Oppositional Defiant and Conduct Disorders
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Children and adolescent who are sullen, argumentative,
uncooperative, miss school, and lie about their
whereabouts, refuse to adhere to curfews, steal money
from home, etc. represent one of the
largest
group of
patients seen in child and adolescent mental health
settings.
They are usually labeled as suffering from oppositional
defiant disorder ODD), conduct disorder (CD), or
disruptive behavior disorder (DBD). The last term was
often used to include also children with ADHD.
D
i
s
r
u
p
t
i
v
e
b
e
h
a
v
i
o
r
d
i
s
o
r
d
e
r
(
D
B
D
)
ODD
CD
ADHD
Individuals with ODD and CD
share many characteristics
. For
example, their conduct is
socially unacceptable
, they cause
disruption or distress to others
more than to themselves (i.e.,
they “
externalize
” their problems), and they are more likely to
be
male
and to find it
difficult to learn from experience
.
5
Individuals with ODD and CD
differ
widely from one another:
they may be
aggressive or not
,
break the law or not
,
feel guilt
and empathy or not
, may be
sensation-seeking or not
.
Children with these problems are
heterogeneous
in relation to
etiology, natural history, response to treatment, and outcome.
6
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D
S
M
-
5
In DSM-5, ODD and CD have been placed in the chapter
“Disruptive, Impulse-Control, and Conduct Disorders”
together with conditions such as intermittent explosive
disorder, pyromania, kleptomania, and antisocial
personality disorder (ASPD).
This grouping seems to assume that these conditions—
involving problems with
self-control
that
impinge on
others
—are part of a continuum with ODD at one end
and ASPD at the other.
D
S
M
-
5
In DSM-IV, a diagnosis of CD pre-empted a diagnosis of
ODD; this exclusion has been removed in DSM-5. That is,
individuals can be diagnosed as suffering from
both ODD
and CD concurrently.
In DSM-5 in a subgroup of
anger/irritability and another
of argumentativeness/defiance
is supported by studies
showing that these behaviors tend to occur together and
predicted, respectively, internalizing and externalizing
behavior later on.
The specifier
“with limited prosocial emotions”
has been
added in DSM-5.
D
S
M
-
5
The specifier
“with limited prosocial emotions”
has been
added in DSM-5.
In recent years, there has been a resurgence in interest
on the traditionally described as “
psychopathic
” traits, in
the case of young people often referred to with the term
“
callous–unemotional
.” These youth are described in
DSM-5 as “with limited prosocial emotions.”
D
S
M
-
5
This label defines children and adolescents who show
lack of remorse and guilt
after doing something wrong,
appear
cold and uncaring
, show
no concern for the
feelings of others
, are
undaunted by their poor
performance at school
, and their
emotions appear
shallow or insincere
.
They
respond poorly to punishment
, show
lower cortisol
levels
,
seek novel, exciting, and dangerous activities
, are
prone to boredom
, and have
lower trait anxiety
than
other youth with the same level of conduct problems.
D
S
M
-
5
DSM-5 highlights that a diagnosis of CD should be made only
when the behavior in question is symptomatic of an underlying
dysfunction within the individual and
not simply a reaction to the
immediate social or cultural context
. This is to circumvent
concerns that a diagnosis of CD may at times be misapplied to
individuals in particular settings (threatening, impoverished, high
crime, war) where patterns of undesirable behavior could be
protective
.
This does not necessarily imply an absence of CD in those
settings, it only means that the
context
in which symptoms occur
needs to be taken into consideration.
E
P
I
D
E
M
I
O
L
O
G
Y
ODD and CD are
two to three
times more prevalent in
males
than females.
Recent surveys (mostly using DSM-IV criteria) in several
countries have produced reasonably consistent results
,overall, about
3%
of children aged 6 to 18 years met
criteria for ODD or CD in the previous 3 or 6 months.
E
T
I
O
L
O
G
Y
Heritability
of antisocial behavior has been estimated at
about
50%
, though it is not diagnosis specific. It appears
that what might be transmitted is a general liability to
externalizing disorders although there are also disorder-
specific liabilities (e.g., for ADHD).
Shared
environment
may specifically influence CD,
highlighting the importance of examining shared
environmental variables as processes underlying the
comorbidity among ODD and CD.
R
i
s
k
F
a
c
t
o
r
s
Risk factors include, among others, socioeconomic
disadvantage, exposure to
family violence and dysfunction
,
lower
IQ
, and
attentional difficulties
.
