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Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in Children and Adolescents: Diagnosis and Treatment

by Jim Chandler, MD, FRCPC

Oppositional Defiant Disorder (ODD) 1

What is it? 1

Conduct disorder 11

Prognosis and Course of Conduct Disorder 17

Long term outcome of ODD/CD. 19

What can be done? 22

Non-Medical Strategies for ODD and CD. 23

Medical Interventions 28

Putting it all together 46

Oppositional Defiant Disorder (ODD)

What is it?

ODD is a psychiatric disorder that is really just the far end of the stubbornness spectrum. The line that divides being just difficult and stubborn from ODD is a set of diagnostic criteria.  The criteria for ODD are:

A pattern of negativistic, hostile, and defiant behavior lasting at least six months during which four or more of the following are present:

1. Often loses temper

2. often argues with adults

3. often actively defies or refuses to comply with adults' requests or rules

4. often deliberately annoys people

5. often blames others for his or her mistakes or misbehavior

6. is often touchy or easily annoyed by others

7. is often angry and resentful

8. is often spiteful and vindictive

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

How often is "often"?

All of the criteria above include the word "often". But what exactly does that mean? Recent studies have shown that these behaviors occur to a varying degree in all children. These researchers have found that the "often" is best solved by the following criteria.

Has occurred at all during the last three months-

8. is spiteful and vindictive
5. blames others for his or her mistakes or misbehavior

Occurs at least twice a week

6. is touchy or easily annoyed by others
1. loses temper
2. argues with adults
3. actively defies or refuses to comply with adults' requests or rules

Occurs at least four times per week

7. is angry and resentful
4. deliberately annoys people

What causes it?

No one is every going to discover the “cure” for ODD because there isn’t just one cause. It takes quite a few risk factors to develop the disorder. The more risk factors, the more chances the child will have it. No one factor will cause it. ref

Biologic Risk Factors

Genetics- Being oppositional is a strongly inherited trait.

Pregnancy- It turns out smoking during pregnancy is a significant risk factor for ODD. This alone should stop every women from smoking! (30) Fetal alcohol Syndrome is another common risk factor for ODD.

Psychologic Risk Factors

Living in an abusive home, not having two biologic parents, multiple separations, and poor attachment to your parents are known risk factors

Social Risk factors

Poverty, lack of community, uninvolved parents, lots of violence, child abuse, substance abuse, and inconsistent parenting are a few

How can you tell if a child has it?

ODD is diagnosed in the same way as many other psychiatric disorders in children. You need to examine the child, talk with the child, talk to the parents, and review the medical history. Sometimes other medical tests are necessary to make sure it is not something else. You always need to check children out for other psychiatric disorders, as it is common the children with ODD will have other problems, too.

Diseases that look like ADHD and ODD

There are a number of sleep disorders which can look like ODD or make it worse. This information is in the a separate


 pamphlet. Click here to go there.

Who gets it?

A lot of children! This is the most common psychiatric problem in children. Over 5% of children have this. In younger children it is more common in boys than girls, but as they grow older, the rate is the same in males and females.

ODD rarely travels alone - Comorbidity

It is exceptionally rare for a physician to see a child with only ODD. Usually the child has some other neuropsychiatric disorder along with ODD. The tendency for disorders in medicine to occur together is called comorbidity.

Common patterns of comorbidity

ODD plus ADHD

If a child comes to a clinic and is diagnosed with ADHD, about 30-40% of the time the child will also have ODD (1). Here are some examples of how this looks across ages.

Pre School Marianne

Marianne is now 4 years old. Her parents were very excited when she turned four that perhaps that would mean that the terrible twos were finally over. They were not. Her parents are very grateful that the Grandparents are nearby. The grandparents are grateful that Marianne's aunts and uncles live nearby. Marianne's Aunt is grateful that this is her niece, not her daughter. Why? Marianne requires an incredible combination of strength, patience, and endurance.

Marianne begins her day by getting up early and making noise. Her father unfortunately has mentioned how much this bothers him. So she turns on the TV, or if that has been mysteriously disconnected, bangs things around until her parents come out. Breakfast is the first battleground of the day. Marianne does not like what is being served once it is placed in front of her. She seems to be able to sense how hurried her parents are. When they are very rushed, she is more stubborn and might refuse it altogether. It would be a safe bet that she would tell her Mom that the toast tastes like poop. This gets her the first “time out” of the day.

In the mornings she goes to pre-school or goes off with her grandmother or over to her aunts. Otherwise Marianne's mother is unable to do anything. Marianne can not entertain herself for more than a few moments. She likes to spend her time purposefully annoying her mom, at least so it seems. Marianne will demand over and over that she wants something. For example, playdough. She knows it must be made first. So her mom finally gives in and makes it. Marianne plays with it about one minute and says, " Let’s do something" . Her mother reminds her that they are doing something, the very thing that Marianne has been demanding for the last hour. " No, Lets do something else"

So after Marianne's mother screamed so hard she was hoarse when her husband came home, Marianne gets to go out almost every morning. At preschool she is almost perfect, but will not ever do exactly what the teacher wants. Only once has she had a tantrum there. Marianne gets along with the other children as long as she can tell them what to do.

