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CD/ODDGail A. Mattox, MD,FAACAPMorehouse Schoolof MedicineThaddeus P. M. Ulzen,MD, FRCP(C)University of AlabamaSchool of Medicine
OppositionalDefiant Disorderand ConductDisorders:Review andDiscussion ofAACAP PracticeGuidelinesGail A. Mattox, MD,FAACAPMorehouse Schoolof Medicine
Gail A. Mattox, MD, FAACAPDisclosures
Research/Grants: None
Speakers Bureau: None
Consultant: None
Stockholder: None
Other Financial Interest: None
Advisory Board: None
LearningObjectiveApply the AACAPPractice Parameters inthe assessment,diagnosis, andmanagement ofoppositional defiantdisorder
Disruptive Behavior Disorders
Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder
Disruptive Behavior Disorders
Commonly encountered
Often associated with aggression
Complex etiology
Biopsychosocial factors are important
Oppositional Defiant Disorder(ODD)
Community prevalence of 1–16% Characterized by negativism, vindictiveness,
and aggression (including verbal abuse andphysical acts)
Frequently comorbid with other psychiatricdisorders
Can precede conduct disorder (CD) Can precede substance use disorders Requires multimodal treatment approachSteiner H, et al. J Am Acad Child Adolesc Psychiatry 2007;46:126-141.
ODDDSM-IV-TR Diagnostic Criteria
Pattern of negativistic, hostile, defiant behavior in which 4(or more) of the following are present for at least 6 months Often loses temper Often argues with adults Often actively defies or refuses to comply with adult
rules/requests Often deliberately annoys people Often blames others for behavior Often touchy or easily annoyed Often angry or resentful Often spiteful or vindictive
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
AACAP Practice ParametersAssessment and Diagnosis
Requires the establishment of therapeuticalliance with child and family
Address cultural issues Obtain info about symptoms, and degree of
impairment from child and parents, as well asmultiple outside informants
Consider comorbid psychiatric conditions Evaluate peer/school functioning Questionnaires and rating scales may be helpfulSteiner H, et al. J Am Acad Child Adolesc Psychiatry 2007;46:126-141.
AACAP Practice ParametersInterventions
Develop an individualized plan based onspecific situations
Consider parent management training Medication may be helpful as adjuncts Intensive and prolonged treatment may be
required if severe and persistent Certain interventions are not effective
– Dramatic, one-time, time-limited, or short-terminterventions not usually successful
Steiner H, et al. J Am Acad Child Adolesc Psychiatry 2007;46:126-141.
Potential Adjunctive Treatments
No FDA-approved agents for ODD Evidence available for
– Atypical antipsychotics– Stimulants, especially when ODD is comorbid
to ADHD–Methylphenidate–D-amphetamine–Lisdexamfetamine
– AtomoxetineSteiner H, et al. J Am Acad Child Adolesc Psychiatry 2007;46:126-141.
Summary
ODD is characterized by negativism,vindictiveness, and aggression
Frequently comorbid with other psychiatricdisorders
Can precede CD, substance use disorders,and delinquency
Requires multimodal treatment approach
Managing ConductDisorders andAggressiveBehavior in YouthThaddeus P. M. Ulzen,MD, FRCP(C)University of AlabamaSchool of Medicine
Thaddeus P. M. Ulzen, MD, FRCP(C)Disclosures
Research/Grants: None
Speakers Bureau: None
Consultant: None
Stockholder: None
Other Financial Interest: None
Advisory Board: None
LearningObjectivesRecognize the earlyprecursors of symptompresentation ofconduct disorderRecognize population-based strategies forpreventing conductdisordersRecognize evidence-based interventionstrategies to improveoutcomes
Disruptive Behavior Disorders
Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder
Conduct DisorderDSM-IV-TR Diagnostic Criteria
Repetitive and persistent pattern of behavior in whichbasic rights of others or major age-appropriate societalnorms or rules are violated as manifested by thepresence of 3 or more of the following criteria in past 12months or with at least 1 criterion in the past 6 months: Aggressive conduct to people and animals Property damage or loss Deceitfulness or theft Serious violations of rules
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
DSM-IV-TR Classification
Conduct disorder, childhood-onset type– Onset of at least 1 criterion prior to age 10
Conduct disorder, adolescent-onset type– Absence of any criteria prior to age 10
Conduct disorder, unspecified onset– Age on onset unknown
Severity– Mild– Moderate– Severe
1. Romano E, et al. Pediatrics 2006;117:2101-2110.2. Bongers IL, et al. Child Dev 2004;75:1523-1537.3. Broidy LM, et al. Dev Psychol 2003;39:222-245.
Early Childhood Precursors
Essential symptoms of ADHD, ODD, and CDare identifiable as toddlers– Hyperactive impulsive behavior noted by age 2
and remain stable through school entry1
– Disregard for rules stable between 2.5-7 yearsHighest levels of oppositional behavior persist untilage 182
– Aggression noticeable after year 1 and increasesuntil age 4 and then decline into adulthood3
Cote SM, et al. Abnorm Child Psychol 2006;34:71-85.