The accumulation of risk may not only act additively, but also
multiplicatively
.
Genetic influences are stronger in children from poor families
than in those from affluent backgrounds , genetic factors
influence individuals’choices and shaping of their own
environment .antisocial individuals are more likely to find
problematic partners (
assortative mating
).
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N
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c
h
o
l
o
g
i
c
a
l
A
s
p
e
c
t
s
Atypical frontal lobe activation
, as detected on EEG, is a
basis for negative affective style in children with ODD.
Positron emission tomography has shown violence to be
associated with decreased glucose metabolism in the
prefrontal cortex
.
Orbitofrontal
lobe damage has been linked to impulsive
aggression.
There is a suggested link between aggression and low
levels of
serotonin
in the CNS.
Children with ODD and CD have a
lower sensitivity to punishment
which may reduce their ability to associate inappropriate
behaviors and consequences (the result of
impaired fear
conditioning
,
reduced cortisol reactivity to stress
,
amygdala
hyporeactivity to negative stimuli
, and altered serotonin and
noradrenaline neurotransmission).
They also show
hyposensitivity to reward
, which is mediated by
sympathetic nervous system hyporeactivity to incentives, low
basal heart rate, orbitofrontal cortex hyporeactivity to reward,
and altered dopamine function.
Impairment in
executive
functions
suggests
poorer control of
emotions
and
decision making
.
C
o
m
o
r
b
i
d
i
t
y
The most frequent comorbidities are with
ADHD (about 10 times
more often than expected),
major depression (about seven
times),
and
substance abuse (in adolescents, about four times)
.
DSM-5 allows multiple diagnoses to be made (e.g., ODD and CD,
ODD and ADHD, CD and major depression).
Diagnosis of ODD or CD should not be made if symptoms occur
exclusively
during the course of a psychotic, substance use,
depressive, or bipolar disorder, and the young person does not
meet criteria for disruptive mood dysregulation disorder.
Rather than physical attack, females are more prone to
use
indirect
,
verbal, and relational violence such as
ostracism and character defamation
.
These behaviors can be
difficult to document
, are not
clearly described as CD symptoms, and may result in
underdiagnosis of CD in girls.
D
i
f
f
e
r
e
n
t
i
a
l
D
i
a
g
n
o
s
i
s
ADHD
Mood disorders
Substance misuse
Anxiety disorders
Tic disorders
Specific developmental and learning disorders
Autism spectrum disorders
Intellectual disability
Disruptive mood dysregulation disorder
Intermittent explosive disorder
Schizophrenia
Antisocial behavior is not uncommon in the prodromal
stage of schizophrenia .
It has been suggested that some children with severe
impulsivity, hyperactivity, unstable mood, irritability,
defiance, and conduct problems may suffer from bipolar
disorder, resulting in a higher prevalence of bipolar
disorder in this age group.
D
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v
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t
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C
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n
s
i
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t
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n
s
Children’s prosocial impulses already become apparent
in the first year of life. . A degree of defiance and
noncompliance is normal in
toddlers
, probably reflecting
the child’s assertiveness and search for autonomy. .
Notwithstanding this, toddlers’ behavior may be
indicative of problems when it is
too intense
,
persistent
,
or
pervasive
.
Distinguishing behaviors that are within the normal
range from problematic defiance or noncompliance is
difficult
at that age.
D
e
v
e
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o
p
m
e
n
t
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C
o
n
s
i
d
e
r
a
t
i
o
n
s
Prosocial behaviors usually
increase up to the age of 3 years
; a
temporary decline then begins to emerge. Defiance and
noncompliance, particularly in boys, may also increase about the
age of 2 or 3 years.
Males
report greater involvement in physical
fights than females.
Aggressive behavior (hitting, biting, smashing objects) is common
in 4 to 8 year olds and decreases with age.
D
e
v
e
l
o
p
m
e
n
t
a
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C
o
n
s
i
d
e
r
a
t
i
o
n
s
Severely aggressive acts start after puberty.
Covert antisocial actions such as property and status violations
(stealing, truancy, running away) increase as children become
older, being more prevalent during adolescence.
Early adolescence is often associated with an increase in
rebellious behavior.
Teachers’ reports indicate that most oppositional symptoms,
such as arguing, screaming, disobedience, and defiance,
peak
between 8 and 11 years
and then decline in frequency.
