An Introduction to Oppositional Defiant Disorder and Conduct Disorder

US Pharm. 2019;44(11):29-32.

ABSTRACT: Disruptive behavior disorders are psychiatric conditions that involve significant behavior impairment. Oppositional defiant disorder (ODD) and conduct disorder (CD) are among the most common disruptive behavior disorders in children and adolescents. Children with ODD and CD have difficulty maintaining appropriate behavioral relationships with peers, family, and authority figures, and they commonly display aggression and anger. Accurate diagnosis is important because other conditions have symptoms that can mimic these disorders. Psychosocial therapy for ODD and CD is crucial; no medications have been FDA approved for these conditions, although stimulants, nonstimulants, antipsychotics, mood stabilizers, and antidepressants have been used off-label. If not managed promptly, ODD can progress to CD, which could then transition to antisocial personality disorder.

Disruptive behavior disorders  are psychiatric conditions that are characterized by significant impairments in behavior. Although most children display disruptive behaviors at times, with DBDs the behavior is severe and lasts longer than normal. Oppositional defiant disorder (ODD) and conduct disorder (CD) are among the most common disruptive behavior disorders in children and adolescents.¹ They share similar symptoms, such as temper tantrums, aggression, and defiance. Children with ODD exhibit developmentally inappropriate behaviors that are negative, defiant, disobedient, and hostile, and they often experience conflicts with parents, teachers, and peers; aggression is more common in girls, with verbal aggression more frequent than physical aggression.² CD typically involves repetitive and persistent violations of the rights of others, destruction of property, theft, and aggression toward people and animals.³ ODD and CD are diagnosed more often in boys than in girls.^3,4 If not managed promptly, ODD can progress to CD, which can then transition to antisocial personality disorder.³

Etiology and Risk Factors

Young children with a significant number of conduct and oppositional complications often have great difficulty in developing healthy relationships with family members and individuals in their community.⁵ These children are regularly exposed to acts of violence and delinquency, and they may sometimes be passed from home to home or end up in the juvenile system.⁵

Although the cause of CD is difficult to determine owing to the interplay of different biological and environmental elements, it is crucial to distinguish the underlying mechanisms of CD in order to correctly assess, and implement effective treatment strategies for, individual patients.⁵ Brain differences and cognitive factors figure significantly in CD because impairments in brain anatomy and brain function manifest via conduct-related behaviors. Compared with normal controls, children with CD appear to have a defect in the frontal lobe of the brain.⁶ This abnormality interferes with the child’s ability to plan, avoid harm, and learn from negative experiences and situations.⁶ In CD, the brain exhibits smaller gray-matter volume in limbic regions such as the amygdala, insula, and orbitofrontal cortex, as well as functional abnormalities in overlapping brain circuits that are responsible for emotion processing, emotion regulation, and reinforcement-based decision making.⁷

Learning disabilities are prominent in children with CD, and academic underachievement is a prevalent problem.⁸ Attention-deficit/hyperactivity disorder (ADHD) is the condition most commonly associated with CD.⁹ Based on this frequent comorbidity, CD is largely identified with underachievement and learning difficulties.⁸ In addition to its neurologic profile, CD also has a genetic component. For example, low monoamine oxidase A activity may contribute to CD, especially if the child is exposed to a dangerous childhood environment.¹⁰ High levels of testosterone also seem to be involved in CD.¹¹

CD is more common in boys than in girls and is more likely to develop in children and teens who come from disadvantaged, dysfunctional, and disorganized backgrounds.⁶ Children with a relative (such as a parent or sibling) with CD are more likely to develop the disorder.¹² CD is more common in children whose biological parents have been diagnosed with alcohol-use disorder, depression, schizophrenia, bipolar disorder, or ADHD.¹² Mothers who smoked cigarettes at the rate of half a pack or more per day during the first trimester of pregnancy are marginally more likely to have a child with CD.¹³ Similarly, children whose mothers consumed an average of one or more alcoholic drinks during the first trimester are three times more likely to experience CD over their lifetime.¹³ Traumatic experiences (e.g., abuse, parental rejection, parental neglect) and severe or inconsistent parenting put children at greater risk for CD, as do exposure to peer rejection, peer delinquency, and neighborhood violence.¹²

The etiology of ODD is similarly complex. ODD is generally considered a milder version of CD, and it is diagnosed at an earlier age. Defects in or injuries to certain areas of the brain can lead to serious behavioral problems in children.¹⁴ It is theorized that ODD may develop as a result of the child having difficulty learning to become independent from a parent or other loved one.¹⁵ Another hypothesis suggests that ODD symptoms are learned from negative reinforcement methods used by parents and other authority figures and that the child’s ODD behaviors increase because they enable the child to obtain the attention and reactions desired from others.¹⁵

Compared with girls, boys are at greater risk for developing ODD, and children with CD or other mental-health disorders, such as ADHD, mood disorders (e.g., depression), and anxiety disorders, also are more likely to develop ODD.¹⁵ Children with a parent who exhibits similar disorders have an increased risk as well.¹⁵ Additionally, ODD is more common in children from low-income households.²

