academic, and/or occupational function
C) If age 18 or older, criteria for Antisocial Personality Disorder are not met.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
The differential includes:
Individual under stress
Anxiety disorders
Mood disorder
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Psychotic disorder
Substance abuse
Medical disorders
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Medications
Allergies (very occasionally)
Mental retardation
Learning disability
Autism spectrum disorder (can co-exist with ADHD)
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Treatments
Treatment depends on severity and resources.
Oppositional Defiant Disorder
Behavioural therapy includes parental and family therapy. Parents should be taught to minimize emotional reactions, give clear instructions and limits, provide positive reinforcement, and to use punishment wisely. Parental training is usually provided by psychologists or social workers.
Limits should be set on screen time (television, video games, computer).
Environmental issues such as poverty or marital conflict should be addressed as effectively as possible.
Other co-morbidities such as depression or ADHD should be treated.
There is no clear role for medication for ODD.
Conduct Disorder
Treating CD is a significiant, difficult task that often requires more than a family doctor or mental health clinic. Ideally, multi-systemic therapy will be in place, involving parents, teachers, community, and the health care team.
Describe the possible long-term prognosis to care-giver.
Structure the child's days, and encourage participation in activities such as sports or Scouts. Haave the care-giver play with the child.
Be consistent with behavioural guidelines. Encourage the parent to be very aware of the child's activities and friends, to reward desirable behaviour, and to consistently communicate and act on consequences if the child behaves poorly.
Substance abuse should be addressed first.
Medications may be used as an ajunct or to address comorbidities. Options include:
- stimulants: methylphenidate, dextroamphetamine
- antidepressants: fluositine, buproprion
- mood stabilizers: phenytoin, carbamazepine, valproic acid, lithium
- TCA: clonidine
Suspension won't work.
Consequences and Course
The majority of children with ODD do not go on to develop CD; of those that do, onset appears to begin before age 10.
Perhaps 30% of children with OD continue to perform illegal activity in adulthood, while 40% are diagnosed with antisocial PD in adulthood.
Resources and References
Topic Development
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