20. Disruptive, Impulse Control, and Conduct Disorder

Question 1

Describe epidemiology: Oppositional Defiant Disorder (2)

Answer 1

• prevalence: 2-16%
• M=F after puberty

Question 2

Describe diagnosis: Oppositional Defiant Disorder (5)

Answer 2

• pattern of negativistic/hostile and defiant behaviour for ≥6 mo, with ≥ 1 non-sibling, with ≥4 symptoms manifested in 3 areas of:
  
  • angry/irritable mood: easily loses temper, touchy or easily annoyed, often angry and resentful
  • argumentative/defiant: argues with adults/authority figure, defies requests/rules, deliberately annoys, blames others for their own mistakes or misbehaviour
  • vindictiveness: spiteful or vindictive twice in past 6 mo
  • note: difference between normal behaviour and ODD is frequency of symptoms (most days if age <5 yr, weekly if age ≥5 yr) exceeds what is normative for one’s age gender, culture
• behaviour causes significant distress or impairment in social, academic, or occupational functioning
• behaviours do not occur exclusively during the course of a psychotic, substance use, or mood disorder
• diagnosis of disruptive mood dysregulation disorder supersedes ODD if criteria for both are met
• severity (mild/moderate/severe) according to number of settings in which symptoms are present

Question 3

Describe features: Oppositional Defiant Disorder (2)

Answer 3

• first symptoms usually appear during preschool and rarely later than early adolescence
• associated with poor school performance, few friends, strained parent/child relationships, risk of developing mood disorders later on, often precedes CD

Question 4

Describe tx: Oppositional Defiant Disorder (4)

Answer 4

• parent: parent management training, psychoeducation for parents and family
• behavioural therapy: to teach, practice, and reinforce prosocial behaviour
• social: school/day-care interventions
• pharmacotherapy for comorbid disorders

Question 5

Name symptoms (acronym): Oppositional Defiant Disorder (8)

Answer 5

ODD kids “ARE BRATS”

• Annoying
• Resentful
• Easily annoyed
• Blames others
• Rule breaker
• Argues with adults
• Temper
• Spiteful/vindictive

Question 6

Describe epidemiology: Conduct Disorder (2)

Answer 6

• prevalence: 1.5-3.4%
• M:F = 4-12:1

Question 7

Describe etiology: Conduct Disorder (8)

Answer 7

• parental/familial factors:
  
  • parental psychopathology (i.e. ASPD, substance abuse)
  • child-rearing practices (i.e. child abuse, discipline)
  • low socioeconomic status (SES)
  • family violence
• child factors:
  
  • difficult temperament
  • ODD
  • learning problems
  • neurobiology

Question 8

Describe diagnosis: Conduct Disorder (3)

Answer 8

• pattern of behaviour that violates rights of others and age appropriate social norms with ≥3 criteria noted in past 12 mo and ≥1 in past 6 mo:
  
  • aggression to people and animals: bullying, initiating physical fights, use of weapons, forced sex, cruel to people and/or animals, stealing while confronting a person (i.e. armed robbery)
  • destruction of property: arson, deliberately destroying others’ property
  • deceitfulness or theft: breaking and entering, conning others, stealing nontrivial items without confrontation
  • violation of rules: out all night before age 13, often truant from school before age 13, runaway ≥2 times at least overnight or for long periods of time
  • disturbance causes clinically significant impairment in social, academic, or occupational functioning
  • if ≥18 yr, criteria not met for ASPD
• diagnostic types
  
  • childhood-onset ( ≥1 criterion prior to age 10)
  • adolescent-onset (no criteria until age 10)
  • unspecified- onset (insufficient information)
  • mild, moderate, severe
• differential: ADHD, depression, head injury, substance abuse

Question 10

Describe tx: Conduct Disorder (8)

Answer 10

• early intervention necessary and more effective; long-term follow-up required
• psychosocial:
  
  • parent management training
  • anger replacement training
  • CBT
  • family therapy
  • education/ employment programs
  • social skills training
• pharmacotherapy for comorbid disorders

Question 11

Describe prognosis: Conduct Disorder (7)

Answer 11

• poor prognostic indicators include:
  
  • early-age onset
  • high frequency
  • variety of behaviours
  • pervasiveness (i.e. in home, school, community)
  • comorbid ADHD
  • early sexual activity
  • substance abuse
• 50% of CD children become adult ASPD

Question 12

Describe acronym for conduct disorder diagnosis (4)

Answer 12

TRAP

• Theft: breaking and entering, deceiving, non-confrontational stealing
• Rule breaking: running away, skipping school, out late
• Aggression: people, animals, weapons, forced sex
• Property destruction

Question 13

Describe diagnosis: Intermittent Explosive Disorder (3)

Answer 13

• recurrent behavioural outbursts representing a failure to control aggressive impulses in children age ≥6, manifested as either
  
  • verbal or physical aggression that does not damage others or property, occurring ≥2 times per wk for 3 mo
  • 3 outbursts involving physical damage to another person, animal or piece of property in the last 12 mo
• outbursts are out of proportion to triggers are not premeditated or for primary gain
• outbursts cause clinically significant distress or impairment in occupation or interpersonal functioning, or financial/legal consequences