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"Chris" is a 14-year-old boy who has been suspended from school 4 times this year for arguing with his teachers. When asked about the suspensions, he admits that he loses his temper easily but is quick to blame other students or his teachers for "unfair" treatment.
His mother adds that Chris has always been "a handful" at home and at school--often going out of his way to annoy family members as well as peers. School has been a particular source of stress and, over the past year, he has become more argumentative about completing his homework. Chris is furious with his mother--last month she confiscated his Game Boy after he intentionally tore up his younger sister's homework during an argument.
"Jason," age 17, currently lives in a residential treatment facility for emotionally troubled teenagers. His "file" indicates that as early as the third grade, Jason was labeled as the class bully and often initiated physical fights with peers. During middle school (age 12) he began skipping school and "roaming the streets" at night while using marijuana and alcohol. He was once confronted by a store clerk as he tried to steal a pair of sneakers. In retaliation he spray-painted obscenities across the clerk's car and tossed a brick through the windshield.
When he was 15, Jason attacked a woman with a broken bottle and took her car keys. He was subsequently arrested after her car was traced by the police and he was court-ordered into a locked residential treatment facility.
These vignettes reflect the real-life stories of two of my patients, both of whom were admitted to a residential treatment facility for emotionally disturbed teenagers. Their stories are typical of adolescents who have disruptive behavior disorders. Most providers recognize that these adolescents are profoundly troubled but are frustrated that they do not have the time or knowledge to help them. For primary care pediatricians, the goal is to recognize behaviors that are out of the realm of normal, and to refer patients in the hope of curtailing the development and severity of disruptive behavior disorders.
Here I focus on oppositional defiant disorder (ODD) and conduct disorder (CD)--the principal disruptive behavior disorders. I describe assessments that a general pediatrician can perform as part of a preliminary evaluation and review some of the treatment options.
DEFINING THE PROBLEM
Disruptive behavior disorders are occasionally referred to as "externalizing disorders" because they commonly affect the world around the person rather than manifesting as internal psychic distress.
The DSM IV-TR criteria for ODD and CD are listed in Tables 1 and 2.1 Familiarity with these criteria can help you recognize a patient whose behavior is not normal.
Oppositional defiant disorder. "Chris"--the adolescent described in the first scenario--demonstrates most features of ODD. According to the DSM-IV, ODD affects 2% to 16% of the population.1 Those most often affected come from troubled families or have at least 1 parent with a history of a mood disorder, ODD, CD, substance use disorder, attention deficit disorder (ADD), or antisocial personality disorder.
ODD generally presents by early adolescence. Limited studies suggest that earlier emergence predicts a more severe course. Oppositional and defiant behavior can manifest in specific situations (such as around only teachers, parents, or law enforcement officers) or it can be seen as pervasive (around all authority figures).
Several features distinguish ODD from normal adolescent rebellious behavior. ODD behaviors tend to occur with regular frequency and lead to more serious social and occupational consequences than does simple adolescent "acting out." Such behaviors usually begin well before puberty and are present for at least 6 months. Therefore, a teen who suddenly begins to demonstrate some short-lived mild oppositional behavior would probably not meet true criteria for ODD.
Conduct disorder. "Jason's" history, as outlined in the second vignette, suggests that he has CD. CD is a distinct disorder from ODD, but it often develops in teens who have a preexisting untreated ODD. The key feature that distinguishes CD from ODD involves the violation of either the basic rights of others or societal norms and rules. The disorder is graded (mild, moderate, severe) based on the frequency and/or the severity of these violations.
CD presents much more commonly in males than in females. Between 1% and 10% of the overall population may be affected. Risk factors include having a parent with CD, ADD, mood disorders, or antisocial personality disorder.1
CD can present during childhood or adolescence. Its severity is predicted by a younger initial presentation and a longer duration of symptoms.
Simply interviewing a teenager with a disruptive behavior disorder rarely reveals the depth of the problem. Most teenagers either deny that a problem exists or they demonstrate poor insight into how their actions are affecting others. Therefore, the history must be collected from more reliable sources--such as parents, teachers, parole officers, and therapists.
The goal of evaluation is to recognize when the problem behaviors transcend the spectrum of normal adolescent development. The primary care clinician does not necessarily need to formulate a concrete psychiatric diagnosis, but it is particularly important to screen for comorbid conditions that can mimic, contribute to, or exacerbate the disruptive behavior disorder.
Comorbid learning disorders. Teenagers may demonstrate ODD symptoms in school or at homework time when they become frustrated by a learning environment that does not meet their needs. Therefore, referral for psychoeducational testing can uncover problems in information processing, reading, expressive abilities, or deficits in cognitive intelligence. A comprehensive evaluation also includes screening for mild pervasive developmental disorder as well as audiologic screening for hearing deficits or receptive language deficits.