Her grandmother and Aunt all follow the same “time out” plan. This means she goes to a certain room until she calms down. The room is empty now at Marianne's grandmother. Marianne broke the toys, and they were removed. She banged the furniture around and it was removed. What sets Marianne off is not getting to do what Marianne wants. She screams, tells people she hates them, and swings pretty hard for a four old. After a half hour it is usually over, but not always. Marianne will usually tell her mom or Grandmother about these tantrums. The story is always twisted a little. For example, Marianne will tell her Grandmother that her mom locked her in her room because she was watching TV. Her grandmother used to believe these stories, and Marianne could tell the whole story of how she was watching this show, and her mom just came in and dragged her to her room. Now it turns out that Grandma doesn't think much of TV anyways, and so this made a certain amount of sense to her. This led to more than one heated argument between the Grandma and her mom. Of course there was almost no truth to this at all. It took the tables being turned for the Grandma to really believe that her Granddaughter could set up an argument like this. Marianne came home and told her mom that Grandma let her eat four cookies and an ice cream cone for a treat and that she was very full. Marianne's mom doesn't think much of treats, and could see how this might happen and thought she would have to talk to her mom. Finally they both realized what Marianne was doing.

Most of the afternoon with Marianne is spent chasing her around trying to wear her out. It doesn't seem to work, but it is worth a try. When she is at her aunts, she tries to wreck her cousin’s stuff. When is she good? When there are no other cousins around and she has the complete attention of her Aunt or Grandpa.

Marianne loves the bedtime battle. She also loves to go to the Mall. But she never gets to go there or hardly anywhere else. She acts up so badly that her family is very embarrassed. Her mother shops and visits only when Marianne goes to preschool. It is hard to know who is more excited about Marianne going to school next year, her mother or Marianne!

Elementary School Ryan

Ryan is 10. Ryan's day usually starts out with arguing about what he can and can not bring to school. His mother and his teacher have now made out a written list of what these things are. Ryan was bringing a calculator to school and telling his teacher that his mother said it was alright. At first his teacher wondered about this, but Ryan seemed so believable. Then Ryan brought a little (Ryan's words) knife. That lead to a real understanding between the teacher and Ryan's mother.

Ryan does not go to school on the bus. He gets teased and then retaliates immediately. Since it is impossible to supervise bus rides adequately, his parents and the school gave up and they drive him to school. It is still hard to get him there on time. As the time to leave approaches, he gets slower and slower. Now it is not quite as bad because for every minute he is late he loses a dime from his daily allowance. Once at school, he usually gets into a little pushing with the other kids in those few minutes between his mother's eyes and the teacher's. The class work does not go that badly now. Between the daily allowance which is geared to behavior and his medicine, he manages alright. This is good for everyone. At the beginning of the school year he would flip desks, swear at the teacher, tear up his work and refuse to do most things. Looking back, the reasons seem so trivial. He was not allowed to go to the bathroom, so he flipped his desk. He was told to stop tapping his pencil, so he swore at the teacher.

Recess is still the hardest time. Ryan tells everyone that he has lots of friends, but if you watch what goes on in the lunch room or on the playground, it is hard to figure out who they are. Some kids avoid him, but most would give him a chance if he wasn't so bossy. The playground supervisor tries to get him involved in a field hockey game every day. He isn't bad at it, but he will not pass the ball, so no one really wants him on his team.

After school was the time that made his mom seriously consider foster care. The home work battle was horrible. He would refuse to do work for an hour, then complain, break pencils and irritate her. This dragged 30 minutes of work out to two hours. So, now she hires a tutor. He doesn't try all of this on the tutor, at least so far. With no home work, he is easier to take. But he still wants to do something with her every minute. Each day he asks her to help him with a model or play a game at about 4:30. Each day she tells him she can not right now as she is making supper. Each day he screams out that she doesn't ever do anything with him, slams the door, and goes in the other room and usually turns the TV on very loud. She comes up, tells him to turn it down three times.  He doesn't and is sent to his room. She calculated that she has made about 1500 suppers since he was five years old. Could it be that they have gone through this 1500 times? She decides this is not a good thought to follow through. After supper Ryan's dad takes over and they play some games together and usually it goes fine for about an hour. Then it usually ended in screaming. So Ryan's grandmother had the bright idea of inviting them over for desert at about 8:00 pm most nights. But what about days when there is no school? Ryan's parents try very hard not to think about that.

High School Tasha

Tasha is 15. She is in ninth grade and from her marks, you would say there is no big problem. She is passing everything, but her teachers always comment that she is capable of much more if she tried. If they gave marks for getting along with others, it would be a different story. Tasha's best friend is currently doing a 6 month sentence for vandalism and shoplifting. Tasha and Sylvie have been friends since fall, if you can call it that. Since Tasha has almost no other friends, she will do anything to be Sylvie’s friend. At least that is what her parents think. Tasha thinks it is "cool" that Sylvie is at the Shelbourne Youth Centre. One sign of this friendship was that Tasha almost always gave her lunch money to Sylvie. Why? Because Sylvie wanted it. Tasha thought that Sylvie was her friend, but everyone could see that Sylvie was just using her. What seemed saddest to Tasha's parents is that Tasha could not see this at all. But this was nothing new. She would make a friend, smother them with attention, and that would be the end of it. Or, the friend would not do exactly what Tasha wanted and there would be a big fight, and it would be over. But mostly Tasha complained that everyone bugged her. What seemed to save Tasha was the nursing home. Somewhere along the way Tasha got involved working there. To hear the staff there talk about her, you would never guess it was the same girl. Helpful, kind, thoughtful - they couldn't say enough good about her. In fact her parents joked that maybe if they all moved to the nursing home, it would stop the fighting at home. They figured it out when another teenager volunteered to help one of the same afternoons as Tasha. Unfortunately the "other" Tasha came out. She was tattling, annoying, disrespectful and hard to get along with. Tasha could get along with any one, as long as they weren't her age, a teacher, or a relative!