O
u
t
c
o
m
e
In some children, ODD symptoms begin in infancy, persist during
childhood, and evolve into CD, often after puberty. Other young
people show noncompliance and defiance for short periods or do
not progress to CD; this may occur more often in
females
than in
males.
The continuity between childhood CD and adult ASPD has long
been known, so much so that DSM-5 requires evidence of CD
symptoms prior to the age of 15 to make a diagnosis of ASPD—
implying that ODD, CD, and ASPD are part of a dimension of
psychopathology.
O
u
t
c
o
m
e
Childhood DBDs are associated not only with ASPD but
with a wide range of other psychiatric disorders in
adulthood (e.g.,
substance
abuse
,
major
depression
,
psychosis
), as well as with many adverse outcomes such
as
suicidal
behavior
,
delinquency
,
educational
difficulties
,
unemployment
, and
teenage pregnancy.
Childhood DBDs often trigger a chain of events that
increase the likelihood of such unfavorable outcomes
O
u
t
c
o
m
e
Studies by and large show a
dose–response
relationship:
The higher the number and variety of disruptive
behaviors, the worse the adult outcomes.
Most
adolescents with CD
do not develop
ASPD in
adulthood.
A large
decline
in delinquent and antisocial activities is a
commonly reported phenomenon in
early
adulthood.
O
u
t
c
o
m
e
Some data suggest heterotypic continuity between
symptoms of
irritability
(losing temper, being touchy or
easily annoyed, angry and resentful) and later
internalizing
problems
, particularly depression.
Adolescents with
callous–unemotional
traits are at a
higher risk of violent reoffending earlier than their young
offender peers.
T
R
E
A
T
M
E
N
T
Children with DBDs are treated with a variety of
psychological, behavioral, or pharmacologic approaches,
alone or in combination, targeting the child and/or the
family.
Therapy is of limited effectiveness in the patients with
CD typically seen in mental health settings (
more
chronic
,
more disturbed
, and usually with
comorbid
conditions
).
Treatment is more likely to be effective when
administered
early
in the course of the disorder.
Treatment should involve the parents . Improving
parenting
skills and
parent–child
interactions
are core
goals.
Comorbid
conditions
(ADHD, depression) ought to be
identified and, if appropriate, treated.
Parental
depression, psychosis, or substance abuse
should also be noted and treated. It is very useful to
ascertain children’s and families’
strengths
and build on
them in addition to focusing on their problems.
In ODD, the main goal of treatment is to
increase
compliance
and
reduce
conflict
.
The treatment plan should include ways of helping the
young person become
more cooperative, less
argumentative, and be better accepted by peers
, often in
a
family therapy
context.
Medication
should
not be offered for the routine
management of ODD or CD.
In cases of severe aggressive behavior that has not
responded to psychosocial interventions, the use of
risperidone
can be considered in the short term.
P
a
r
e
n
t
M
a
n
a
g
e
m
e
n
t
T
r
a
i
n
i
n
g
Parent management training (PMT) is based on the
principles of operant conditioning and social learning
theory. In PMT, parents are encouraged to use
positive
reinforcement
, to adopt more effective
discipline
strategies
, and to learn how to
negotiate
with their
children .
PMT has been the
most
extensively researched therapy
in this field.
M
u
l
t
i
m
o
d
a
l
I
n
t
e
r
v
e
n
t
i
o
n
s
Multisystemic Therapy (MST)
Families and Schools Together (FAST Track)
I
n
d
i
v
i
d
u
a
l
I
n
t
e
r
v
e
n
t
i
o
n
s
Problem-solving skills training
)
using various techniques
including games, structured activities, stories, modeling, role
play, and reinforcement)
Assertiveness training
Anger control/stress inoculation
Rational emotive therapy
CBT(small-to moderate effect )
Medication is not a mainstay of treatment of ODD and
CD.
The dosing strategy of “start low, go slow, taper slowly.
Before switching, augmenting, combining, or
discontinuing medications because of a lack of
response, it should be ensured that patients have
received an adequate trial (dose and duration) as well as
psychosocial interventions.
Risperidone
for the treatment of aggressive behavior
Stimulants
are effective in children with ADHD with
oppositional behavior, conduct problems, or aggression.
Treatment with atomoxetine, guanfacine, and clonidine
may also provide some lesser symptom relief.
Caution and careful monitoring should be exercised
when prescribing stimulants to adolescents with CD,
given the high rate of substance misuse in this
population.