Diagnosis and Clinical Manifestations

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is considered the gold standard for diagnosing psychiatric disorders. Accurate diagnosis is important because other conditions can mimic the symptoms of disruptive disorders. ADHD, major depressive disorder, substance abuse, and intermittent explosive disorder are differentials for ODD and CD.⁴ CD may present with aggression to people or animals, property destruction, violation of rules set by authority figures, and constant lying to avoid consequences. Argumentativeness, irritability, defiance, and vindictiveness are typical in ODD. See TABLES 1 and 2 for an overview of diagnostic criteria for CD and ODD, respectively.^16,17

Management

Nonpharmacologic Treatment: Psychosocial therapy for ODD and CD is crucial, as no medications have been FDA approved specifically for these conditions. A licensed psychologist or therapist is generally involved, and family members have a role in therapy. Parental training, parent-child interaction therapy, individual and family therapy, social-skills training, cognitive problem-solving training, and cognitive-behavioral therapy have proven benefits in ODD or CD.

Psychosocial therapy for CD generally involves psychotherapy, which enables the child to control anger and express it in more socially acceptable ways. A more specific branch of psychosocial therapy, known as cognitive-behavioral therapy, can position the child’s thinking to be cognitive and reason-based.¹⁸ Cognitive-behavioral therapy may incorporate impulse-control and anger-management skills. For ODD, individual cognitive-behavioral therapy helps the child acquire skills in controlling anger and impulses and in solving problems that could potentially elicit an exacerbation.¹⁸ Family therapy and parental training generally focus on ways to stop the child from throwing temper tantrums to get his or her way. Cognitive problem-solving training defines current relationships that may elicit manifestations of ODD and modifies them to enable symptom management. Social-skills training, which includes the parent, models for the child how to interact appropriately and positively with peers.^19,20

Pharmacologic Treatment: Pharmacotherapy is used adjunctively in the management of both CD and ODD. Since both of these disruptive disorders usually coexist with conditions such as ADHD and major depressive disorder, medication management of comorbidities is first-line treatment. ODD and CD may be comorbid in more than 50% of ADHD cases. In addition, 14% of children with ODD or CD have comorbid anxiety disorder and 9% have comorbid depression. Therefore, it is imperative to manage the coexisting condition. Stimulants, nonstimulants, antipsychotics, mood stabilizers, and antidepressants have been used off-label for CD and ODD.^21,22

Methylphenidate and dextroamphetamine are the most commonly used stimulants for ODD and CD, although methylphenidate has demonstrated greater efficacy.^2,4,21,22 Studies evaluating stimulant use have been conducted mainly in children with comorbid ADHD. Stimulants help improve symptoms of aggression in coexisting ADHD. The improvement in attention afforded by stimulants may enhance these children’s capacity to benefit from psychosocial therapies.⁴ Nonstimulants may be used second-line for aggression in ODD with comorbid ADHD. Atomoxetine, clonidine, and guanfacine have been used; atomoxetine provides the best results, although in the absence of comorbid ADHD it has no efficacy.²¹ Clonidine may also be beneficial in CD, assisting with impulsivity and outbursts.⁴

As is the case with many other disruptive behaviors that involve significant aggression, antipsychotics have been used for CD and ODD. Risperidone, an atypical antipsychotic, has the best evidence for treating aggression in these disorders, although aripiprazole and quetiapine have also yielded improvements.^21,23-25 Metabolic effects, such as increases in blood glucose, lipids, and weight, should be monitored, as they tend to occur more often in children than in adults.²² Typical antipsychotics such as molindone and thioridazine are efficacious for treatment of aggression, and molindone is better tolerated.²⁶ Haloperidol has shown variable effects on aggression.²¹ Monitoring for extrapyramidal side effects is necessary, especially with typical antipsychotics. Lithium and anticonvulsants are commonly used as mood stabilizers to treat aggression. Several studies have shown positive results in managing aggression in CD with lithium, and close monitoring of lithium levels is important.^4,27,28 For mood stabilization, valproic acid is preferred for ODD over lithium and carbamazepine.²¹ The antidepressants bupropion and fluoxetine are beneficial for treating aggression in CD and ODD.^2,4,21 Bupropion has been shown to have positive effects in ADHD.⁴ Tricyclic antidepressants (i.e., desipramine and imipramine) may be used for aggression in ODD, but cardiotoxicity is a concern.^2,21

Conclusion

ODD and CD are among the most common behavior disorders occurring in children and adolescents. Because of similarities in presentation, constant monitoring of the child’s severity level and symptom duration is important in order to distinguish them from other age-appropriate childhood behaviors. It is imperative to implement behavioral therapies in order to help the child and the parent or parents cope with and manage these conditions. Because no FDA-approved medications are available, medication management targets direct symptoms and other comorbid conditions. Pharmacists should be aware of the signs and symptoms of ODD and CD and should be familiar with nonpharmacologic and pharmacologic therapies because they are in a key position to counsel parents about treatments and help identify any drug interactions.