 These examples stress some of the common features of this comorbid combination. Extremely major social problems with relatively little academic problems are not uncommon. Recent research suggests that all things being equal, girls with ODD plus ADHD have significantly worse social problems than boys with ODD plus ADHD (2). Tasha in the above example illustrates this.

ODD plus Depression/Anxiety

This is the other common combination with ODD. If you look at children with ODD, probably 15-20% will have problems with their mood and even more are anxious. (1) Here are some examples of how this can present

Preschool -Arriane

Arriane is 4. She has not been an easy child. Her mom does not like to compare children, but it is hard not to! Her brother is easy to get along with, excited, and energetic. She expected to have arguments with Arriane about doing a chore or task, but she ends up having an argument with Arriane about doing something fun! Arriane's first response to almost any activity is "No, I don't want to". Her mother has learned that if she can get Arrianne out the door and to pre-school, for example, she does quite well once she is there. That is, as long as everything is going her way. It does not take much of a problem for Arriane to lose her temper. Two days ago she was called to preschool when another boy bumped Arriane and she dropped her cheese and cracker on the carpet. Arriane belted the child and screamed "I hate you, I hate this place, I hate it!" until her mother came. Of course the next day she was back again and things were going alright. Arriane's mother has some unusual memories, or at least she thinks so. She remembers last fall when they took Arriane horseback riding for the first time. Arriane's face showed true joy for a whole hour. Her mother did not know whether to cry or not, as she could not remember such an expression on her child's face before for more than a few moments. That memory makes her hopeful that somehow she can bring that joy back to Arriane.

It is not an easy task. The combination of being irritable and oppositional tests everyone's patience. She did not realize how stressful it was until she started bringing Arriane to a babysitter so she could go out and visit her friends. Finally she did not have to be thinking about how to keep Arriane from losing it every minute. She is finally coming to the decision that try as she might, she can not make Arriane's life as smooth as Arriane wants it.

Elementary School Rick

Ricky is 11 years old. Ricky spends a lot of time in his room doing legos and making models. Then, all of a sudden there is a scream and stuff gets thrown around. If his parents are so unwise as to go up there, they will get to hear Ricky say that he hates this world, hates legos, and hates this stupid model. Then he will usually look up and say something awful to his parents. That is why they just leave him up there. He comes home from school crabby and throws his homework down and goes up plays in his room. His parents realize that he needs to get out and do something, but the only thing they can ever get him to do is go lift weights at the YMCA. Ricky's father has absolutely no interest in lifting weights, but he has done a pretty good job of convincing Ricky that he likes to go. That gets him out of the house about three times a week. As far as playing with other kids, unless his cousins come over, he won't play with anyone. His parents used to ask why and the answer was because no one likes me. Sad to say, it is not hard to figure out why Ricky would have that idea. When a friend comes over, he is so demanding and insists that the child do things just the way Ricky wants. Usually Ricky ends up sulking part of the time when he doesn't get his way. So now, his mom invites friends over for Ricky, but she plays right along side of the friend and Ricky. At least they aren't scared off that way. At school, it is even worse. Everyone seems to know how easy it is to get Ricky to loose his temper. It happens almost every day. He bangs the desk, takes a swing at someone, swears, or kicks them. He is usually caught, and since he is so irritable anyway, the teachers hear a fair amount of defiance. Amazingly, he does pretty well in school once he gets going on something. This year he has changed classes. His old teacher was humble enough to admit that Ricky had pushed her too far and she could not take it any longer. She said she just could not remain professional. Ricky's mom knows how that could happen. Sometimes she just takes off for a walk when Ricky is driving her nuts. She knows she shouldn't leave him alone at home, but she figures if she doesn't go out in the woods for a walk there would be far greater dangers awaiting Ricky at home than if he was there alone. Ricky mostly wishes people would just stop bugging him. Once in awhile, right before bed, Ricky will ask him mom if it hurts to die or what it is like to be dead. She can't tell if he means it or is just saying that to bug her. She is afraid to even think about it.

High School Justin

Justin is now 18. Things are going great for Justin this year. He is back in school, off drugs, and actually is getting along with his parents. In fact, he actually missed them when they went away. He has been helping his Dad put up dry wall after school. Both he and his parents are grateful for his recovery, but they wished they could have picked it up earlier, like when he was 12 or 13. That's when things really started to get worse. Justin had always had a hot temper and still does, but then it was unreal. At age 12 his parents would not let him go to a dance. He broke all the windows in their car. He lasted two months in 8th grade before he was suspended for fighting. Justin lost the few friends he had by getting kicked off the hockey team. He swore at a judge during a probation hearing and got two months in the Youth Centre which was extended to six months after he tried to attack a guard. All the while he was so irritable and never happy. When he came home from the Youth centre he wanted to be able to drive. They said no, and he decided that was it and went out to hang himself in the barn. His parents still remember those words, "You'll all be f-ing better off without me and if you come after me I'll f-ing kill you, too". That horrible day was the turning point. It took five mounties to get him to go to the hospital. It took a careful evaluation to figure out that he wasn't just oppositional , stubborn, and hot headed. He was very depressed, too. Now after 6 months of medical and non-medical interventions, he is 100% better. Justin admits that if he had to go back to living the way he was, he'd start thinking of suicide.

