Transcript Conduct disorder, oppositional defiant disorder and its associated

Conduct disorder,
oppositional defiant disorder
and its associated problems
The paediatrician’s perspective
Conduct disorder
• Number one costly disorder of childhood
• 1) Unresponsive to treatment
(only 20-40% respond to routine treatments)
• 2) 60% of children with CD have a poor prognosis
• 3) CD is intergenerationally transmitted (1*)
• 4) 4-14% of the entire population
Co-morbidity of conduct disorder and
the major DSM 4 diagnoses (1*)
Conduct
disorder
ADHD
Major
Anxiety
depression
disorder
CD
ADHD
23.3%
Depression
16.9%
10.5%
Anxiety
14.8%
11.8%
16.2%
What is conduct disorder?
What is conduct disorder (CD) ?
• A repetitive and persistent pattern of behaviour
in which the basic rights of others or major ageappropriate norms or rules are violated.
• The presence of three or more of the following
criteria in the past 12 months with at least one
criterion present in the past 6 months
Aggression
to people or animals
• Often threatens, bullies, or intimidates others
• Often initiates fights
• Has used a physical weapon that can cause
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serious physical harm to others
Has been physically cruel to others
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity
Destruction of property
• Has deliberately destroyed other peoples
property
• Has deliberately engaged in fire setting
Deceitfulness or theft
• Has broken into someones house ,
building or car
• Often lies to obtain goods or favours or
avoid obligations
Serious violation of the rules
• Often stays out late despite parental
prohibitions
• Has run away from home at least twice
while living in parental home and stayed
away for lengthy period
• Is often truant at school prior to age 13
years
Results
• In a serious impairment in social academic
or occupational function
What causes conduct disorder?
History
• Biopsychosocial causes
• No one specific factor
• a) Genetic
• (twin and adoption studies criminality,
though evidence not as strong in children)
• Chromosomal problems- rare
What causes CD?
• B) Brain injury (intrauterine, post natal
CNS trauma)
• Antisocial behaviour is more common in
more common in children with neurologic
conditions
• ?reason for this is more hyperactivity,
impulsivity, lability leading to impaired
learning of social norms
What causes CD?
• C) Individual child problem
• “difficult to raise”
• “difficult temperament”
• Clash of temperament between child and
parent
What causes CD?
• Family
• It is the task of the family to rear and socialise the child
• Which families are vulnerable to problems meeting the
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needs of the child to be socialised?
Families with parents with
a) mental illness and intellectual difficulties
B) drug and alcohol problems
C) domestic violence
D) single parent families*
What is that families do that lead to
antisocial behaviour?
• Lack of house rules- not set routine for meals and other
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activities.
Lack of clarity as to how children are to behave
Lack of effective contingencies- that is inconsistent
responses to undesired behaviour with failure to follow
through on consequences or with rewards
Lack of techniques to deal with crises or resolve conflict
within family
Lack of supervision is strongly associated with
delinquency
Factors outside the family
• School• bully victim- turned bully at school
• Changing schools may help or worsen the
situation
Let the hunt begin:
Assessing for the co-morbid problems
• Formulation of the cause or the childs problems
• CD
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Comorbid screening
ADHD- Connors, DSM 4, various checklists
Reading disability (30% of CD have RD)
Depression
Drug abuse
Deviant sexual behaviour
Getting on with it
Treatments for conduct disorder
• Psychological therapy
• Medication
What is the evidence that family
and parenting interventions work
with conduct disorder?
• Cochrane review 2001 Woolfenden,
Williams and Peat
• Determine if family and parenting
interventions improve the children aged
10-17 behaviours, parental mental health
• RC Trials 56 in number
What is the evidence that family
and parenting interventions work
with conduct disorder?
• They do results in an improvement in
aggressive behaviour
• Mixed or single sexed schools, boys and
girls
• Uncertain if they reduce violent injuries
What about aggression at schools?
• Similar results to conduct disorder trials
• 56 trials, 749 children
• Aggression was significantly reduced in
treatment group
• Reduction in delinquency/ incarceration
• May be a cost saving
Commencing therapy for the child
and family
• Parental counselling
• Family therapy
• CBT with child
• Exercise (trial in progress of regular
exercise and CD)
• Harnessing support/ respite care
Dubbo resources
• School counsellors
• Community Health Centre- Palmer Street for
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primary school CDs
Hawthorn St Mental Health for high school
Private psychologists
DoCS- funding
Burnside
Churches on individual basis
Medications treat symptoms not
psychiatric diagnoses
• Dexamphetamine/Ritalin- ADHD
• Risperidone- aggression
• Selective serotonin reuptake inhibitors-
anxiety & depression
• Strattera- atomoxetine ADHD, aggression,
anxiety
Evolution of problems
• ADHD – ODD – CD
• ADHD may prime a child for CD, so treat
early and aggressively with behaviour and
medication
Linking of resources
• Hawthorn St- School link psychologist
• Palmer St
• Private Psychologists
• DoCS
• DADHC
• Schools
References
• (1*) Basic Child Psychiatry – Philip Barker
2001
• (2*) Child and Adolescent Clinical
Psychology – Alan Carr
• (3*) Cochrane Database