REFERENCES

1. Kaminski JW, Claussen AH. Evidence base update for psychosocial treatments for disruptive behaviors in children. J Clin Child Adolesc Psychol. 2017;46(4):477-499.
2. Hamilton S, Armando J. Oppositional defiant disorder. Am Fam Physician. 2008;78(7):861-866.
3. Mullen S. Neurodevelopmental, disruptive, impulse-control and conduct disorders. College of Psychiatric & Neurologic Pharmacists 2018-2019 psychiatric pharmacotherapy review book. https://cpnp.org/ed/university/course/2018-review/neurodevelopmental. Accessed October 16, 2019.
4. Searight HR, Rottnek F, Abby SL. Conduct disorder: diagnosis and treatment in primary care. Am Fam Physician. 2001;63(8):1579-1588.
5. Murrihy RC, Kidman AD, Ollendick TH, eds. Clinical Handbook of Assessing and Treating Conduct Problems in Youth. New York, NY: Springer; 2010.
6. Stanford’s Children’s Health. Conduct disorder in children. www.stanfordchildrens.org/en/topic/default?id=conduct-disorder-90-P02560. Accessed October 16, 2019.
7. Passamonti L, Fairchild G, Goodyer IM, et al. Neural abnormalities in early-onset and adolescence-onset conduct disorder. Arch Gen Psychiatry. 2010;67(7):729-738.
8. Frick PJ, Kamphaus RW, Lahey BB, et al. Academic underachievement and the disruptive behavior disorders. J Consult Clin Psychol. 1991;59(2):289-294.
9. Waschbusch DA. A meta-analytic examination of comorbid hyperactive-impulsive-attention problems and conduct problems. Psychol Bull. 2002;128(1):118-150.
10. Foley DL, Eaves LJ, Wormley B, et al. Childhood adversity, monoamine oxidase A genotype, and risk for conduct disorder. Arch Gen Psychiatry. 2004;61(7):738-744.
11. Coie J, Dodge K. Aggression and antisocial behavior. In: Damon W, Eisenberg N, eds. Handbook of Child Psychology, Volume 2: Social, Emotional, and Personality Development. 5th ed. New York, NY: Wiley; 1998:779-862.
12. Child Mind Institute. Conduct disorder basics. https://childmind.org/guide/guide-to-conduct-disorder. Accessed October 16, 2019.
13. Larkby CA, Goldschmidt L, Hanusa BH, Day NL. Prenatal alcohol exposure is associated with conduct disorder in adolescence: findings from a birth cohort. J Am Acad Child Adolesc Psychiatry. 2011;50(3):262-271.
14. WebMD. Oppositional defiant disorder. www.webmd.com/mental-health/oppositional-defiant-disorder#1. Accessed October 16, 2019.
15. John Hopkins Medicine. Oppositional defiant disorder (ODD) in children. www.hopkinsmedicine.org/health/conditions-and-diseases/oppositional-defiant-disorder. Accessed October 16, 2019.
16. Reynolds CR, Kamphaus RW. BASC3: conduct disorder. http://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ConductDisorder.pdf. Accessed September 7, 2019.
17. Reynolds CR, Kamphaus RW. BASC3: oppositional defiant disorder. https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_OppositionalDefiantDisorder.pdf. Accessed September 7, 2019.
18. MentalWebMD. Health and conduct disorder. www.webmd.com/mental-health/mental-health-conduct-disorder#3. Accessed October 16, 2019.
19. Rodden J. ODD help: how to treat oppositional defiant disorder. www.additudemag.com/oppositional-defiant-disorder-odd-treatment. Accessed October 16, 2019.
20. Mayo Clinic. Oppositional defiant disorder (ODD). www.mayoclinic.org/diseases-conditions/oppositional-defiant-disorder/diagnosis-treatment/drc-20375837. Accessed October 16, 2019.
21. Ghosh A, Ray A, Basu A. Oppositional defiant disorder: current insight. Psychol Res Behav Manag. 201;10:353-367.
22. Pisano S, Muratori P, Gorga C, et al. Conduct disorders and psychopathy in children and adolescents: aetiology, clinical presentation and treatment strategies of callous-unemotional traits. Ital J Pediatr. 2017;43(1):84.
23. Pringsheim T, Hirsch L, Gardner D, Gorman DA. The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: a systematic review and meta-analysis. Part 2: antipsychotics and traditional mood stabilizers. Can J Psychiatry. 2015;60(2):52-61.
24. Ercan ES, Kutlu A, Cikoglu S, et al. Risperidone in children and adolescents with conduct disorder: a single-center, open-label study. Curr Ther Res Clin Exp. 2003;64(1):55-64.
25. Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev. 2017;(8):CD008559.
26. Turgay A. Psychopharmacological treatment of oppositional defiant disorder. CNS Drugs. 2009;23(1):1-17.
27. Campbell M, Adams PB, Small AM, et al. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. J Am Acad Child Adolescent Psychiatry. 1995;34(4):445-453.
28. Rifkin A, Karajgi RA, Dicker R, et al. Lithium treatment of conduct disorders in adolescents. Am J Psychiatry. 1997;154(4):554-555.

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