Oppositional Defiance Disorder and Conduct Disorder

By
ALADEJARE S.A.
 Outline
• Introduction
• Historical Perspectives
• Epidemiology
• Aetiology
• Classification
• Assessment and Diagnosis
• Management
• Comorbidity
• Prognosis
 Introduction
• Professionals get reports from care givers about children with conduct
related problems. Drawing the line on whether this qualifies as
conduct disorder could be challenging.
• However, conduct disorder (CD) is only given to a child if such
behaviours are persistent and impinge on the basic rights of others, if
major age-appropriate societal norms are violated, and if there is
significant impairment in everyday functioning at home or school.
• CD is distinguished by a persistent pattern of behavior in which the
basic rights of others and major age appropriate societal norms are
violated. Children with this disorder have great difficulty following
ruess and behaving in a socially acceptable way. They are ofyten
viewed by other children,teachers and parents as bad or delinquent,
rather than mentally ill. They are troublesome children, more often
than troubled children. (The Association of chief psychologists of
Ontario school boards)
 Epidemiology
• Rates in general population range from 1-10%.
• M>F
• Prevalence higher in lower socioeconomic groups, and if parents have
antisocial personality disorder.
 Aetiology
Biological factors
• Studies suggest a familial clustering of ODD, CD, attention deficit
hyperactivity disorder(ADDH) and substance use disorders, 50%
heritability.
• Siblings in the same environment have similar conduct problems.
• Prenatal or early developmental exposure to toxins, e.g. lead
• Exposure to nicotine in utero
• Deficient nutrition and vitamins.
• Abnormalities in the pre-frontal cortex which makes it difficult to plan,
avoid harm and learn from negative experiences.
• Altered neurotransmitter function in the serotonergic, noradrenergic,
and dopaminergic systems.
• Low cortisol and elevated testosterone
• Physical illness especially those affecting the central nervous system.
Psychological factors
• Attachment difficulties: Behavioural manifestations of insecure
attachment and disruptive behavioural disorders, are similar
• Inconsistent Parenting: reliance on use of punishment to change
behavior, failure to provide a supportive and nurturing environment,
inconsistent use of discipline(negatively reinforces child’s behaviour).
• Temperaments: impulsive
• Deficient social learning and information processing.
• Reading problems
Social factors
• Low socioeconomic status
• Peer relationship difficulties
• Parental mental illness
• Parental substance abuse and criminality
• Parental disharmony, family dysfunction including domestic violence.
• ODD is the least severe form of disruptive behavioural disorder in which children
show an age- inappropriate and persistent pattern of irritable, hostile and defiant
behavior.
• Defined by two separate sets of problems: aggressiveness and the tendency to
bother and irritate others.
• Frequently, this behaviour is most evident in interactions with adults or peers whom
the child knows well, and signs of the disorder may not be evident during a clinical
interview.
• The key distinction from other types of conduct disorder is the absence of behaviour
that violates the law and the basic rights of others, such as theft, cruelty, bullying,
assault, and destructiveness.
• The definite presence of any of the above would exclude the diagnosis.
There are 3 subtypes
• Childhood – onset type – at least one criterion before 10years
• Adolescent onset type after age 10 years
• Conduct disorder, unspecified onset

Severity specifier:These could be mild, moderate or severe.

ICD 10 uses similar criteria but emphasis is on the social network of the young
person.
Behavioural and emotional disorders with onset usually occurring in childhood
and adolescents
1. confined to family setting
2. oppositional defiant disorder
3. Socialized
4. Non-socialized
5. Other conduct disorders
6. CD unspecified.
 Assessment
• History of current problems – onset, duration, frequency and location
• Developmental history – Temperament, separation from family, peer
relationship.
• Medical history – head injuries, seizures CNS infections.
• Family history of medical or mental health problems.
• Parenting behaviour – what strategies have been tried.
• Social history – parental employment, accommodation, current stressors and
support.
• Clinical interview with the child and adolescent.
• Physical examination including neurological examination.
• Collateral information from teachers or others
• Psychological assessment – IQ,
• Specific questionnaires and Rating scales
a) Child Behavioural Checklist (Achen back and Edelbrock, 1991).
b) Conners Parent and Teacher Rating Scales (Conners 1989, 1998).
c) Eyberg Child Behaviour Inventory (Eyberg, 1992).
 Management
• Treatment is individualized following the Biopsychosocial formulation
of the case and identified co-morbidity.
• Treatment is likely to be most effective before the age of 8 years
because anti-social habits will be less ingrained. They are less likely to
have become part of a deviant group.
• In cases of comorbidity, treat comorbidities first.
• They are more likely to resist treatment.
Psychosocial Interventions
The National Institute for Health and Clinical Evidence (NICE)
recommends the group based parent training/education programmes
should be the mainstay of treatment for children of 12 years and
under with ODD and CD.
• Parent Management Training – Parents learn from each other in terms
of improving family relationships, reinforcement of pro-social
behaviour, use of time-out , loss of tokens/privileges, etc.
• Promoting good behavior and positive relationship, setting clear rules
and commands, remaining calm, managing difficult situations.
Individual or group behavioural training for the child effective when run
in conjunction with parent management training.
Others
• School based interventions and family therapy have yielded
inconsistent results.
Psychological interventions for established CD show little
effectiveness.
• Some evidence of that multimodal interventions like “multisystemic
therapy are of modest benefit. Addresses contextual influences of
family, peer relations, school and community. Benefits may be linked
to the approaches by being intensive, proactive, addressing
therapeutic barriers and involving all domains of a young person’s life.
Pharmacological
Should not be the first or only intervention. Should not be started until
psychological interventions have been attempted.
• Typical and Atypical antipsychotics in aggression.
• Treatment of CD with co-morbid conditions
• Lithium carbonate reduce aggression and temper outburst.
• SSRI’s used for reduction of impulsivity, irritability and lability of mood
in CD.
• Methylphenidate
 Comorbidity
• Attention deficit hyperactivity disorder
• Mental retardatioin
• Substance abuse
• Specific developmental disorders
• Post-traumatic stress disorder
• Adjustment disorder
• Anxiety disorder
• Seizure disorders
• Major depressive disorder
• Psychoses.
 Conclusion
CD is linked with
• Failure to complete schooling
• Joblessness and financial dependency
• Poor interpersonal relationships
• Family break-up and divorce.
• CD affects individual, family and community

• It appears in various forms and various factors contribute to its

development and maintenance

• Effective intervention should be an integrated approach and should

consider the child , family and the community