Development of PhysicalAggression from Toddlerhoodto Pre-Adolescence
Low Desisters 31.1%Moderate Desisters 52.2%High Desisters 16.6%
Low Desisters PredictedModerate Desisters PredictedHigh Desisters Predicted
Romano E, et al. Pediatrics 2006;117:2101-2110.
Development and Predictionof Hyperactive Symptoms
Very Low 4.5%Low 42.0%Moderate 46.3%
Low PredictedModerate PredictedHigh Predicted
High 7.2% High Predicted
Note: The value in parentheses is the mean correlation between the predictor and theoutcome, adjusted to equate the source studies on relevant methodological features."Predictors of Violent or Serious Delinquency in Adolescence and Early Adulthood”; LipseyMW, Derzon JH; in: Serious and Violent Juvenile Offenders: Risk Factors and SuccessfulInterventions, eds. Loeber R, Farrington DP; Sage Publications, Inc., 1998.
Predictors of Violence andSerious Delinquency
Ranking of Predictors of Violent or Serious DelinquencyAges 6–11 and Ages 12–14
Predictors at Ages 6–11 Predictors at Ages 12–14
Rank 1 Group General offenses (.38)Substance use (.30)
Social ties (.39)Antisocial peers (.37)
Rank 2 GroupGender (male) (.26)Family socioeconomic status (.24)Antisocial parents (.23)
General offenses (.26)
Rank 3 Group Aggression (.21)Ethnicity (.20)
Aggression (.19)School attitude/performance (.19)Psychological condition (.19)Parent-child relations (.19)Gender (male) (.19)Physical violence (.18)
Predictors of Violence andSerious Delinquency (cont.)
"Predictors of Violent or Serious Delinquency in Adolescence and Early Adulthood”; LipseyMW, Derzon JH; in: Serious and Violent Juvenile Offenders: Risk Factors and SuccessfulInterventions, eds. Loeber R, Farrington DP; Sage Publications, Inc., 1998.
Ranking of Predictors of Violent or Serious DelinquencyAges 6–11 and Ages 12–14
Predictors at Ages 6–11 Predictors at Ages 12–14
Rank 4 Group
Psychological condition (.15)Parent-child relationship (.15)Social ties (.15)Problem behavior (.13)School attitude/performance (.13)Medical/physical characteristics (.13)IQ (.12)Other family characteristics (.12)
Antisocial parents (.16)Person crimes (.14)Problem behavior (.12)IQ (.11)
Rank 5 GroupBroken home (.09)Abusive parents (.07)Antisocial peers (.04)
Broken home (.10)Family socioeconomic status (.10)Abusive parents (.09)Other family characteristics (.08)Substance abuse (.06)Ethnicity (.04)
Comorbidities of CD
Attention deficit hyperactivitydisorder
Oppositional defiant disorder
Intermittent explosive disorder
Substance use disorder
Mood disorders (bipolar anddepressive)
Post-traumatic stress disorder
Dissociative disorders
Borderline personality disorder
Somatization disorder
Adjustment disorders
Organic brain disorder
Seizure disorder
Paraphilias
Narcissistic personality disorder
Learning disabilities
Mental retardation
Schizophrenia
Ulzen T, Hamilton H. Can J Psychiatry 1997;42:617-622.
1. Findling RL, et al. J Am Acad Child Adolesc Psychiatry 2000;39:509-516.
Psychopharmacology
Insufficient to treat CD Often useful in crisis management or
treatment of comorbid disorders More recently, a trend of using atypical
antipsychotics, particularly risperidone,in aggressive CD patients has emerged1
Insufficient RCT studies at present
See supplemental bibliography for full references.
Evidence-Based Early Preventionand Intervention Programs
Helping the Noncompliant Child Program Parent-Child Interaction Therapy The Incredible Years BASIC (2-year-olds) Family Check Up—19-29 months Nurse Family Partnership (NFP)
– Broader scope RCT—Elmira, Denver, Memphis Triple P + motivational interviews for parents Multisystemic therapy (MST) Multidimensional treatment foster care (MTFC)
Prevention of CD andCost to Society
The cost of each delinquent’s life-long criminal careeris between $1.7m to $2.3m over each person’slifetime
We need to identify risk factors for CD that are bothplausible causal factors and alterable withintervention
These factors should have a high attributable risk fornegative outcome and have a high enoughprevalence that their eradication would significantlyreduce the number of cases with negative outcome
Cohen MA. J Quant Criminol 1998;14:5-33.
Petitclerc A, et al. Can J Psychiatry 2009;54:222-231.