These examples show how very difficult the combination of ODD and depression can be for the family and the child. Often the depression gets mixed in the midst of dealing with the aggression and defiance. I commonly run across children like Justin who have been oppositional and depressed but no one ever notices the depression until they make a suicide attempt. Looking for depression in ODD youth is very important, (see treatment section)

What happens to children who have this when they grow up?

There are three main paths that a child will take.

First, there will be some lucky children who outgrow this. About half of children who have ODD as preschoolers will have no psychiatric problems at all by age 8.(19)

 Second, ODD may turn into something else. About 5-10 % of preschoolers with ODD will eventually end up with ADHD and no signs of ODD at all. (19) Other times ODD turns into conduct disorder (CD). What predicts a child with ODD getting CD? A history of a biologic parent who was a career criminal, and very severe ODD.

 Third, the child may continue to have ODD without any thing else. However, by the time preschoolers with ODD are 8 years old, only 5% have ODD and nothing else.

Fourth, They continue to have ODD but add on comorbid anxiety disorders, comorbid ADHD, or comorbid Depressive Disorders. By the time these children are in the end of elementary school, about 25% will have mood or anxiety problems which are disabling. (14) That means that it is very important to watch for signs of mood disorder and anxiety as children with ODD grow older.

Will children with ODD end up as criminals?

Unfortunately, severe and early onset ODD does predict getting conduct disorder in adolescence, and some of those become criminals. In other words, if you take 100 children in grade 1 with ODD, roughly 30 will have conduct disorder as teenagers, and about 10 will be criminals as adults. (31)

What is the difference between ODD and ADHD?

ODD is characterized by being oppostional, but not impulsiveness. In ODD people annoy you purposefully, While it is usually not so purposeful in ADHD. ODD signs and symptoms are much more difficult to live with than ADHD. Children with ODD can sit still.

What difference does it make if you have ADHD or ADHD plus ODD?

A lot! Children and adolescents with ADHD alone do things without thinking, but not necessarily oppositional things. An ADHD child may impulsively push someone too hard on a swing and knock the child down on the ground. She would likely be sorry she did this afterward. A child with ODD plus ADHD might push the kid out of the swing and say she didn't do it.

My child has been diagnosed with ODD. I don't like to say this, but no one can stand him. Is this common?

Unfortunately, it is quite common. In comparison to ADHD alone, children and adolescents with ODD plus ADHD or just ODD are much more difficult to be with. The destructiveness and disagreeableness are purposeful. They like to see you get mad. Every request can end up as a power struggle. Lying becomes a way of life, and getting a reaction out of others is the chief hobby. Perhaps hardest of all to bear, they rarely are truly sorry and often believe nothing is their fault. After a huge blow up, the child with ODD is often calm and collected. It is the parents who look as they are going to lose it, not the child. This is understandable. The parents have probably just been tricked, bullied, lied to or have witnessed temper tantrums which know no limits.

My father in law says the whole problem is my husband and I. My daughter convinced him that she is a victim of uncaring parents. How often does this happen?

Too often! Children and adolescents with ODD produce strong feelings in people. They are trying to get a reaction out of people, and they are often successful. Common ones are: inciting spouses to fight with each other and not focus on the child, making outsiders believe that all the fault lies with the parents, making certain susceptible people believe that they can "save" the child by doing everything the child wants, setting parents against grandparents, setting teachers against parents, and inciting the parents to abuse the child. I frequently see children with ODD in which teachers and parents and sometimes others are all fighting amongst each other rather than with the child who is causing all the turmoil in the first place.

Conduct disorder

In some ways, conduct disorder is just a worse version of ODD. However recent research suggests that there are some differences. Children with ODD seem to have worse social skills than those with CD. Children with ODD seem to do better in school. (1). Conduct disorder is the most serious childhood psychiatric disorder. Approximately 6-10% of boys and 2-9% of girls have this disorder.

Here is the Definition.

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major society rules are violated. At least three of the following criteria must be present in the last 12 months, and at least one criterion must have been present in the last 6 months.

Aggression to people and animals

often bullies, threatens, or intimidates others

often initiates physical fights

has used a weapon that can cause serious physical harm to others (a bat, brick, broken bottle, knife, gun)

physically cruel to animals

physically cruel to people

has stolen while confronting a victim ( mugging, purse snatching, extortion, armed robbery)

Destruction of property

has deliberately engaged in fire setting with the intention of causing serious damage

has deliberately destroyed other's property other than by fire setting

Deceitfulness or theft

has broken into someone else's house, building or car

often lies to obtain goods or favors or to avoid work

has stolen items of nontrivial value without confronting a victim (shoplifting, forgery)

Serious violations of rules

often stays out at night despite parental prohibitions, beginning before 13 years of age

has run away from home overnight at least twice without returning home for a lengthy period

often skips school before age 13

B. The above problem causes significant impairment in social , academic, and occupational functioning.

So how are ODD and CD related?

