Children conduct disorders

Because the symptoms are so disruptive to the family and to the child, conduct disorder is one of the most common reasons for referral to a pediatrician or child psychiatrist. In patients with MR, this disorder is seen less as organized, planned illicit activities and more as impulsive, unpredictable acts of violence or destruction. Such individuals may exhibit aggression toward caregivers, teachers, family members, or themselves, and they may be emotionally labile. If behavior therapy has not been effective, pharmacological treatment may be necessary. 

If the client is an adolescent or child and engaging in antisocial behavior, then comorbid Conduct Disorder should be considered, although such behavior also may indicate an Oppositional-Defiant Disorder if there is little deviant behavior but lots of arguing and defying the wishes of authorities such as parents and teachers. Adult antisocial behavior is difficult to treat but usually involves use of behavior modification (see Chapter 5) through the use of incentives. Conduct Disorder and Oppositional-Defiant Disorder can be successfully treated with behavior modification and by modifying the youth s environment (e.g., using multisystemic therapy or the community reinforcement model — see Chapter 5). 

Other Childhood Disruptive Disorders. The child with ADHD typically avoids schoolwork that taxes his/her attention. Difficulty completing work can quickly become a frustrating experience independent of one s age. A child with ADHD who complains about an assignment in many respects resembles the defiant refusal of a child with oppositional defiant disorder or conduct disorder. These disorders must be carefully distinguished from ADHD, but it is entirely possible that a child with ADHD may also have a comorbid disruptive behavior disorder. 

A child with attention-deficit hyperactivity disorder [ADHD] and conduct disorder is treated with 45 mg/d of methylphenidate and 2 mg/d of risperidone. A new diagnosis of complex partial seizures is made and the child is started on carbamazepine. About 10 days after the initiation of carbamazepine, the child develops withdrawal dyskinesias of mouth and tongue. After discontinuation of carbamazepine, the movements last for 1 week. 

Riggs, P.D., Leon, S.L., Mikulich, S.K., and Pottle, L.C. (1998) An open trial of bupropion for ADHD in adolescents with substance use disorders and conduct disorder. J Am Acad Child Adolesc Psychiatry 37 1271—1278. 

Campbell, M., Adams, P.B., Small, A.M., Kafantaris, V., Silva, R.R., Shell, J., Perry, R., and Overall, J.E. (1995) Lithium in hospitalized aggressive children with conduct disorder a double-blind and placebo-controlled study. / Am Acad Child Adolesc Psychiatry 34 445-453. [published erratum appears in / Am Acad Child Adolesc Psychiatry 1995 34(5) 694]. ... 

Findling, R.T., McNamara, N.K., Branicky, T.A., Schluchter, M.D., Temon, E., and Blumer, J.T. (2000a) A double-blind pilot study of risperidone in conduct disorder. / Am Acad Child Adolesc Psychiatry 39 509-516. 

Conduct disorder 1. Parent 2. Teacher, sitter, coach, scout leader, bus driver 3. Child 1. Adolescent 2. Parent, teacher... 

Kaplan, S.L., Busner, J., Kupietz, S., Wasserman, E., and Segal, B. (1990) Effects of methylphenidate on adolescents with aggressive conduct disorder and ADDH a preliminary report. J Am Acad Child Adolesc Psychiatry 29 719-723. 

Recently, Janssen Pharmaceutica launched several studies of risperidone in children with borderline IQ or MR and a diagnosis of disruptive behavior disorder (usually oppositional defiant disorder or conduct disorder). To be admissible into the study, subjects needed to be 5 to 12 years old, inclusive, and score above 24 on the Conduct Problem subscale of the Nisonger Child Behavior Rating Form (NCBRF). One 6-week acute trial (n = 118) was conducted in the United States (Aman et al., in press), whereas the other n = 110) was based in Canada (Snyder et al., in press). The findings of the two studies were virtually identical, with... 

Aman, M.G., Findling, R.L., Derivan, A., and Merriman, U. (2000) Risperidone versus placebo for severe conduct disorder in children with mental retardation [NCDEU abstract]. / Child Adolesc Psychopharmacol 10 253. 

Biederman, ]., Faraone, S.V., Chu, M.P., and Wozniak, J. (1999) Further evidence of a bidirectional overlap between juvenile mania and conduct disorder in children. / Am Acad Child Adolesc Psychiatry 38 468 76. 

Kovacs, M., and Pollock, M. (1995) Bipolar disorder and comorbid conduct disorder in childhood and adolescence./ Am Acad Child Adolesc Psychiatry 34 715-723. 

In 1995, Bramble published a study on the prescription frequency of antidepressants by British child psychiatrists (Bramble, 1995). A brief postal questionnaire was circulated to 350 members of the British Royal College of Psychiatrists, Child and Adolescent Psychiatry Specialist Sections. There was a 71% response rate, and 85% of the 238 respondents had employed antidepressants, the most popular of these being amitriptyline and imipramine. Nearly one-third of the psychiatrists at that time used neuroagents occasionally, and the SSRIs were used only very rarely. The antidepressant medication was used for a wide range of child and adolescent disorders beyond those of depression and nocturnal enuresis. Approximately 20% of the prescriptions were given for ADHD (hyperkinetic disorder), conduct disorder, and a few cases of autistic disorder. Clomipramine was apparently given for OCD. On the basis of these 1994 data. Bramble concluded that British child psychiatrists tend to use antidepressant medication far less often than American psychiatrists. 

The issues of whether depression is underdiagnosed, and more generally, whether the construct of depression is also applicable to children, have been discussed in both Europe (Rutter et ah, 1986) and the United States (Beardslee et ah, 1985). As in the DSM-IV, the ICD-10 has no specific category for depressive disorder in childhood, so diagnostic criteria developed for adult patients must be applied to children. However, a combination category for depression and conduct disorder is included in the ICD-10, depressive conduct disorder, for which the child must fulfill criteria for both depression and conduct disorder. 

Inasmuch as these studies were retrospective, the possibility always exists that the ability of the child and the family to stay in treatment was a more critical variable than medication. The available evidence, however, suggests that effective treatment of ADHD may have long-lasting effects on the psychosocial adjustment of the patient. In a related follow-up study, conduct disorders in adolescents almost exclusively occurred in those who retained features of ADHD ( 86). Conceivably, effective intervention early in childhood may alter the course, decreasing the likelihood of development of conduct disorder as an adolescent and antisocial personality disorder with its various complications (e.g., alcohol and drug abuse, criminality) as an adult. 

Derivan A, Aguiar L, Preskorn S, et al. A study of venlafaxine in children and adolescents with conduct disorder. Annual Meeting of the American Academy of Child and Adolescent Psychiatry, New Orleans, 1995. 

Campbell M, Adams PB, Small AM. Lithium in hospitalized aggressive children with conduct disorder a double blind placebo controlled study. J Am Acad Child Adolesc Psychiatry 1995 34 445-453. 

Findling RL, McNamara NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. A double-blind pilot study of risperidone in the treatment of conduct disorder. J Am Acad Child Adolesc Psychiatry 2000 39(4) 509-16. 

---