Common Diagnoses in Children and Adolescents

CONDUCT AND OPPOSITIONAL

DEFIANT DISORDERS

DSM-IV AXIS Axis I includes clinical disorders & other

conditions that may be a focus of clinical attention (diagnoses usually first diagnosed in infancy, childhood, or adolescence except mental retardation, which is on Axis II)

Axis II includes personality disorders and mental retardation

DSM-IV AXIS--CONTINUED Axis III includes general medical conditions

Axis IV includes Psychosocial and environmental problems (problems with primary support group, educational problems, access to services, etc.)

Axis V includes Global assessment of functioning (GAF) (clinical judgment of person’s overall level of functioning)

Oppositional Defiant Disorder A recurrent pattern of negativistic,

defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months

CONDUCT DISORDER A repetitive and persistent pattern of

behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.

Four Main Groupings of Behaviors Aggressive Conduct:Causes or threatens physical harm to other

people or animals Nonaggressive Conduct: Causes property loss or damage Deceitfulness Theft

Three or more of the behaviors must have been present during the past 12 months, with at least one behavior present in the past 6 months.

Must include significant impairment in social, academic, or occupational functioning.

Oppositional Defiant Disorder(the lesser of two evils!) A recurrent pattern of negativistic, defiant,

disobedient, and hostile behavior toward authority figures that persists for at least 6 months and is characterized by the frequent occurrence of at least 4 of the following behaviors: Losing temper Arguing with adults Actively defying or refusing to comply with the

requests or rules of adults

Criteria--continued Deliberately doing things that will annoy other

people Blaming others for his/her own mistakes or

misbehaviors Being touchy or easily annoyed by others Being angry and resentful Being spiteful or vindictive(must occur more frequently than is typically observed in

individuals of comparable age and developmental level and must lead to significant impairment in social, academic, or occupational functioning.

Expression of behaviors:

Persistent stubbornness Resistance to directions Unwillingness to compromise, give in, or

negotiate with adults or peers Deliberate or persistent testing of limits Ignoring orders, arguing, and failing to

accept blame for misdeeds

…behaviors continued

Hostility can be directed at adults or peers and is shown by deliberately annoying others or by verbal aggression (usually without the more serious physical aggression seen in conduct disorder)

Behaviors are almost always present in the home, but may not be seen in the school setting or within the community setting

ASSOCIATED FEATURES & DISORDERS In males, more prevalent among those who exhibited

problematic temperament or high motor activity during preschool years.

May exhibit low self esteem, mood labiality, low frustration tolerance, or swearing.

May use alcohol, tobacco, or illicit drugs. Often conflicts with parents or family members More prevalent in families where childcare is disrupted

by a succession of different caregivers, or where harsh, inconsistent, or neglectful child rearing practices are common.

PREVALENCE Rates of Oppositional Defiant Disorder from 2%-

16% have been reported, depending on the nature of the population sample

More common in boys than in girls in younger children, but evens out after puberty

Rarely travels alone (usually coupled with another disorder, such as ADD)

What happens to them when they grow up? Some lucky kids outgrow it, but not the majority

(aggressive behavior is very stable, an aggressive 2 year old will likely be an aggressive 20 year old)

May evolve into Conduct Disorder (usually happens fairly early; if after 3-4 years of ODD no CD, won’t)

May remain ODD Can evolve into axis II diagnosis in adulthood (such

as antisocial personality disorder; borderline personality disorder)

Will Kids with ODD end up as criminals??

Probably not unless they develop conduct disorder.

People with ODD when grown up usually do better if they stay away from drugs/alcohol (still have the tendency to irritate others)

Most common diagnosis, yet not much research done

Work Together Common for ODD kids

to convince others that they have been mistreated or abused (splitting!!)

Need to meet with parents, teachers and others involved regularly

Make it a policy (at home, school, etc) never to rely on the info the child has provided.

Don’t include the child in these discussions

Have a plan in place to deal with the behaviors before they occur (shows solidarity)

Target a few key behaviors (rather than focus on “being good”)

Behaviors must be clear: “listen when I tell you something” would be better as “sit down and look at me when I talk to you.”

Rewards should not be $$ or purchased items, but privileges.(don’t need bank loan)

MAKE A PLAN AND STICK TO IT

There needs to be an even mix of +/- reinforcers. (Their program should not be like candyland, but it should not be like Dorchester Prison either)

Plans should be written down and signed.

Plans should be simple and straight forward

CASE: Jim never comes home when he is supposed to. This drives his parents nuts and they would like to kill him when he finally does come home. The behavior they want is to have Jim come home on time.

CANDYLAND VS. ALCATRAZ

If you come home on time, we will pay you five dollars or you will be able to stay up as late as you want at our house that night. If you don’t come home, nothing bad will happen.

If you are one minute late, you will be grounded for a week to your room.

The Good Parents The positive reinforcer (the carrot) would

be if he comes home on time for 5 days, he can have a friend stay over and they can stay up late. The negative reinforcer (the stick) would be that if you are more than 5 minutes late, you will not be able to go out by yourself the next day. You will have to go out with the parent when it is convenient for the parent.