Currently, the research shows that in many respects, CD is a more severe form of ODD. Severe ODD can lead to CD. Milder ODD usually does not. The common thread that separates CD and ODD is safety. If a child has CD there are safety concerns. Sometimes it is the personal safety of others in the school, family, or community. Sometimes it is the safety of the possessions of other people in the school, family or community. Often the safety of the child with CD is a great concern. Children with ODD are an annoyance, but not especially dangerous. If you have a child with CD disorder in your home, most likely you do not feel entirely safe. Or, you do not feel that your things are entirely safe. It is the hardest pediatric neuropsychiatric disorder to live with as a sibling, parent, or foster parent. Nothing else even comes close. It is worse than any medical disorder in pediatrics. Some parents have told me that at times it is worse than having your child die.

Conduct Disorder and comorbidity

It has been common in the past for people to think that conduct disorder is just the beginning of being a criminal. Up until the last few years, children with conduct disorder were often "written off". It is now clear that this is true only with a minority of cases. It is very easy to focus on the management of the CD child and forget to check the child out for other neuropsychiatric disorders. A careful examination of children with CD almost always reveals other neuropsychiatric disorders. Some of the most exciting developments in this area of medicine involve understanding these phenomena. It is called comorbidty, that is the tendency for disorders to occur together.

It is very common to see children with CD plus another one or two neuropsychiatric diagnoses. By far the most common combination is CD plus ADHD. Between 30-50% of children with CD will also have ADHD (1). Another common combination is CD plus depression or anxiety. One quarter to one half of children with CD have either an anxiety disorder or depression (3). CD disorder plus substance abuse is also very common. Also common are associations with Learning Disorders, bipolar disorder and Tourettes Syndrome. It is exceptionally rare for a child to present for evaluation by a pediatric psychiatrist to have pure CD. Here are some examples of the comorbid presentations.

Looking for comorbid disorders in every child with conduct disorder is absolutely essential. Many of the treatments of these children depend on what comorbid disorder is also present.

CD plus substance abuse

Sadly, this is very common. In my clinic, every child with CD is assumed to be abusing substances until proven otherwise. Compared with children who do not have CD, children who have CD are three times more likely to smoke cigarettes, 2.5 times more likely to drink, and five times more likely to smoke pot. As far as having a problem from drug use, children with CD a 5.5 times more likely to be addicted to cigarettes, six times more likely to be alcoholics, 7 times more likely to be addicted to pot. (16)This is certainly the most common comorbidity and often goes along with the one's below.

Terry

When Terry was 9, he told his mom that he wanted to buy lunch instead of bring it. His mom at that point still believed that some of what Terry said was innocent of any other purpose, and so she let him. She did notice that he was very hungry when he came home from school. He said the lunches were small and for an extra 75 cents he could get seconds. She believed this. Two weeks later the principal called to report that Terry was caught with cigarettes on the playground. Terry's mom was amazed, as she did not smoke and neither did her husband. Not only that, but he had a whole pack. Well, it took a lot of "interrogation" to get the story out. The lunch money went to buy cigarettes from a boy in Jr. High. Terry then smoked a few of those and then sold the rest at a big profit. His parents remembered that two years later when he was found drunk in the locker room at Jr. High. Now his parents are lots wiser. Terry still thinks his parents are totally unreasonable. The rule is you get your allowance and phone privileges as long as those random urine drug screens are normal. If he doesn’t cooperate, then they are assumed to be positive. So he ended up poor and lonely for a few weeks, but now that is under control. As far as cigarettes go, if he can buy them, he can smoke them outside. If he is caught drinking or around people who are drinking, good-bye allowance and phone. Terry hates it and can't wait until he moves out so he can finally do what he wants.

ADHD plus CD

When these two disorders are present, usually the ADHD symptoms are much more severe than when ADHD is present without CD (1) .

Stephen

Stephen is now 14. When his mother thinks back to his infancy, she could actually see it coming at age 18 months. At that age he got up in the middle of the night, put a chair up to the door, opened it and went walking outside. The Mounties found him a while later and brought him home. If only that had been his only contact with them!

Stephen's mother hated school almost as much as Stephen did. Almost every day there were calls from the school about Stephen. In grade primary he tried to stab a child with scissors. He was swearing at his teachers by grade one. On Grade two it was stealing lunch money. Every time they seemed to get one problem under control, he was into something else. Everyone seemed at a loss about what to do except her brother, who took him  Irish mossing every chance he could. It didn't matter what the weather was like, Stephen was out there. His uncle said that by the time he was ten, he could do the work of a grown man. There was no fear in Stephen. Cold weather, big swells, nothing bothered him. He refused to do any homework from fourth grade on. Up until that grade, his teachers let him go out for a walk around the building every hour or so, but when a set of keys went missing and were "discovered" by Stephen a few days later, the walks ended. Still, compared to the last few years, this was easy.

Stephen was suspended from 7th grade after two weeks when he threw a match into a boy's locker. Why? The boy called him stupid. He was out for a week, then after only two more days, he was thrown out for making death threats against the teacher. His parents tried home school and they thought they were getting somewhere. Until they got a call from the bank. They were overdrawn. When it all came out Stephen had stolen the cash card and figured out the password and had taken out $500 dollars. They still don't know how he did it. Before they could even sort that out, Stephen was arrested for vandalizing the school. He would have only received probation, but after giving the judge the finger, he was sent to the Shelbourne Youth Centre. It was the staff there that finally figured it out. This guy could not sit still for anything, he said the first thing that came to his mouth, and was constantly getting in bigger trouble for it. He saw the doctor, ADHD was diagnosed, and he was given medication for this in the Youth Centre. But what will happen in two months when he gets out? His motherShe spends a lot of sleepless nights thinking about that.

