Conduct Disorders

aggression is SYMPTOM, not disease in itself

by motivation

impulsive/affective/reactive

proactive/instrumental/appetitive

callous/unemotional

adolescent-onset/peer-facilitated

by behavioral features (destructive vs non-destructive, overt vs covert)

by longitudinal features

early age --> life course persistent more likely

starting in adolescence --> usu adolescence limited

oppositional behavior

all kids are oppositional from time to time

normal part of development for 2-3 year olds and early adolescents

becomes a concern when it's so frequent and consistent that it stands out compared to other kids of same age

ODD

behavior more frequent than typically observed in kids of comparable age/developmental level - needs to show up in multiple different locations

angry/irritable mood

argumentative/defiant behavior (deliberately annoying, blaming others for mistakes)

vindictiveness

5-10% of kids; often comorbid w/ ADHD/mood disorders

more likely to develop SUD as adult

serious temper tantrums involving threats of suicide/destruction of property when denied something they want --> ER eval

etiology

biology

poor affective modulation

deficits w/ executive cognitive skills

social

family w/ patterns of inconsistent behavior management

difficult limit setting

parents are argumentative and resistant to authority

tx

behavior interventions

parent training

coping skills for kid

meds (for comorbid ADHD): stimulants, alpha adrenergic - clonidine, guanfacine

Conduct disorder

repetitive, persistent pattern of behavior - violating basic rights of others or major social norms

behaviors

aggression to people and animals

deliberate destruction of property

deceitfulness/theft

serious violations of rules: truancy, running away from home

onset

childhood onset < 10 yo: M>F, physical aggression, disturbed relationships, more likely to have conduct disorder persist in adulthood

adolescent onset > 10: more balanced gender ratio, less likely to be physically aggressive, more normative peer relationships, less likely to have conduct disorder into adulthood

unspecific onset

specify if "limited prosocial emotions": lack of remorse/guilt/empathy, unconcerned about performance, shallow or deficient affect

typically angry/sullen in context of adult world: pressure to conform, stay in school, persist in dull activities/

usually happy around peers

seemingly tough but usu have feelings of self-doubt and worthlessness

etiology

heritability ~50%

biological

hormones: oxytocin, vasopression, cortisol

NT: decreased serotonin --> aggression; decreased dopamine --> impulsive

social

parent separation/divorce

poor parenting styles: inconsistent, abandonment

adopted children have higher rates

child abuse

treatment

behavioral interventions: preventive measures toward risk factors, parent training, multisystemic therapy (targets individual, family, peer, school, and neighborhood)

meds used for comorbid disorders or decrease impulsive aggression

ADHD: stimulants, alpha agonists

severe aggression/impulsive rage: antipsychotics - Risperdal - and lithium

ODD: 30% get --> conduct disorder: 40% get --> antisocial personality disorder

DMDD (disruptive mood dysregulation disorder)

irritable and angry most of the time, but don't have other s/s of ODD or depression

severe recurrent temper outbursts way out of proportion to situation; inconsistent w/ developmental level, 3+/week

no FDA approved tx or guidelines - individualized approach to account for other comorbidities