Behavior Modification Must be followed strictly Does not work for everyone (a lot of kids just don’t

have anything they are willing to try that hard for). May have to be changed/modified often to find the

best “fit.” Try not to react strongly/emotionally—they are

trying to “push your buttons.” This is time consuming, requires a lot of patience,

and does not work well with severely aggressive kids.

When do you consider medications?

If medically treatable co-morbid (other) conditions are present (ADD, depression, seizure disorder, psychosis, etc.)

If non-medical interventions (therapies and behavior modifications) are not successful

When the symptoms are very severe

Which drugs do you use?

Drugs that have been proven safe for children

Drugs that have no long-term side effects Drugs that have been proven in studies to

be effective in extremely aggressive adolescents or in co-morbid conditions

Start low, Go slow, Monitor Carefully

HOSPITALIZATION When behavior modification strategies have

failed When aggressive behaviors increase When they have everyone fighting with each

other and are controlling the family When the end of the rope is in sight and you are

too exhausted to hang on (there may be other conditions occurring that need evaluation; hospitalization allows for medication evaluation, psychiatric evaluation, and psychiatric testing)

CONDUCT DISORDER A REPETITIVE AND PERSISTENT

PATTERN OF BEHAVIOR IN WHICH THE BASIC RIGHTS OF OTHERS OR MAJOR AGE-APPROPRIATE SOCIETAL NORMS OR RULES ARE VIOLATED

Four Main Groupings

Aggressive conduct that causes or threatens physical harm to other people or animals

Non-aggressive conduct that causes property loss or damage

Deceitfulness or theft Serious violation of rules

Three (or more) characteristics or behaviors must have been present during the past 12 months

At least one of the behaviors must have been present in the last 6 months

Disturbance in behavior must cause clinically significant impairment in social, academic, or occupational functioning

Conduct Disorder can be diagnosed in individuals older than age 18 ONLY if the criteria for Antisocial Personality Disorder are not met

Behaviors are present in a variety of settings (home, school, or the community.

Additional Symptoms

Initiate aggressive behavior and react aggressively to others

Display bullying, threatening, or intimidating Initiate frequent physical fights Use weapons that could cause serious physical harm Be physically cruel while confronting a victim Serious deliberate destruction of property (fire

starting, smashing windows, school vandalism) Lying or breaking promises to gain goods/favors or

avoid debts or obligations

SUBTYPES

Childhood Onset Type: defined by onset of at least one criterion prior to age 10 years. Usually male Frequently display physical aggression toward others Have disturbed peer relationships May have ODD during early childhood Have symptoms meeting Conduct DO criteria prior to

puberty Likely to have persistent Conduct DO & develop

Antisocial Personality DO

…subtypes continued

Adolescent Onset Type Defined by the absence of any criteria characteristics

of Conduct DO prior to age 10 years Less likely to display aggressive behaviors Tend to have more normative peer relationships (get

along fairly well with kids their own age, but often display conduct problems in the company of others)

Less likely to have persistent Conduct DO or to develop adult Antisocial Personality DO.

Ratio of males to females with Conduct DO is lower than that of the childhood onset type.

Associated Features May have little

empathy or concern for others

May exhibit false guilt or remorse (they learn that expressing guilt reduces or prevents punishment)

Readily “rat out” their peers

Self-esteem is usually low (but they act “tough”)

Poor frustration tolerance Irritability, temper outbursts Accident rates higher Associated with early onset

sexual behavior, drinking, smoking, drug use and risk taking behaviors

May be associated with lower than average intelligence

MEDICATIONS—Again, for co morbidity

Prozac—antidepressant

Celexa—new antidepressant

Paxil—antidepressant (also helps with anxiety)

Zoloft--antidepressant

Ritalin—old medication; helps with ADHD; allows kids to slow down and think, slows impulsivity.

Adderall—newer medication helps with ADHD in same way as Ritalin (and not yet crushed / snorted by kids)

SUMMARY ODD less severe (less of a label) than Conduct ODD does not exhibit the severity in

symptomology or physical attacks/behaviors Medications helpful for co morbid conditions Best plan is a solid behavioral plan that involves

all parties concerned in kids care Keep your cool; they want a reaction, and the

more severe your reaction, the better their “pay off”

Prevalence Appears to have increased over the last decades May be higher in urban than rural settings Males under 18 years rate is 6%-16% Females under 18 years rates from 2%-9% Conduct Disorder is one of the most frequently

diagnosed conditions in outpatient and inpatient mental health facilities for children/adolescents

More info…. Conduct disorder has both genetic and

environmental components Risk is increased in children with a biological or

adoptive parent with Antisocial Personality Disorder or a sibling with CD

Appears to be more common in children of biological parents with Alcohol Dependence, Mood Disorders, or Schizophrenia or biological parents who have a history of Attention Deficit/Hyperactivity Disorder or CD

ODD does not include the persistent pattern of the more serious forms of behavior in which either the basic rights of others or age-specific societal norms and rules are violated.

When the pattern of behavior meets both criteria for ODD and CD, CD takes precedence

Kids with ADHD may exhibit some of the same behaviors, but do not meet criteria for CD

Some criteria may be exhibited in kids having a MANIC episode

Adjustment DO may be considered if significant conduct problems that do not meet the criteria for CD or ODD are present