CD and depression

Charlene

Charlene is 14, too. Her life didn't start out quite so difficult. In fact, her mom swears that until she was almost 10, there were no problems. That is hard for everyone to believe now. Her mom remembers thinking that Charlene was certainly starting the teen years early. At age 11 she was having a tantrum about not being able to go out with her boyfriend who was 15. You could hardly blame her. By the time Charlene was 11, she looked like she was 15 or 16. Unfortunately, she did not have the maturity of a 16 year old. She ran away from home at age 12 for a week before they could find her. She brought a bottle of rum to school and got drunk. But more than this, she was absolutely unbearable to live with. She had become super defiant, and would fight her parents or anyone else for no reason at all. She never seemed happy, just angry. Unless she was with her friends, which by age 13 or 14 were 18 or so. Her parents kept asking themselves, "what had happened to their old daughter?” She was failing in school mostly because she was never there. She was never where she told her parents she said she was. The first clue came when she came home high on something and told her parents she was going up stairs to bed. They heard a crash and came in the bathroom to find her trying to cut herself with a broken mirror. Charlene wanted to die. Her boyfriend of two months had left her. For a few weeks she just hung around the house and lay on her bed and listened to music. Her parents let her out one night to go to her girlfriend's house. They got a call later that night that Charlene had admitted to taking a half a bottle of Tylenol.

It is not uncommon that a mood disorder along with CD gets missed. There are usually so many pressing problems to sort out and so many different stressors, that it isn't until suicide is tried or talked of that many families, physicians, and other health professionals consider comorbid depression. Recent studies of teenagers who have committed suicide have found that these children are about three times more likely to have CD and 15 times more likely to abuse substances.(15) Suicide is worth worrying about in CD.

CD plus Tourettes, OCD, and ADHD

Marc

Marc is now 12. He has seen more doctors, nurses, and psychologists than most people will see in a lifetime. His father worried that maybe his son could have Tourette's like him, but he never dreamed it could get like this. When he was 4 he was thrown out of pre-school for fighting. Because of his reputation, he was the first child where the school approached the parents about getting a teacher's aide in grade primary rather than the parents approaching the school. Lucky for Marc, he never seemed to have all of these problems at once. Usually he would have a tic, especially blinking, which would last a few weeks or so. Then he would have to touch things, and then that might go away, too. The tics and OCD were nothing compared to his behavior. His temper was incredible. The usual pattern was that the excitement of being around other kids would get him so wound up that he was literally bouncing around. This usually led to pushing, fighting, and punishment. He resisted this and usually ended up being sent home as they could not deal with him. He attacked him sister. He attacked his mother and broke her arm. That led to living with different relatives and now a foster home. No one seemed to be able to manage him. The new foster parents were actually being bothered the most by his poor sleep and a nearly constant vocal grunting tic. They brought him to yet another doctor to see if they could do anything about this. He was placed on some medicine for the tic and amazingly, he behavior improved quite a bit. For the first time his parents are hopeful that maybe he can come home again.

Diagnosing Conduct Disorder

Conduct disorder is diagnosed like all things in pediatric psychiatry. The child and the caregivers will be interviewed together and separately to go over the history and check out all other possible comorbid conditions. Usually there are school reports, too. The child is examined to look for signs of many disorders. This usually includes some school work, some parts of the physical exam, and getting the child's perspective on things. Occasionally, there are lab tests and x-rays to do. Unfortunately, is no lab test that proves a child has Conduct disorder.

Prognosis and Course of Conduct Disorder

Perhaps about 30% of conduct disorder children continue with similar problems in adulthood. It is more common for males with CD to continue on into adulthood with these types of problems than females. Females with CD more often end up having mood and anxiety disorders as adults. Substance abuse is very common. About 50-70% of ten year olds with conduct disorder will be abusing substances four years later. Cigarette smoking is also very frequent. A recent study of girls with conduct disorder showed that they have much worse physical health. Girls with conduct disorder were almost 6 times more likely to abuse drugs or alcohol, eight times more likely to smoke cigarettes daily, where almost twice as likely to have sexually transmitted diseases, had twice the number of sexual partners, and were three times as likely to become pregnant when compared to girls without conduct disorder (6).

Looked at from the other direction, by the time they are adults, 70% of children no longer show signs of Conduct disorder. Are they well? Some are, but what often happens is that the comorbid problems remain or get worse. That is, a girl with CD and depression may end up as an adult with depression, but no conduct disorder. The same pattern can be true of CD plus bipolar disorder and other disorders. Here are some examples that illustrate this.

EXAMPLES

Trisha- ADHD plus CD as a child which eventually disappears

Age 4-12 Classic problems with aggressiveness towards others, hyperactivity, and impulsiveness along with running away and shoplifting

Age 12-16 ADHD symptoms become less prominent. Continued fights with teachers, shoplifting, and lying

Age 16-24 Fighting decreases, returns to school and succeeds.

Age 25-35 No sign of psychiatric problems.

Reggie- ADHD plus Conduct Disorder leads to similar problems as an adult (the minority of cases)

Age 3-7 Reggie shows lots of aggression and hyperactivity.