P
R
E
V
E
N
T
I
O
N
Child and adolescent mental health professionals have a
critical role in educating the community and political
leaders on the advantages of prevention over treatment
and retribution, notwithstanding that treatment and law
enforcement are important also.
Reducing DBDs is one of the challenges for child mental health
in the 21st century
Addressing conduct problems without tackling the social,
family, and individual factors associated with these
conditions will lead to disappointment.
Treatment of developmental difficulties such as attention
and learning problems.
Schools can play a key role.
Home visitation
PMT principles, such as Triple-P
Thanks for your attention
Children and adolescents with oppositional defiant disorder (ODD), conduct disorder (CD), or disruptive behavior disorder (DBD) often display challenging behaviors such as sullenness, argumentativeness, and defiance. These disorders share similarities but also have key differences in terms of behavior patterns, emotional responses, and outcomes. Addressing these issues requires a comprehensive understanding of the varying characteristics and treatment approaches for individuals affected by ODD and CD.
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Presentation Transcript
IN THE NAME OF GOD IN THE NAME OF GOD IN THE NAME OF GOD
Oppositional Defiant and Conduct Disorders Sara Dehbozorgi Child Psychiatrist
Children and adolescent who are sullen, argumentative, uncooperative, miss school, and lie about their whereabouts, refuse to adhere to curfews, steal money from home, etc. represent one of the largest group of patients seen in child and adolescent mental health settings. They are usually labeled as suffering from oppositional defiant disorder ODD), conduct disorder (CD), or disruptive behavior disorder (DBD). The last term was often used to include also children with ADHD.
Disruptive behavior disorder (DBD) ODD ODD CD CD ADHD ADHD
Individuals with ODD and CD share many characteristics. For example, their conduct is socially unacceptable, they cause disruption or distress to others more than to themselves (i.e., they externalize their problems), and they are more likely to be male and to find it difficult to learn from experience.
Individuals with ODD and CD differ they may be aggressive or not, break the law or not, feel guilt and empathy or not, may be sensation-seeking or not. Children with these problems are heterogeneous in relation to etiology, natural history, response to treatment, and outcome. differ widely from one another:
ICD ICD- -11 11 DSM DSM- -5 5 ICD ICD- -11 11 DSM DSM- -5 5 ) ( ODD ODD ) ( ) ( CD CD IED IED ) ( ASPD ASPD ) ( - 6 9 4 - . 6 ODD ODD . 15 3 . 12 : 6 ( . ) CD CD
( CD CD ODD ODD DSM- -5 5 DSM ) ) ( Conduct disorder ODD ODD ) ( ) ( / (1 (2 (3 (4 (5 (6 (7 (1 (1 (2 (2 (3 (3 / (8 (9 (1 (1 (2 (2 (3 (3 (4 (4 (8 (9 (1 (1 (10 (8 (9 13 13 (10
DSM-5 In DSM-5, ODD and CD have been placed in the chapter Disruptive, Impulse-Control, and Conduct Disorders together with conditions such as intermittent explosive disorder, pyromania, kleptomania, and antisocial personality disorder (ASPD). This grouping seems to assume that these conditions involving problems with self-control that impinge on others are part of a continuum with ODD at one end and ASPD at the other.
DSM-5 In DSM-IV, a diagnosis of CD pre-empted a diagnosis of ODD; this exclusion has been removed in DSM-5. That is, individuals can be diagnosed as suffering from both ODD and CD concurrently. In DSM-5 in a subgroup of anger/irritability and another of argumentativeness/defiance is supported by studies showing that these behaviors tend to occur together and predicted, respectively, internalizing and externalizing behavior later on. The specifier with limited prosocial emotions has been added in DSM-5.
DSM-5 The specifier with limited prosocial emotions has been added in DSM-5. In recent years, there has been a resurgence in interest on the traditionally described as psychopathic traits, in the case of young people often referred to with the term callous unemotional. These youth are described in DSM-5 as with limited prosocial emotions.
DSM-5 This label defines children and adolescents who show lack of remorse and guilt after doing something wrong, appear cold and uncaring, show no concern for the feelings of others, are undaunted by their poor performance at school, and their emotions appear shallow or insincere. They respond poorly to punishment, show lower cortisol levels, seek novel, exciting, and dangerous activities, are prone to boredom, and have lower trait anxiety than other youth with the same level of conduct problems.
