In conduct disorder

Klein, R., Abikoff, H., Klass, E., Ganales, D., Seese, L., and Pollack, S. (1997) Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psychiatry 54 1073—1080. 

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. 

The main indications for atypical antipsychotics are the acute and maintenance treatment of schizophrenic disorders, with an emphasis on the treatment of refractory and chronic disorders. However, because of the lower risk of EPS and in particular of tardive dyskinesia, there is a tendency toward a wider range of indications for some of the atypical neuroleptics. Favorable effects in drug-induced psychoses have been demonstrated for olanzapine. Clozapine seems effective in the treatment and relapse prevention of manic episodes and bipolar disorders, and risperidone has been shown to have good efficacy in conduct disorders and in the pervasive developmental disorders. 

Klein, R.G. (1991) Preliminary results lithium effects in conduct disorder. In CME Syllabus and Proceeding Summary, Symposium 2 The 144th Annual Meeting of the American Psychiatric As-sociation, New Orleans, LA, May 11-16, 1991. Washington, DC American Psychiatric Association, pp. 119-120. 

Comings, David E. 1995. "The Role of Genetic Factors in Conduct Disorder Based on Studies of Tourette Syndrome and Attention-Deficit Hyperactivity Disorder Probands and Their Relatives." Journal of Developmental and Behavioral Pediatrics 16 142-57. 

In addition, it exerts beneficial effects in many disorders as an adjuvant to other treatment modalities. Such effects are apparent only if it is administered to an already pharmacologically treated patient. For example, in unresponsive major depressive disorder, the co-administration of lithium to an ongoing antidepressant treatment increases the response rate by up to 50%. In most cases, the response to lithium augmentation is either considerable or not at all ( all-or-none phenomenon). Some (currently not convincing) results have also been reported in unipolar depression, bulimia nervosa, and attention deficit hyperactivity disorder (ADHD). Lithium also exerts antiaggressive effects in conduct disorder, independent of any mood disorder, and can reduce behavioral dyscontrol and self-mutilation in mentally retarded patients. One of the most striking effects of lithium is its antisuicidal effect in patients who suffer from bipolar and unipolar depressive disorder irrespective of comorbid axis I disorder. ... 

Low dose risperidone is occasionally used for short-term aggression management in conduct disorder or autism... 

The skeletal muscle relaxants are contraindicated in patients with known hypersensitivity. Baclofen is contraindicated in skeletal muscle spasms caused by rheumatic disorders. Carisoprodol is contraindicated in patients with a known hypersensitivity to meprobamate. Cyclobenzaprine is contraindicated in patients with a recent myocardial infarction, cardiac conduction disorders, and hyperthyroidism, hi addition, cyclobenzaprine is contraindicated within 14 days of the administration of a monoamine oxidase inhibitor. Oral dantrolene is contraindicated in patients with active hepatic disease and muscle spasm caused by rheumatic disorders and during lactation. See Chapter 30 for information on diazepam. 

Compared to antipsychotics, there are even fewer studies on the prescribing patterns of antidepressants done in Asian countries. Pi etal. (1985) conducted a survey of psychotropic prescribing practices reported by psychiatrists in 29 medical schools in 9 Asian countries. Daily dose range of tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, and nortriptyline in Asian countries was comparable to the practice in USA. This is despite differences found between Asian and non-Asian populations in the pharmacokinetics of TCAs (Pi et al, 1993). A questionnaire on the practical prescribing approaches in mood disorders administered to 298 Japanese psychiatrists was reported by Oshima et al. (1999). As first-line treatment, the majority of respondents chose newer TCAs or non-TCAs for moderate depression and older TCAs for severe depression. Combination of antidepressants and anxiolytics was preferred in moderate depression, while an antidepressant and antipsychotic combination was common in severe psychotic depression. Surprisingly, sulpiride was the most favored drug for dysthymia. In a naturalistic, prospective follow-up of 95 patients with major depression in Japan, the proportion of patients receiving 125 mg/day or less of imipramine was 69% at one month and 67% at six months (Furukawa et al., 2000). 

Children of opiate addicts have been shown to have poorer social, educational and health status and to be at higher risk of abuse than their peers (Keen et al., 2000). However, given the high rates of psychiatric comorbidity (in particular, depression) in opiate-dependent patients (Brooner et al., 1997 Khantzian and Treece, 1985), it may be that some of the increased risk in children stems from this greater parental depression. Nunes et al. (1998) reported higher incidence of conduct disorder and global and social impairment for children of addicts with major depression compared to addicts without depression and controls, but not compared with children of depressed patients without substance use disorders. 

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). 

ADHD, Conduct Disorder, and Oppositional-Defiant Disorder in youth... 

Comings, D. E., Gade-Andavolu, R., Gonzalez, N., et al. (2000) Multivariate analysis of associations of 42 genes in ADHD, ODD and conduct disorder. Clin. Genet. 58, 31-40. 

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. 

Serotonin-Boosting Antidepressants. Antidepressants that enhance serotonin activity in the brain have also been studied in ADHD. In particular, fluoxetine (Prozac) and the serotonin-selective TCA clomipramine (Anafranil) have been the most extensively evaluated, with mixed success. They provide some benefit for aggression and impulsivity but don t significantly improve the poor attention of ADHD. As a result, the SSRls and other serotonin-boosting antidepressants do not appear to be effective first-line treatments for ADHD. Conversely, depressed patients without ADHD often show improvements in symptoms of concentration and attention when treated with a SSRI. Although SSRls are not widely used in the treatment of ADHD, they may be worthy of consideration in ADHD patients whose impulsivity is not controlled by stimulants alone. Those with comorbid conduct disorder or ODD who are prone to agitation and at times violent outbursts may be helped by the addition of a SSRI. 

One of the major limitations in studies of the genetics of behavioural disorders in children arises from the overlap with other conditions. For example, nearly 50% of the patients with ADHD also have co-morbid conduct disorders. In addition, a subtype of the disorder may exist in those children in which the disorder persists into adulthood. An additional problem arises from the overlap between ADHD and bipolar disorder this has been estimated to be as high as 16%. 

Mefloquine prophylaxis can be undertaken v/ith caution in cardiac conduction disorders. It should be avoided in epilepsy, during pregnancy and breastfeeding and for 3 months after pregnancy. 

Behaviorai probiems- For the treatment of behavioral problems in children with combative, explosive hyperexcitability that cannot be accounted for by immediate provocation. Reserve for use in these children only after failure to respond to psychotherapy or medications other than antipsychotics. Hyperactivity- For short-term treatment of hyperactive children who show excessive motor activity with accompanying conduct disorders consisting of... 

In severely disturbed, nonpsychotic children or in hyperactive children with conduct disorders, short-term administration may suffice. There is little evidence that behavior improvement is further enhanced by dosages more than 6 mg/day. 

Psychosis or mania Antidepressants can precipitate manic episodes in bipolar disorder patients during the depressed phase of their illness and may activate latent psychosis in other susceptible individuals. The sustained-release formulation of bupropion is expected to pose similar risks. There were no reports of activation of psychosis or mania in clinical trials conducted in nondepressed smokers. 

---