Ages 7-12 Besides being hyperactive, Reggie lies, cheats, steals, and eventually forces a child to take of their clothes

Ages 13-18 In and out of trouble with the law, and more involved with alcohol, Reggie quits school at age 16.

Age 18-24 Reggie has spent two years of the last six behind bars. He successfully stays off drugs and alcohol, but meets old friends, quits his job, and is back bootlegging again.

Sarah - CD with more and more signs of mood disorder. Eventually CD disappears

Age 4-12 Sarah slowly gets into more and more trouble with everyone. She starts to get irritable

Age 12-18 Sarah continues to have troubles with gambling, shoplifting, and vandalism. Occasional thoughts of suicide

Age 18-24 Sarah is hospitalized twice for depression, eventually recovers and seems to settle down

Age 24-50 A few more hospitalizations for post partum depression but no CD features.

Mitchell -Learning problems, CD, and drug abuse leads to schizophrenia

Age 4-12 Trouble in School, zero social skills, and constant conflict with family and peers

Age 13-18 Using drugs and occasionally hears voices and sees things. Goes away when he is clean

Age 18-30 Slowly but surely he gets the substance abuse under control. The hallucinations and unusual thoughts continue on and require medical treatment.

Jeff - CD plus ADHD leads to mania

Age 4-11 typical ADHD.

Age 12-14 Totally out of control. Assaults everyone, gets drunk, pulls fire alarms, attacks father, steals a car all in the space of a week. Diagnosed by a psychiatrist who visits the youth prison as manic.

Age 14-20 At least 10 episodes of mania and or depression. Hyperactivity and CD not present except while manic.

Long term outcome of ODD/CD

ODD/CD and Personality Disorder

This is one of the "labels" psychiatry uses to describe people who have traits in their personality that cause them major problems. These are not things that come and go but last for years and even decades. A person's personality starts to form as a teenager, and that is when we see personality disorders start to form. We have all met people with these types of problems. They fit into a few big categories that have lots of different names.

One group is people who are strange, different, and keep to themselves. This is called cluster A.  Another group is people who are dramatic, have lots of mood problems, are forever getting into trouble, and whose lives are quite mixed up. This is called cluster B. They are often very difficult to get along with over the long run. Another group are people who are withdrawn, scared, and have to do things a certain way. This is called cluster C.  When any of these problems screw up people's relationships, ability to work, get them in trouble with the law, or make them miserable, we call it a personality disorder.

Recent studies have shown that children who have certain psychiatric problems are much more likely to get personality disorders as adults. Children who have multiple psychiatric problems are even more at risk. Children who have ODD are about four times more likely to have a personality disorder when they grow up, that is about a 15% chance. If they already have some signs of personality disorder as a young teenager, they are 25 times as likely to have a personality disorder as adults. What this tells us is that the longer these problems go on in childhood and as teenagers, the more likely they are to lead to personality disorders as adults. (17)

There are two types of Personality Disorder in Cluster B which are especially associated with ODD/CD. These are Borderline Personality Disorder and Antisocial Personality Disorder.

Borderline Personality Disorder is called this because patients have many traits from different psychiatric disorders. They have very unstable moods, like bipolar disorder. They often have strange experiences, like people with schizophrenia. Their relationships with others are usually quite unstable. They often don’t have much of a sense of who they really are or where they are going. They often cut themselves. Most of the people with this problem are female. If you have ODD/CD and are female, you have approximately a 15% chance of getting this. (24)

Antisocial Personality Disorder is basically a continuation of Conduct Disorder. People with this problem continue to not respect the rights of others or their property. They continue to get in fights or worse. They often are stealing or cheating. Usually they are involved with the law. They have extremely high rates of substance abuse and high rates of suicide and other unnatural causes of death. This is primarily a male diagnosis. Almost 20% of teenagers with ODD/CD with have Antisocial Personality Disorder as a result. (24)

How bad are Personality Disorders?

If you have a personality disorder as a teenager, by the time you are a young adult, here are the chances that these bad  things will happen to you:

  1. Make a suicide attempt- 6-10%
  2. Serious assault on another 25-35%
  3. Not get as far in school as you should have been able to 25%
  4. Difficulties with interpersonal Relationships 20-30%
  5. Ending up with other Psychiatric problems 35-40%
  6. Having at least one of the above bad outcomes 70-80%
  7. Having at least two of the above bad outcomes 50% (25)

This seems really bad. Do people with personality disorders ever get better?

Yes, some personality disorders are much more likely to improve over time. After 15-25 years, only about 10% of adults who had Borderline Personality Disorder continue to have it. That means 90% got over it. Antisocial Personality disorder tends to improve, too. However, about 25% of people with Antisocial Personality Disorder die prematurely. Of those that do not die, most are better, but few have recovered completely.(26)

-ODD leading to personality disorder

Tina

When Tina was four or five, she pretty much controlled the house. Somehow she had figured out exactly what she could get away with. She also was able to figure out where her parent's weak points were. More amazingly, she figured out where the weak points in their marriage were. This got so bad that her parents went to marriage counseling and finally adopted a policy of "united we stand, divided we fall" in regards to Tina. This certainly helped keep Tina in line in her elementary school years. Tina also had ADHD, but it was never too severe. She only had to take medication for a few years at the end of elementary school. As she became a teenager, she began to have problems. The loss of a boyfriend led to cutting her wrists. She always was in some sort of turmoil with her friends or the youth group. People were always trying to "save" her. The school counselor and the youth group leader both "knew in their hearts" that Tina needed a lot of attention and special care and encouraged her parents to be more understanding on her sensitive nature. Tina's grandfather said that he "knew in his heart" that Tina needed a swift kick in the rear. As the teenage years went on, these problems just continued. She got involved in some minor crimes like shoplifting, tried vomiting to lose weight, and smoked pot. Each time she made such a big deal about the whole thing that her parents could hardly stand it. When she was 18, she moved in with an older guy who she thought "really understood her". They have been separated about six times so far. Her life continues in turmoil.