DSM-5 DSM-5 highlights that a diagnosis of CD should be made only when the behavior in question is symptomatic of an underlying dysfunction within the individual and not simply a reaction to the immediate social or cultural context. This is to circumvent concerns that a diagnosis of CD may at times be misapplied to individuals in particular settings (threatening, impoverished, high crime, war) where patterns of undesirable behavior could be protective. This does not necessarily imply an absence of CD in those settings, it only means that the context in which symptoms occur needs to be taken into consideration.
EPIDEMIOLOGY ODD and CD are two to three times more prevalent in males than females. Recent surveys (mostly using DSM-IV criteria) in several countries have produced reasonably consistent results ,overall, about 3% of children aged 6 to 18 years met criteria for ODD or CD in the previous 3 or 6 months.
ETIOLOGY Heritability of antisocial behavior has been estimated at about 50%, though it is not diagnosis specific. It appears that what might be transmitted is a general liability to externalizing disorders although there are also disorder- specific liabilities (e.g., for ADHD). Shared environment may specifically influence CD, highlighting the importance of examining shared environmental variables as processes underlying the comorbidity among ODD and CD.
Risk Factors Risk factors include, among others, socioeconomic disadvantage, exposure to family violence and dysfunction, lower IQ, and attentional difficulties. The accumulation of risk may not only act additively, but also multiplicatively. Genetic influences are stronger in children from poor families than in those from affluent backgrounds , genetic factors influence individuals choices and shaping of their own environment .antisocial individuals are more likely to find problematic partners (assortative mating).
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * /
Neuropsychological Aspects Atypical frontal lobe activation, as detected on EEG, is a basis for negative affective style in children with ODD. Positron emission tomography has shown violence to be associated with decreased glucose metabolism in the prefrontal cortex. Orbitofrontal lobe damage has been linked to impulsive aggression. There is a suggested link between aggression and low levels of serotonin in the CNS.
Children with ODD and CD have a lower sensitivity to punishment which may reduce their ability to associate inappropriate behaviors and consequences (the result of impaired fear conditioning, reduced cortisol reactivity to stress, amygdala hyporeactivity to negative stimuli, and altered serotonin and noradrenaline neurotransmission). They also show hyposensitivity to reward, which is mediated by sympathetic nervous system hyporeactivity to incentives, low basal heart rate, orbitofrontal cortex hyporeactivity to reward, and altered dopamine function. Impairment in executive functions suggests poorer control of emotions and decision making.
Comorbidity The most frequent comorbidities are with ADHD (about 10 times more often than expected), major depression (about seven times), and substance abuse (in adolescents, about four times). DSM-5 allows multiple diagnoses to be made (e.g., ODD and CD, ODD and ADHD, CD and major depression). Diagnosis of ODD or CD should not be made if symptoms occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder, and the young person does not meet criteria for disruptive mood dysregulation disorder.
Rather than physical attack, females are more prone to use indirect, verbal, and relational violence such as ostracism and character defamation. These behaviors can be difficult to document, are not clearly described as CD symptoms, and may result in underdiagnosis of CD in girls.
Differential Diagnosis ADHD Mood disorders Substance misuse Anxiety disorders Tic disorders Specific developmental and learning disorders Autism spectrum disorders Intellectual disability Disruptive mood dysregulation disorder Intermittent explosive disorder Schizophrenia
Antisocial behavior is not uncommon in the prodromal stage of schizophrenia . It has been suggested that some children with severe impulsivity, hyperactivity, unstable mood, irritability, defiance, and conduct problems may suffer from bipolar disorder, resulting in a higher prevalence of bipolar disorder in this age group.
Developmental Considerations Children s prosocial impulses already become apparent in the first year of life. . A degree of defiance and noncompliance is normal in toddlers, probably reflecting the child s assertiveness and search for autonomy. . Notwithstanding this, toddlers behavior may be indicative of problems when it is too intense, persistent, or pervasive. Distinguishing behaviors that are within the normal range from problematic defiance or noncompliance is difficult at that age.
Developmental Considerations Prosocial behaviors usually increase up to the age of 3 years; a temporary decline then begins to emerge. Defiance and noncompliance, particularly in boys, may also increase about the age of 2 or 3 years. Males report greater involvement in physical fights than females. Aggressive behavior (hitting, biting, smashing objects) is common in 4 to 8 year olds and decreases with age.
