57.

CONDUCT DISORDER
Paula DeGrafenreid Riggs, M.D., and Elizabeth A Whitmore, Ph.D
1. Define conduct disorder. Conduct disorder is a psychiatric disorder of children and adolescents characterized by a persistent and repetitive pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules. According to the specific diagnostic criteria in DSM IV, three (or more) characteristic behaviors must have been present during the past 12 months, with at least one behavior present in the past 6 months (criterion A). Such behaviors generally are present in various settings and cause clinically significant impairment in social, academic, or occupational functioning (criterion B ). The diagnostic criterion behaviors of conduct disorder fall into four main groupings: Aggressive conduct that causes or threatens harm to other people or animals (bullying, fighting, use of weapons, physical cruelty to people or animals, stealing with confrontation of victim, forced sex) Nonaggressive conduct that causes property loss or damage (deliberate destruction of property or fire-setting) Deceitfulness or theft (breaking and entering, conning others, theft of nontrivial items without confrontation of victim) Serious violations of rules (staying out late at night despite parental prohibitions before age 13, running away from home overnight at least twice, truancy from school before age 13). 2. Are there subtypes? Yes. Conduct disorder is subdivided into two main subtypes: Childhood-onset type-defined by onset of at least one conduct disorder behavior before age 10. Youths with this type of conduct disorder are usually male and aggressive, with disturbed peer relationships, and meet full criteria for conduct disorder before puberty. The prognosis for these individuals is worse, because these behaviors are more likely to persist into adulthood, and many of these individuals will develop antisocial personality disorder. Adolescent-onset type-defined by the absence of any criterion of conduct disorder before age 10. Patients are generally less aggressive than those with childhood-onset conduct disorder and have more normative peer relationships. Youths with adolescent onset are less likely to have persistent conduct disorder evolving into antisocial personality disorder. Thus, they more often have adolescent-limited conduct disorder, and their prognosis is better. Girls with conduct disorder are more likely to have this type.
3. How common is conduct disorder? Conduct disorder is the most common reason for referral of children for psychiatric evaluation and treatment. It is about 2-3 times more common in boys (6-16% prevalence) than in girls (2-9% prevalence).
4. What causes conduct disorder? There is no single cause of conduct disorder. Generally, factors associated with and contributing to conduct disorder can be categorized as intrinsic and extrinsic. Intrinsic factors are more likely to influence the childhood-onset type than the adolescent-onset type. Intrinsic factors include: Genetics. Although definitive studies on the genetics of conduct-disorder have been lacking, at least one behavioral genetics study (that accounts for both environmental and genetic effects) indicates that there is a substantial genetic influence on conduct disorder (accounting for as much as 70% of the variance).
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Temperamental features. Hyperactivity, early aggression, impulsivity, sensation seeking, lack of empathy, and guilt have all been associated with the development of conduct disorder. Cognitive impairment and distorted information processing. Conduct-disordered children have been noted to have verbal and planning skills deficits. They also have a marked tendency to misperceive the intentions of others as hostile and aggressive, especially in ambiguous situations. Dysregulation of serotonin levels (see Question 9). Autononiic hyporeactivity. Low reactivity may make it more difficult to influence conductdisordered children with positive and negative reinforcement. Extrinsic factors include: Family factors such as (1) low maternal affection; (2) fathers deviance (alcoholism or criminality); (3) substance use disorders in parents or parental surrogates; (4) parental aggression, violence, harsh discipline and/or physical or sexual abuse of children; ( 5 ) inability of the parents to provide adequate supervision, consistent structure, and limits; and (6) lack of consistent parental emotional investment, support, and affection. Sociocultural factors, such as low socioeconomic status, unemployment, and association with delinquent peers. 5. What is the differential diagnosis of conduct disorder? Oppositional defiant disorder includes some features of conduct disorder but does not include the persistent pattern of more serious deviant behavior in which the basic rights of others or age-appropriate societal norms or rules are violated. According to DSM IV, when an individual meets criteria for both conduct disorder and oppositional defiant disorder, the diagnosis of conduct disorder supersedes the diagnosis of oppositional defiant disorder. Children with attention deficit-hyperactivitydisorder (ADHD) often exhibit hyperactive and impulsive behavior and low frustration tolerance, which may be disruptive. Yet this behavior does not violate age-appropriate societal norms and does not usually meet criteria for conduct disorder. The key features of ADHD are inattentiveness, motoric hyperactivity, and poor concentration. Such features distinguish ADHD from conduct disorder. The irritability and impulsivity of a manic or hypomanic episode, characteristic of bipolar disorder, may contribute to behavioral problems. These features usually are distinguished from the disruptive behavioral pattern of conduct disorder based on episodic course and other symptoms, such as pressured speech, reduced need to sleep, and racing thoughts. The diagnosis of adjustment disorder (with disturbance of conduct and emotions) should be considered if clinically significant conduct problems, not meeting criteria for another specific disorder, develop in clear association with the onset of a psychosocial stressor. For individuals over the age of 18 years, conduct disorder may be diagnosed only if the criteria for antisocial personality disorder are not met. The diagnosis of antisocial personality disorder cannot be given to individuals under the age 18 years. On the other hand, the diagnosis of antisocial personality disorder requires evidence of conduct disorder before age 15 (DSM IV). Aggression, impulsivity, and behavioral problems may be manifestations of various neurologic problems, including seizures. Usually such disorders are easily distinguished from conduct disorder by considering longitudinal course and associated features. The same is true for chronic psychotic disorders. However, both psychosis and neurologic disorders may be separately comorbid with conduct disorder. Moreover, many different kinds of psychiatric disorders may present with behavior problems, and the diagnostic criteria for conduct disorder are broad. Therefore, it is essential for the clinician to perform a detailed comprehensive psychiatric evaluation before making the diagnosis of conduct disorder. It is equally essential to assess thoroughly for comorbid disorders.
6. What other disorders are associated with conduct disorder? Substance use disorders and conduct disorder are highly associated both in adolescence and later adulthood. Although the exact prevalence of substance abuse or dependence with conduct disorder in

