Oppositional Defiant and
Conduct Disorders
Michael Kisicki, M.D.
Seattle Children’s Hospital
Echo Glen Children’s Center
University of Washington, Department of Psychiatry.

Safety
Assess and treat comorbid conditions
Address risk factors and bolster strengths
Behavioral interventions first
Medications secondary and adjunctive

6 year old
Angry when video games limited
Poked mom’s face out of family portraits
Talks back to teachers
Provokes peers, bossy
Hits younger sister

9 year old cranky girl
Aggressive and destructive tantrums
Cries unpredictably
Treated for ADHD, without benefit
Low energy, appetite

15 year old boy in Wyoming Boy’s School
Assault, burglary, arson, shoplifting
Drug commerce and use
Parents have criminal history

14 year old girl, psychiatric inpatient
Aggression towards family
History of sexual abuse by babysitter
Difficulty sleeping, nightmares
Hyperarousal, irritability

9 year old, language delay
Toe walking, spins when toilet flushes
No interest in social play
Pulls hair of dog and sister

Development of contrary and aggressive behavior
Psychological factors
Environmental factors
Physiological factors
Determining pathologic

From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)

From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)

From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)

Infants promote bonding with behavior
Anger expression by age 6 months
Toddlers show defiance as they individuate
Tantrums diminish in school age children
Social conformity progresses in elementary
Testing limits, debating, experimenting in early teens

Genetics
Autonomic nervous system
Endocrine
Neuroanatomy
Serotonin
Toxins

Caspi, et al 2002

Orbito/frontal: reactive aggression, negative affective style, impulsivity
Temporal: unprovoked aggression
Amygdala: interpretation of social cues

Safety
Variety of symptoms and settings
Proactive aggression and cruelty
Use of weapon
Contrary to social group
Behavior atypical for age

Abuse, neglect
Presence of weapon
Past behavior
Use of drugs/alcohol
Acute psychiatric illness (mania, psychosis)
Suicide

When, how, what,? Focusing on modifiable variables
Hot or cold?
Time course, association with stressor?
Risk factors
Strengths
Information from multiple sources
Measures, scales (Vanderbilts, OAS)

Family history (ADHD, DBD, PDD, mood)
Temperament, affect dysregulation
Reading, speech/language
Social skills
Prenatal, environmental toxic exposure

Parental mental illness
Low involvement
High conflict
Poor monitoring
Harsh inconsistent discipline
Physical punishment
Lack of warmth and involvement
Parental burn out

Physical abuse and neglect predict APD, criminal behavior, violence
Abused children have social processing deficits
Sexual abuse victims of both genders develop DBD, girls have more internalizing
Risk reduced when removed

Rejected and reinforced by prosocial peers
Uneasy affirmation by anti-social peers
Females more sensitive to rejection

More predictive of DBD than any other psychopathology
Public housing outweighs all protective factors
Disorganization, drugs, adult criminals, racial prejudice, poverty, unemployment

Defiance, anger, quick temper, bullying, spitefulness, usually before 8 years of age
Usually resolves, 1/3 develop conduct disorder
High rate of comorbidity
Irritability is a component (think about when considering Bipolar NOS)

Repetitive + persistent, violates basic rights of others or societal norms
Aggression, property destruction, theft, deceit, truancy
Prognosis depends on age, aggression and social withdrawal
Boys: higher prevalence, more persistence and aggression
Girls: less persistent, more covert behavior and problematic relationships
Less Aggression and more rights violations with age.

5% of kids
ODD: 2-16% of community, 50% of clinic
CD: 1.5-3.4% of community adolescents,
30-50% in clinic
Usually resolves, 1/3 of ODD develop CD
Adult antisocial personality disorder: 2.6%
Boys >> girls, unless you consider relational aggression

ADHD, 10x the prevalence; inattention, impulsivity, hyperactivity. Vanderbilts.
MDD, 7x the prevalence; mood complaints, neurovegative symptoms.
SMFQ.
Substance abuse, 4x the prevalence; by history, UA. CRAFFT
(car, relax, alone, forget, friends, trouble)
PTSD, Autism, Bipolar

Education
Treat co-morbid medical and psychiatric conditions
Parenting support
Psychotherapy
Community/Multimodal services
Medication

Attention to your own demeanor, environment
Provide some sense of control, choices
Distractions, food
Medications (oral, risperidone liquid/Mtab)
Careful with benzos and Benadryl

Drugs, toxins
Parenting/abuse
Parent mental health
Learning problems
Peers, community
Safety precautions
Available resources
Communication

46 leading experts surveyed
10 years of “ballooning” off-label use of antipsychotics
Decline in psychosocial interventions
Mismatch between research and clinical practice
Martin & Leslie, 2003

ADHD: medication and parenting support +/- behavioral therapy
Substance abuse: targeted treatment, motivational interviewing, consider residential
Mood/Anxiety: individual therapy
(CBT) +/- medication

Part of a broader program
Problem solving, peer mediation
Social skills
Moral development
Anger/assertiveness training