Life Course View ofPrevention of CD
Target maternal health behavior duringpregnancy
Address parenting behavior at crucialpoints during infancy, early childhood,and adolescence
Target child social behavior and cognitiveskills in early and middle childhood
Address birth control in early adolescence
Summary
Symptoms of CD are identifiable in toddlers
Need to identify risk factors for CD
High rate of psychiatric comorbidities
Important to address parenting behavior atcrucial points in infancy throughadolescence
an educational series offered byCME Outfitters, LLC
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Oppositional Defiant Disorder and Conduct Disorders: Review and Discussion of AACAP Practice Guidelines Gail A. Mattox, MD, FAACAP
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
Steiner H, Remsing L; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry 2007;46:126-141.
Managing Conduct Disorders and Aggressive Behavior in Youth Thaddeus P. M. Ulzen, MD, FRCP(C) Bongers IL, Koot HM, van der Ende J, Verhulst FC. Developmental trajectories of externalizing behaviors in childhood and adolescence. Child Dev 2004;75:1523-1537.
Broidy LM, Nagin DS, Tremblay RE, et al. Developmental trajectories of childhood disruptive behaviors and adolescent delingquency: a six-site, cross-national study. Dev Psychol 2003;39:222-245.
Cohen MA. The monetary value of saving a high-trsk youth. J Quant Criminol 1998;14:5-33.
Cote SM, Vaillancourt T, LeBlanc JC, Nagin DS, Tremblay RE. The development of physical aggression from toddlerhood to pre-adolescence: a nation wide longitudinal study of Canadian children. J Abnorm Child Psychol 2006;34:71-85.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
Findling RL. Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents. J Clin Psychiatry 2008;69(Suppl 4):9-14.
Fisher PA, Chamberlain P. Multidimensional treatment foster care-a program for intensive parenting, family support, and skill building. J Emotional and Behav Disorders 2000;8:155-164.
Henggeler SW, Melton GB, Brondino MJ, Scherer DG, Hanley JH. Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination. J Consult Clin Psychol 1997;65:821-833.
Kembree-Kigin TL, McNeil CB. Parent-Child Interaction Therapy. New York: Plenum;1995.
Lipsey MW, Derzon JH. Predictors of Violent or Serious Delinquency in Adolescence and Early Adulthood. Loeber R, Farrington DP, eds. In: Serious and Violent Juvenile Offenders: Risk Factors and Successful Interventions. Sage Publications, Inc.; 1998.
McMahon RJ, Forehand RL. Helping the Noncompliant Child: Family Based Treatment for Oppositional Behavior. 2nd ed. Londn: The Guildford Press: 2003.
Olds DL, Sadler L, Kitzman H. Programs for parents of infants and toddlers: recent evidence from randomized trials. J Child Psychol Psychiatry 2007;48:355-391.
Petitclerc A, Tremblay RE. Childhood disruptive behaviour disorders: review of their origin, development, and prevention. Can J Psychiatry 2009;54:222-231.
Romano E, Tremblay RE, Farhat A, Cote S. Development and prediction of hyperactive symptoms from 2 to 7 years in a population-based sample Pediatrics 2006;117:2101-2110.
Sanders MR, Markie-DaddsC, Turner KMY, Practitioner’s Manual for Standard Triple P. Brisbane: Parenting and Family Support Centre; 2000.
Shaw DS, Dishion TJ, Supplee L, Gardner F, Arnds K. Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. J Consult Clin Psychol 2006;74:1-9.
Ulzen TP, Carpentier R. The delusional parent: family and multisystemic issues. Can J Psychiatry 1997;42:617-622.
Webster-Stratton C. The Incredible Years: A Trouble-Shooting Guide for Parents of Children Age 3-8. Toronto Ontario: Umbrella Press; 1992.
Supplemental Bibliography for: Managing Conduct Disorders and Aggressive Behavior in Youth Thaddeus P. M. Ulzen, MD, FRCP(C) Slide Title: Evidence-Based Early Prevention and Intervention Programs Fisher PA, Chamberlain P. Multidimensional treatment foster care-a program for intensive parenting, family support, and skill building. J Emotional and Behav Disorders 2000;8:155-164.
Henggeler SW, Melton GB, Brondino MJ, Scherer DG, Hanley JH. Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination. J Consult Clin Psychol 1997;65:821-833.
Kembree-Kigin TL, McNeil CB. Parent-Child Interaction Therapy. New York: Plenum;1995.
McMahon RJ, Forehand RL. Helping the Noncompliant Child: Family Based Treatment for Oppositional Behavior. 2nd ed. Londn: The Guildford Press: 2003.
Olds DL, Sadler L, Kitzman H. Programs for parents of infants and toddlers: recent evidence from randomized trials. J Child Psychol Psychiatry 2007;48:355-391.
Sanders MR, Markie-DaddsC, Turner KMY, Practitioner’s Manual for Standard Triple P. Brisbane: Parenting and Family Support Centre; 2000.
Shaw DS, Dishion TJ, Supplee L, Gardner F, Arnds K. Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. J Consult Clin Psychol 2006;74:1-9.
Webster-Stratton C. The Incredible Years: A Trouble-Shooting Guide for Parents of Children Age 3-8. Toronto Ontario: Umbrella Press; 1992.