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adolescence is not clear, the Epidemiologic Catchment Area study demonstrated that 84% of individuals with antisocial personality disorder (vs. 17% of the general population) had diagnoses of a substance use disorder in adulthood, and all had conduct disorder as youth^.^ Most antisocial adults with substance use disorders begin substance abuse in adolescence. As the number of conduct syrnptoms increases, so does the incidence of associated substance use disorder. ADHD occurs in 30-50% of cases of conduct disorder in both epidemiologic and clinically referred samples. Although both conduct disorder and ADHD are classified as disruptive behavior disorders and may have some symptoms in common, recent studies support that they are separate disorders and that ADHD does not cause conduct disorder. If the diagnostic criteria for both disorders are met, both should be diagnosed and treated. Depressive disorders occur with conduct disorder in 15-24% of cases in both epidemiologic and clinically referred samples. Anxiety disorders are also more prevalent among youths with conduct disorder (1524%) than among those without conduct disorder (5-1 1%). There are few data regarding the co-occurence of bipolar disorder with conduct disorder, partly because of the low prevalence of bipolar disorder in adult populations (approximately 1%). A manic or hypomanic episode with prior depression presenting before age 15 is even more rare. Some studies indicate that adolescents with bipolar disorder may have higher rates of conduct disorder than found in the general population. However, large community-based or multicenter studies will be necessary to address this comorbidity more adequately. Learning disabilities (especially reading disabilities) are comorbid with conduct disorder in 10-90% of cases. The broad range is most likely due to differences in assessment and diagnosis of learning disorders. Nevertheless, the literature supports high rates of comorbid learning disabilities with conduct disorder overall. Most conduct-disordered children are not severely retarded, but many score in the low normal or borderline ranges of intelligence. Conduct-disordered individuals show a pattern of having lower verbal IQ scores compared to their performance IQ scores, suggesting that they may have specific verbal deficits. Language deficits may contribute to a tendency to express feelings and attitudes physically instead of verbally.

7 . Are there gender differences in conduct disorder?

