Paediatrics: Oppositional defiant and conduct disorders

Oppositional defiant and conduct disorders

Oppositional defiant disorder (ODD) and conduct disorder (CDD) are related disruptive behaviour disorders, typified by defiance, disobedience, and violation of social rules and the rights of others.

Epidemiology

·  Prevalence varies greatly depending on the age of the sample and the diagnostic criteria used.

·  Both CDD and ODD are more common in males.

·  ODD is more common in younger children (<10yrs).

·  ODD prevalence in 5–10yr olds is around 4.8% boys and 2.1% girls.

·  CDD prevalence increases with age: 71% in children and 4% in adolescents.

Causes

Longitudinal studies of delinquency suggest the causes are complex. Many are likely to have an underlying genetic vulnerability and an association with various pre- and perinatal risk factors. Subsequent exposure to coer-cive parenting (intrusive parenting and subsequent reinforcement of child counterattack and parent withdrawal) early in life has also been implicat-ed. Later involvement of vulnerable individuals with a deviant peer group predicts a CDD pathway as does a variety of psychosocial risk factors, e.g. low socioeconomic status, peer relationship difficulties, parental mental illness, and child maltreatment, neglect, and abuse.

Clinical features

The name ODD is highly descriptive, i.e. hostile, negativistic, and defiant, particularly to the parents. The defiant behaviour pattern must last at least 6mths and cause impairment across a variety of domains. CDD is defined by more serious aggressive behaviour and rule violations, property dam-age, theft, arson, truancy, and running away, which again must have been present for at least 6mths and result in functional difficulties.

Differential diagnosis

Comorbidity with other disruptive behaviour disorders is common, e.g. ADHD. Speech and language deficits may be comorbid or on a causal pathway.

Management

Prevention is the best approach. Early intervention with ODD in very young children using universal parenting programmes targeting coercive parenting and parental abuse is indicated. If ODD and CDD are estab-lished, programmes that employ intensive interventions that involve children, parents, and other participants in the child’s social ecology have proved effective.¹ Multisystemic therapy is an example of such an inter-vention. Remedial education is likely to be needed and can also be helpful as self-esteem rises.

Psychopharmacology research on disruptive behaviour disorders, other than ADHD, presently provides no definitive guidelines.

·ADHD comorbidity should be treated.

·Planned, premeditated aggression is not an indication for drug therapy.

·Impulsive aggression or aggression in an individual with prominent affective symptoms may prove responsive to a 5-HT blocking agent or an atypical antipsychotic (e.g. risperidone). Further research is required before these pharmacological strategies can be demonstrated to be both safe and effective enough to be used in routine clinical practice.

Prognosis

Management of established disruptive behaviour disorders is difficult. Children often fail at school. Poor prognosis with ODD is associated with;

·early onset of symptoms;

·longer duration of symptoms;

·comorbid mood, anxiety, ADHD, impulse control and substance use disorders;

·development of conduct disorder.

Two patterns of CDD are described. Early onset- (onset before the age of 11yrs) and adolescent onset-CDD. Whilst adolescent onset CDD is most often self-limiting and does not typically persist into adulthood, early onset CDD is associated with a particularly poor prognosis. This is also the case for conduct disorder which is comorbid with ADHD. Almost 50% of all youths that initiated serious violent acts before the age of 11 con-tinued this type of offending beyond the age of 20 twice the rate of those who started in adolescence. Approximately 40% of prepubertal children with conduct disorder may develop antisocial personality disorder and most antisocial adult report a history consistent with conduct disorders as a child.²