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.