Parent management training (PMT): effective across settings and overtime, but does not bring out of clinical range with
ADHD
Parent-Child Interaction Therapy (PCIT): clinically significant improvement with
ODD. 1. Child directed interaction. 2.
Parent directed
Family Therapy has greater drop out than
PMT

1-2-3 Magic (2004) by Thomas Phelan,
PhD (multiple languages and video)
Winning the Whining Wars, and other
Skirmishes (1991) by Cynthia Whitham
MSW
The Difficult Child (2000) by Stanley
Turicki, MD
Parenting Your Out-of-Control Teenager by Scott Sells, PhD

Positive reinforcement
Balanced emotional valence
Time outs

Response cost: withdrawing rewards
Token economy
Consistency of response
Priorities and sharing responsibility

Get Creative!
Scouts, Boys and Girls Clubs, Big
Brother/Sister, after school activities and sports, communal parenting
Be careful of bringing together kids with
ODD/CD
More formal programs: treatment foster care, school-based programs, bullying programs
Promotes social skills and supervision

Strongest evidence for actual therapeutic effect in Conduct disorder
Foster care, juvenile justice, public mental health
Multisystemic therapies (MST, FFT,
FIT): family, peer, school, and neighborhood interventions plus behavior therapy, problem solving,
+/- DBT skills

Feeling more successful in school always helps behavior
Testing (learning, speech, language)
Accomodations
Special classroom
Social skills, problem solving, peer mediation

Target medication responsive diagnoses
Covert, premeditated generally not responsive
Meds should be adjunctive and secondary to behavioral interventions
Most benign first, informed consent
Quantify and track results (OAS)
Stop one before starting second
Assess compliance, all meds can be diverted

ADHD = ADHD+ODD in stimulant response
Non-Stimulant medications not as consistent
11x the non-compliance with ODD
Meds + parenting and/or behavioral therapy
Combination therapy is better when comparing “normalization,” and dosage of medication and parent preference
Jensen et al, 2001

18 studies (15 RCTs). 429 kids, mostly elementary boys. ADHD and/or ODD/CD with aggressive behavior.
Greatest ES in ADHD + aggression, 0.9.
Lowest in MR, 0.3. Average was 0.78.
At least 3 small studies (N=99) reduced aggression in ODD,CD without ADHD
Good first choice for impulsive, reactive aggression. Quick trial, relatively benign.
Pappadopulos et al, 2006

Clonidine. 7 studies (4 RCTS). 114 kids. ADHD,
CD, PTSD, Tourettes, Autism.
RCTs showed efficacy DBDs>Tourettes.
Watch for sedation, dizziness, hypotension
Guanfacine. 4 studies, 1 controlled. 72 kids.
ADHD +/- tics
Mixed results. Better tolerated than clonidine.
ADHD kids who don’t tolerate stimulants, or kids with hyperarousal
Pappadopulos et al 2006

Seretonin and aggression in rats
SSRIs treat “impulsive aggression” in adults, primates
30-40% of depressed adults are aggressive
Bupropion 3 RCTs, 2 open. 117 kids. CD and
ADHD. “solid support.”
SSRIs mixed results, but still consideration for anxious/depressed.
Trazodone in DBD, effective for aggression.
Small open trial (22)
Pappadopulos et al 2006

Since 2000, 9 studies in CD/ODD, ADHD,
DBD, MR, Autism. 875 kids
Risperidone, low doses, short trials
ES ranging from 0.7-1.96.
Aripiprazole, 1 RCT, 218 children, efficacy and SE’s increased with dose.
Movement and metabolic disorders
Large/broad effect, short term management
Pappadopulos et al 2006

Lithium. 5 RCTs. Mostly inpatient CD.
Mixed. More effective in “affective, explosive.”
Valproic Acid. 2 studies (1 RCT). 30 kids.
Superior to placebo in aggression in CD.
Carbamazepine. 1 RCT showed no benefit
Oxcarbazepine. No data

Lithium monitoring. Baseline Cr and Ur specific gravity, TSH, ?EKG. Lithium level 1 week after dose change. Monitor level, kidney, TSH every
2-3 months. Weight.
VPA monitoring. CBC+LFTs prior. Repeat, with
VPA level every few weeks in first couple months, then 1-2 times/year. Weight
Carbamazepine. CBC, LFTs, Renal, TSH prior.
Repeat q2wks for 2m, then every 3-6m.

Propranolol (others have  intolerance)
Some evidence in adults with “impulsive, explosive” rage, aggression in MR, DD dementia.
5 studies (1 RCT). 101 kids. Various dx
(ADHD, DD, PTSD, “organic”). Largely positive
1 RCT. 32 kids. CD. Pindolol not superior to MPH, with significant SE’s

Thank you for coming!
Please feel free to email me with any questions
Michael.kisicki@seattlechildrens.or
g
For specific clinical questions, contact PAL at 1-
866-501-72575

Acknowledgement
Dr. Terry Lee
Dr. Robert Hilt
Dr. William French