Developmental Considerations Severely aggressive acts start after puberty. Covert antisocial actions such as property and status violations (stealing, truancy, running away) increase as children become older, being more prevalent during adolescence. Early adolescence is often associated with an increase in rebellious behavior. Teachers reports indicate that most oppositional symptoms, such as arguing, screaming, disobedience, and defiance, peak between 8 and 11 years and then decline in frequency.
Outcome In some children, ODD symptoms begin in infancy, persist during childhood, and evolve into CD, often after puberty. Other young people show noncompliance and defiance for short periods or do not progress to CD; this may occur more often in females than in males. The continuity between childhood CD and adult ASPD has long been known, so much so that DSM-5 requires evidence of CD symptoms prior to the age of 15 to make a diagnosis of ASPD implying that ODD, CD, and ASPD are part of a dimension of psychopathology.
Outcome Childhood DBDs are associated not only with ASPD but with a wide range of other psychiatric disorders in adulthood (e.g., substance abuse, major depression, psychosis), as well as with many adverse outcomes such as suicidal behavior, delinquency, educational difficulties, unemployment, and teenage pregnancy. Childhood Childhood DBDs often trigger a chain of events that DBDs often trigger a chain of events that increase the likelihood of such unfavorable increase the likelihood of such unfavorable outcomes outcomes
Outcome Studies by and large show a dose response relationship: The higher the number and variety of disruptive behaviors, the worse the adult outcomes. Most adolescents with CD do not develop ASPD in adulthood. A large decline in delinquent and antisocial activities is a commonly reported phenomenon in early adulthood.
Outcome Some data suggest heterotypic continuity between symptoms of irritability (losing temper, being touchy or easily annoyed, angry and resentful) and later internalizing problems, particularly depression. Adolescents with callous unemotional traits are at a higher risk of violent reoffending earlier than their young offender peers.
TREATMENT Children with DBDs are treated with a variety of psychological, behavioral, or pharmacologic approaches, alone or in combination, targeting the child and/or the family. Therapy is of limited effectiveness in the patients with CD typically seen in mental health settings (more chronic, more disturbed, and usually with comorbid conditions). Treatment is more likely to be effective when administered early in the course of the disorder.
Treatment should involve the parents . Improving parenting skills and parent child interactions are core goals. Comorbid conditions (ADHD, depression) ought to be identified and, if appropriate, treated. Parental depression, psychosis, or substance abuse should also be noted and treated. It is very useful to ascertain children s and families strengths and build on them in addition to focusing on their problems.
In ODD, the main goal of treatment is to increase compliance and reduce conflict. The treatment plan should include ways of helping the young person become more cooperative, less argumentative, and be better accepted by peers, often in a family therapy context. Medication should not be offered for the routine management of ODD or CD. In cases of severe aggressive behavior that has not responded to psychosocial interventions, the use of risperidone can be considered in the short term.
Parent Management Training Parent management training (PMT) is based on the principles of operant conditioning and social learning theory. In PMT, parents are encouraged to use positive reinforcement, to adopt more effective discipline strategies, and to learn how to negotiate with their children . PMT has been the most extensively researched therapy in this field.
Multimodal Interventions Multisystemic Therapy (MST) Families and Schools Together (FAST Track)
Individual Interventions Problem-solving skills training ) using various techniques including games, structured activities, stories, modeling, role play, and reinforcement) Assertiveness training Anger control/stress inoculation Rational emotive therapy CBT(small-to moderate effect )
Medication is not a mainstay of treatment of ODD and CD. The dosing strategy of start low, go slow, taper slowly. Before switching, augmenting, combining, or discontinuing medications because of a lack of response, it should be ensured that patients have received an adequate trial (dose and duration) as well as psychosocial interventions. Risperidone for the treatment of aggressive behavior
Stimulants are effective in children with ADHD with oppositional behavior, conduct problems, or aggression. Treatment with atomoxetine, guanfacine, and clonidine may also provide some lesser symptom relief. Caution and careful monitoring should be exercised when prescribing stimulants to adolescents with CD, given the high rate of substance misuse in this population.
PREVENTION Child and adolescent mental health professionals have a critical role in educating the community and political leaders on the advantages of prevention over treatment and retribution, notwithstanding that treatment and law enforcement are important also. Reducing Reducing DBDs is one of the challenges for child mental health DBDs is one of the challenges for child mental health in the in the 21 21st century st century
Addressing conduct problems without tackling the social, family, and individual factors associated with these conditions will lead to disappointment. Treatment of developmental difficulties such as attention and learning problems. Schools can play a key role. Home visitation PMT principles, such as Triple-P
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