As mentioned, conduct disorder is about 3 times more common in boys than in girls. Boys are also more likely to have the childhood-onset type of conduct disorder and associated ADHD than are girls. Boys are more likely to have persistence of conduct disorder, evolving into antisocial personality disorder in adulthood. Girls may be more likely to have associated depressive disorders than boys. Gender differences are also found in specific types of conduct problems. Boys with a diagnosis of conduct disorder frequently exhibit fighting and other aggressive acts, stealing, vandalism, and school discipline problems. Girls with a diagnosis of conduct disorder are more likely to exhibit lying, truancy, running away, and prostitution. Conduct disorder in girls also places them at much higher risk for adolescent pregnancy, promiscuity, and contracting sexually transmitted diseases. Both boys and girls with conduct disorder have a high prevalence of cornorbid substance use disorders. 8. Are there effective treatments for conduct disorder? Several recent reviews have highlighted the four major intervention strategies used to treat conduct disorder: (1) parent- and family-targeted programs, especially parent management training; (2) social-cognitive programs; (3) peer- and school-based programs; and (4) community-based programs. Parent management training (PMT) is aimed at redirecting interactional processes between the parent and child or within the family that may inadvertently develop and sustain aggressive and antisocial behavior. PMT has been demonstrated to be effective in clinically referred populations. A potential problem with PMT, however, is that parents of conduct-disordered children are often not able to participate because of their own psychopathology, substance abuse, marital discord, or family dysfunction. Social-cognitive and problem-solving skills training assume that changing cognitions and affects will lead to changed or enhanced behavioral adjustments. Children and adolescents with conduct disorder have been shown to have deficits in problem-solving skills, perceptions, self-statements, and

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self-attributions. For instance, aggressive children are more likely to interpret the intentions and actions of others as hostile and to have poor social relations with peers, teachers, and parents. They often have a limited verbal and behavioral repertoire from which to draw their reactions to strong affects or situations. Thus, a cognitive-behavioral therapeutic approach is aimed at enhancing and broadening this repertoire to help conduct-disordered youths better deal with anger-provoking situations as well as their own impulsive behaviors. Although cognitive and social shlls training therapies appear to have some usefulness, their long-term efficacy has not been established. Practical behavioral approaches targeting problem-solving skills appear to be more successful. Peer- and school-based interventions are focused on the role of peer relations and schools in the development of conduct disorder and antisocial behavior. The theoretical basis is that parental factors are more important in the development of conduct disorder in the preschool years, but that school and peer factors may become ascendent in the early to middle school years. Forty percent of peer-rejected children are aggressive and at high risk to develop antisocial behavior in adolescence. Thus, this treatment focuses on prosocial skills training aimed at reducing aggressive behavior, improving peer and teacher relations, and preventing the development of antisocial behavior. Some evidence supports the short-term effectiveness of this intervention, but no long-term benefit has been demonstrated. Community intervention strategies are aimed at strengthening the ability of the community to promote prosocial behavior and to deter antisocial and delinquent behavior through changing or enhancing existing systems. Some of the most promising, empirically-supported approaches (e.g., multisystemic therapy and functional family therapy) combine aggressive community case management, intensive family therapy, and specific behavioral approaches to reduce criminality, deviant peer associations, substance use, and out-of-home placements. These types of therapy appear to have the greatest long-term impact on the youths behaviors. Treatment of comorbid disorders such as substance use disorders, depression, ADHD, and learning disorders is essential. Specific treatment modalities for comorbidities must be used in conjunction with the behavioral management of the conduct problems; concurrent treatment of the comorbid disorder(s) may enhance the effectiveness of management and treatment of conduct disorder. Overall, the available literature indicates that early intervention and treatment may be more effective than later intervention. Individual, psychodynamic therapy does not appear to be effective in this population. Because no single intervention works to treat severe conduct disorder, multimodal interventions that target problem behaviors/areas (i.e., criminality, family dysfunction, poor parenting, interactions with deviant peers, school performance) appear to be the most effective. 9. Is there evidence of a specific neurochemical abnormalityin conduct disorder and its associated features? Yes. A growing database supports abnormalities of serotonin in the modulation of brain functions in the disruptive behavior disorders of childhood. A low serotonin syndrome has been associated with early onset of impulsive violent behavior, chronic impulsivity, aggression, and substance abuse-all clearly associated with conduct disorder. Depression and suicidality occur at high rates among conduct-disordered youth and are associated with low central serotonin. Current data are insufficient to determine whether serotonergic agents are helpful in the treatment of conduct disorder. Data indicate that lithium, a nonselective serotonergic agent enhancing 5HT function, is better than placebo in improving the behavior of children with aggressive conduct disorder as well as aggression in adult felons. Additional neuroimaging and neurochemical studies are needed to explore other potential structural or neurotransmitter (e.g., dopamine) abnormalities.
BIBLIOGRAPHY
1. Bukstein OG, Brent DA, Kaminer Y: Comorbidity of substance ahuse and other psychiatric disorders in adolescents. Am J Psychiatry 146:1131-1141, 1989. 2. Crick NR, Dodge KA: A review and reformulation of social information processing mechanisms in childrens social adjustment. Psycho1 Bull l 15:74-101, 1994.

