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Oppositional Defiant Disorder and Conduct Disorder
CLINICAL PEARLS
Opposition Defiant Disorder (ODD) and Conduct Disorder (CD) are considered a spectrum of disruptive behavior disorders.
First-line treatment should include a culturally-sensitive, family-based therapy.
Conduct Disorder with callous and unemotional traits holds a worse prognosis.
Co-Morbidity with ADHD, anxiety, substance use, depression, and trauma-related symptoms is common. If indicated, pharmacological treatment should focus on co-morbid diagnosis if therapy is not effective.
Medications are typically reserved for severe disruptive and aggressive behavior.
RATING SCALES
Vanderbilt Assessment Scales https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf
Children’s Aggression Scale https://www.parinc.com/products/pkey/38
TREATMENT APPROACH
Stage 1: Family-based therapy (e.g. parent-child interaction therapy for ODD, multisystemic therapy, functional family therapy for CD) is considered first-line, including school and other systems when indicated.*
THERAPY PRINCIPLES
1. 2.
3. 4. Reduce positive reinforcement of disruptive behavior. Increase reinforcement of prosocial and complaint behaviors (parental attention is imperative). Apply consequences for disruptive behavior. Make parental responses predictable, contingent and immediate.
1A: Monitor for treatment response with rating scale. If improvement is noted, continue therapy.
Otherwise, follow up with therapist.
Stage 2: If symptoms persist or co-morbid anxiety/depression/ADHD, ensure adequate treatment for co-morbid disorders.
Stage 3: Monitor for treatment response. If patient is not improving and/or aggression is severe consider protocol for managing aggressive behaviors.
*Boot Camps, scared-straight scenarios are not recommended.
REFERENCES
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Balia, C., Carucci, S., Coghill, D., Zuddas, A. (2018) The Pharmacological Treatment of Aggression in Children and Adolescents with Conduct Disorder. Do Callous-unemotional Traits Modulate the Efficacy of Medication? Neuroscience and Biobehavioral Reviews, 91: 218–238
Blader, J.C., Schooler, N.R., Jensen, P.S., et al. (2009) Adjunctive divalproex versus placebo for children with ADHD and aggression refractory to stimulant monotherapy. American Journal of Psychiatry, 166(12):1392–1401.
Burke, J.D., R. Loeber,B. Birmaher. (2002) Oppositional Defiant Disorder and Conduct Disorder: A Review of the past 10 Years, Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 1275–1293.
Campbell, M., Small, A.M., Green, W.H., Jennings, S. J., Perry, R., Bennett, W.G., Anderson, L. (1984) Behavioral Efficacy of Haloperidol and Lithium Carbonate. A Comparison in Hospitalized Aggressive Children with Conduct Disorder. Archives of General Psychiatry, 41(7):650–656.
Connor, D.F., Mclaughlin, T.J., Jeffers-Terry, M. (2008) Randomized Controlled Pilot Study of Quetiapine in the Treatment of Adolescent Conduct Disorder. Journal of Child and Adolescent Psychopharmacology, 18(2):140–56.
Donovan, S.J., Stewart, J.W., Nunes, E.V., et al. (2000) Divalproex treatment for youth with explosive temper and mood lability: a doubleblind, placebo-controlled crossover design. American Journal of Psychiatry, 157(5):818–820.
Findling, R.L., Mcnamara, N.K., Branicky, L.A., Schluchter, M.D., Lemon, E., Blumer, J.L. 2000) A Double-blind Pilot Study of Risperidone in the Treatment of Conduct Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 39(4): 509–516.
Gorman, D.A., et al. (2015) Canadian Guidelines on Pharmacotherapy for Disruptive and Aggressive Behaviour in Children and Adolescents with Attention-deficit Hyperactivity Disorder, Oppositional Defiant Disorder, or Conduct Disorder. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 60(2):62-76
10. Knapp, P., Chait, A., Pappadopulos, E., Crystal, S., Jensen, P.S. (2012) Treatment of Maladaptive
Aggression in Youth: CERT Guidelines I. Engagement, Assessment, and Management. Pediatrics, 129(6):E1562–76.
11. Malone, R.P., Delaney, M.A., Luebbert, J.F., et al. (2000) A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Archives of General Psychiatry, 57(7):649–654.
12. Masi, G., Milone, A., Manfredi, A., Brovedani, P, Pisano, S., Muratori, P. (2016) Combined
Pharmacotherapy-multimodal Psychotherapy in Children with Disruptive Behavior Disorders.
Psychiatry Research, 238:8–13.
13. Pappadopulos, E., et al. (2003) Treatment Recommendations for the Use of Antipsychotics for
Aggressive Youth (TRAAY). Part II. Journal of the American Academy of Child and Adolescent
Psychiatry,42(2):145–61.
14. Steiner, Hans et al. (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(1):126–141.
15. Pringsheim, T., Hirsch, L., Gardner, D., Gorman, D.A. (2015) The Pharmacological Management of
Oppositional Behaviour, Conduct Problems, and Aggression in Children and Adolescents with
Attention-deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder:
A Systematic Review and Meta-analysis. Part 2: Antipsychotics and Traditional Mood Stabilizers.
Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 60(2):52–61.
OTHER RESOURCES
Lives in the Balance https://www.livesinthebalance.org/
The Explosive Child, by Dr. Ross Green Blueprints for healthy youth development https://www.blueprintsprograms.org/program-search/