This points out the fact that sometimes, even with great parenting, things don't turn out so well. However, many times with aggressive intervention things go more like this-

Richard -

Richard was always hyper and always quite the con artist. The neighborhood moms never really trusted him. He got referred after he hit the teacher hard enough to knock her down in second grade. We did everything. He took medications for his ADHD. The parents followed through with every type of intervention for ODD. He was very involved in cadets as a teenager. When he was about 19, I met his mother in a store. She wanted to tell me how well he turned out. He was still a bit of a hot head and was still on meds for ADHD, but he was working and had a steady girlfriend. He was hoping to join the militia. Richard had turned out just fine.

 

Families and CD

It is not unusual to see signs of stress in the parents and other siblings when a child has CD. One of the hardest questions is figuring out whether or not difficulties in the family are causing CD or whether the stress of CD is causing family problems. Often it is impossible to determine this or there are reasons to suggest both the CD is casing the family problems and the family is causing the CD to be worse. . CD is a very difficult problem to live with. It would be very unusual to see a family where it was not causing grave distress. This obviously needs to be addressed in any treatment plan.

 Some of the things parents have told me about their conduct disordered child are noted below.

 "If you have a child with CD, everyone will initially assume it is your fault. You will be blamed by everyone for what the child does. You may know all about Family and children services, probation, youth court, residential homes, RCMP procedures, and mental health services. "

 "You will often have the feeling that no one knows what they are doing with your child and they are just trying to pass the buck to someone who does. "

 "You can end up divorced, depressed, alcoholic, hopeless, or all of these from dealing with such a child. It will often make or break your faith in yourself and your faith in God."

 "You can see yourself where the child's problems are leading, but can be unable to do anything about it or find anyone else who can do anything about it."

Don't give up! There is a lot to that can be done!

 

What can be done?

Over the last decade, many new strategies, both medical and non-medical) have been investigated for treating ODD and CDThere are hundreds of psychological techniques which have been tried, but none have been found to be always successful. They involve behavior modification, working with families, and tight supervision. the best results have been found with what is called multisystem therapy. What that means is, do a lot of different things at the same time. As far as this pamphlet goes, it means you should not rely on just one type of intervention. Ideally, you should use a little of all of them. Overall, since CD is usually just a very severe form of ODD, all of the below can be useful in CD. At the end of this section are some other suggestions for CD.

Treat Comorbid disorders

CD plus ADHD

Treating the comorbid disorders is absolutely key. Recent studies have shown that treating CD plus ADHD with stimulants helps the conduct disorder and the ADHD symptoms. This effect appears independent of how bad the ADHD is (4) Since 60-70% of children who go to a clinic for help with CD also have ADHD, this is extremely important. Serious consideration should be given to medically treating all children with CD plus ADHD. Although this type of medical intervention does not make the children "normal", it can make a big difference. It often means that the non-medical interventions will work much better.

CD plus depression

Recent work also suggests that treating depression in the context of CD be effective (5)While Prozac was used in this study, most likely other drugs in that same family would be effective. See details depression and its treatment in the Depression handout.

CD plus Substance abuse, movement disorders, bipolar disorder, psychosis, Pervasive Developmental Disorders

Although there is not as much data on these areas, it is a good idea to always vigorously treat any disorder comorbid with CD. The importance of treating comorbid conditions can not be overstated.

Non-Medical Strategies for ODD and CD

Containment

The essence of this group of interventions is to make it impossible for ODD to "work." That is, it is a way of making sure all these attempts to irritate and annoy others and to cause fighting between others are not as successful. There are three elements to this.

1. Come together

Children and adolescents with ODD convince mothers that fathers have mistreated them. They convince parents that the teachers are treating their child unfairly. They convince teachers that the parents are bad, etc. You have to come together and never believe anything the child with ODD tells you about how others treat them. In order to do this, all parties need to talk directly with each other without the child as an intermediary. Mothers need to talk face to face with fathers. Parents need to talk with teachers and with principals. Sometimes Parole officers, parents, teachers and others have to all sit down together for the purpose of making it impossible for the child to play one person or group off against another. Here are some concrete suggestions.

Ask to sit down with the principals and teachers regularly.

Make it school and home policy to never rely on information your child with ODD gives you about what others have done.

Do not include the child in these discussions.

Sit down with all caregivers (grandparents, uncles, baby-sitters, parents, etc.) to make sure they understand ODD and they follow the above policy.

2. Have a plan

That is, a plan to deal with all of this oppositional and defiant behavior. If you react on the spur of the moment, your emotions will guide you wrongly in dealing with children and adolescents with ODD. They will work to provoke intense feelings in everyone. Everyone needs to agree on what happens when the child with ODD does certain things. What do we do if she disrupts class, annoys others incessantly, fights, has a major temper tantrum, states she is going to kill herself or run away?

You need a behavior modification or management plan.

Is that what "1-2