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3. Crowley TJ, Riggs PD: Adolescent substance use disorder with conduct disorder, and comorbid conditions. In Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. NIDA, Research Monograph Series, 1995. 4. Kazdin AE: Psychosocial treatments for conduct disorder in children. J Child Psycho1 Psychiatry 38: 161-178, 1997. 5. Lewis DO: Conduct disorder. In Lewis M (ed): Child and Adolescent Psychiatry: A Comprehensive Textbook. Baltimore, Williams & Wilkins, 1991, 6. Moftitt TE: The neuropsychology of conduct disorder. Dev Psychopathol 5:135-15 I , 1993. 7. Moffitt TE: Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psycho1 Rev 100:67&701, 1993. 8. Offord DR, Bennett KJ: Conduct disorder: Long-term outcomes and intervention effectiveness. J Am Acad Child Adolesc Psychiatry 33:1994. 9. Raine A, Lenez T, Bihrle S, LaCass L, Colletti P: Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Arch Gen Psychiatry 57: 1 19-127, 2000. 10. Riggs PD, Whitmore EA: Substance use disorders and disruptive behavior disorders. In Henderson R (ed): Disruptive Behavior Disorders in Children and Adolescents. Washington, DC, American Psychiatric Association Press, 1999. 1 1. Robins LN, Regier DA (eds): Psychiatric Disorders in America. The Epidemiologic Catchment Area Study. New York. Macmillan, 1991. 12. Rutter M, Giller H, Hagell A: Antisocial Behavior in Young People. Cambridge, UK, Cambridge University Press, 1998. 13. Steiner H: Practice parameters for the assessment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry 36(10 Suppl): 122S-I39S, 1997. 14. Zubieta JK, Alessi NE: Is there a role of serotonin in the disruptive behavior disorders? A literature review. J Child Adolesc Psychopharm 3: 1993.

58. OBSESSIVE-COMPULSIVE DISORDER IN CHILDREN A N D ADOLESCENTS

Frederick B. Hebert, M D
1. Define obsessive-compulsivedisorder. Obsessive-compulsive disorder (OCD) was formerly thought to be rare and to have a poor prognosis. It is now known to be one of the most treatable of psychiatric disorders. OCD is a lifelong condition that waxes and wanes and often is complicated by depression and anxiety. Defined as a type of anxiety disorder, the symptoms of OCD consist of obsessions or compulsions, and sometimes both. 2. What are obsessions? Obsessions are demonstrated by recurrent and persistent ideas, thoughts, impulses, or images that are felt as intrusive and recognized as senseless. The person attempts to ignore, suppress, or neutralize the obsessions with some other thought or action. The obsessions are recognized as the product of the persons own mind rather than imposed from without (except perhaps in children). If another disorder is present, the content is not related (i.e., the obsession is not about guilt or depression). Typical themes are aggression, fear of contamination, doubting, or ordering of objects.

3. What kinds of behavior demonstrate compulsions? Compulsions consist of repetitive behaviors that appear purposeful and intentional, performed in response to an obsession or according to certain rules in a stereotyped fashion. The behavior is designed to neutralize or prevent discomfort or some dreaded event; however, the activity is not connected in a realistic way or is clearly excessive. The person recognizes that the behavior is excessive or unreasonable (children may not). Common compulsions are hand-washing, checking, counting, hoarding, or touching performed in a rigid manner.