Many local governments have enacted legislation that requires the school system to provide these evaluations at the parents' request. If your patient's local school system does not provide this service--or the parents mistrust the validity of the school's evaluation--then referral to a private testing program is a reasonable (albeit often expensive) alternative.
Attention deficit and hyperactivity disorder (ADHD). Approximately half of the population with ODD or CD probably has comorbid ADHD. While ADHD itself probably does not cause CD, data suggest that ADHD (especially the hyperactive and impulsive subtypes) may portend a more severe course of CD. This is important because ADHD is largely treatable. Controlling its symptoms may ultimately modulate the potential severity of the CD.
The American Academy of Pediatrics has developed an ADHD toolkit that contains the Vanderbilt Assessment Survey. This screen surveys a patient's parents and teachers regarding symptoms of ADHD (and its subtypes), CD, ODD, depression, and anxiety and depressive disorders. I advocate use of this toolkit in the office because the forms can be completed while the family is in the waiting room (thus saving the practitioner valuable time). The parents and patient can complete the forms at home and teachers can also contribute input by completing forms at school. Remember, however, that the scales are primarily an organizational tool and do not replace a thorough history and physical examination.
The Vanderbilt Assessment Survey can be obtained online from the American Academy of Pediatrics at www.aap.org.
Mood disorders. Depression can make an adolescent irritable, which, in turn, can exacerbate oppositional and defiant behavior. Studies demonstrate that when depression complicates CD, the risk of suicide and substance abuse increases substantially. If the intensity of the disruptive behavior fluctuates with depressive symptoms, aggressive treatment of the mood disorder may minimize the disruptive actions. In general, mood disorders are largely pharmacologically treatable entities. A delay in treatment can significantly affect the adolescent's present and future well-being.
When screening depressed persons for mood disorders, be sure to inquire about mania within bipolar disorder. Bipolar disorder often coexists with CD. The term "dysphoric conduct disorder" is occasionally used to describe the irritable temper outbursts (seen in juvenile mania) that can manifest as threats or violations against others. There is also some speculation that the grandiosity and elation accompanying mania might reduce the inhibitions to commit serious crimes and violations seen in CD. Whether bipolar disorder leads to conduct disorder (or vice versa) is unclear, but symptoms of florid mania warrant urgent psychiatric evaluation and mood stabilization.
Substance use disorders. When screening a patient for a disruptive behavior disorder, consider the possibility of a comorbid substance abuse disorder. The association between substance abuse and disruptive behavior disorders has been well studied and documented, although data do not clearly demonstrate a causal relationship between the two.
Ask the patient whether he or she uses or has experimented with substances beyond the "traditional" drugs of abuse, such as ethanol and marijuana. Inquire about use of over-the-counter drugs of abuse (eg, dextromethorphan abuse known as "Robotripping"), inhalant abuse, club drugs (eg, methamphetamine, gammahydroxybutyrate, MDMA, ketamine), hallucinogens (eg, LSD) or even abuse of prescribed medications (eg, nasal inhalation of methylphenidate).2
REFERRAL AND TREATMENT
When you suspect or have diagnosed a disruptive behavior disorder and its comorbidities, refer the patient to a mental health specialist with experience in managing the behaviors. The patient who presents with uncontrolled aggression may warrant hospitalization to protect himself and those around him.
Generally, patients with ODD or CD require multidisciplinary care that involves psychiatric consultation combined with individual, family, and group therapy. Patients with severe disruptive behavioral symptoms occasionally need long-term structured care in a residential or day-treatment setting. Local juvenile justice systems frequently are enlisted to enforce the patient's adherence to the program.
Physicians who have a special interest and expertise in psychopharmacology may wish to remain involved with the patient's care--especially when treating the above-mentioned comorbidities. Many pediatricians have considerable expertise in treating ADHD and depression and may continue as part of the treatment team by prescribing the appropriate stimulant or antidepressant medication. However, I recommend that treatment of patients with complicated mood disorders and substance use disorder be conducted in consultation with a child psychiatrist who can oversee the administration of atypical antipsychotic medications and mood stabilizers.
Data on long-term prognosis for those with disruptive behavioral disorders are limited. Anecdotal data suggest that intensive treatment with stimulants (especially for those with comorbid ADHD) and mood stabilizers improves long-term outcomes. School-based interventions--such as bullying reduction programs--have produced mixed results. The most successful interventions involve family therapy and programs that "train" parents to manage their child's behavior. In addition, multimodal interventions that address all aspects of the adolescent's life (eg, family relationships, peer relationships, school failure, mood disorders, vocational training) have demonstrated both efficacy and cost-efficiency. However, most experts agree that considerable research still needs to be done to definitively determine which programs best curtail the development and severity of disruptive behavior disorders.
Disorders usually first diagnosed in infancy, childhood, or adolescence. In:
DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders.
4th ed. Washington, DC: American Psychiatric Association, 2000:93-102.
Reitman DS. "Club" drugs 101: substance use and abuse for 21st century pediatricians.
Consultant For Pediatricians.