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DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

Seminar for PG Students - Department of Pediatrics

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SLIDE 1: TITLE SLIDE

• A Comprehensive Review for Pediatric Practice
• Department of Pediatrics - PG Seminar
• Date: [Date]
• Presenter: [Name], PG Resident
• Moderator: [Name], Professor & HOD

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SLIDE 2: OVERVIEW / LEARNING OBJECTIVES

1. Define Disruptive, Impulse-Control, and Conduct Disorders (DSM-5-TR)
2. Enumerate and differentiate the types/subtypes
3. Recognize clinical features across age groups
4. Apply diagnostic criteria and perform differential diagnosis
5. Outline integrative management and quality-of-life interventions

• Among the most frequent reasons for child and adolescent psychiatric referral
• Associated with higher public expenditure: mental health treatment, medical care, legal costs
• Early identification = better outcomes

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SLIDE 3: DEFINITION - THE CATEGORY

"Conditions involving problems with the self-regulation of emotions and behaviors, manifested in behaviors that violate the rights of others or bring the individual into conflict with societal norms or authority figures."

• Persons with these disorders have an inability to resist an intense impulse or drive to perform acts harmful to themselves or others
• Before the event: mounting tension and arousal, sometimes with anticipatory pleasure
• During: immediate gratification and relief
• After: remorse, guilt, self-reproach, and dread

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SLIDE 4: THE SIX DISORDERS - OVERVIEW TABLE

• Also: Other Specified / Unspecified Disruptive Disorders

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SLIDE 5: TYPE 1 - OPPOSITIONAL DEFIANT DISORDER (ODD)

1. Angry/Irritable Mood - frequent temper outbursts, being angry, resentful, easily annoyed
2. Argumentative/Defiant Behavior - persistent stubbornness, deliberate testing of limits, ignoring commands, arguing, blaming others
3. Vindictiveness - spiteful behavior (≥2 times in 6 months)

• 4 of 8 possible symptoms for ≥6 months
• Outside of interactions with siblings
• Children <5 yrs: symptoms most days of the week
• Children >5 yrs: symptoms at least once a week
• Must cause significant distress or impairment

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SLIDE 6: TYPE 2 - CONDUCT DISORDER (CD)

"A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are repeatedly violated."

1. Aggression to people and animals (7 criteria)
   • Bullying, initiating fights, use of weapons, physical cruelty to people/animals, robbery with confrontation, forced sexual activity
2. Destruction of property (2 criteria)
   • Deliberate fire-setting, deliberate destruction of property
3. Deceitfulness or theft (3 criteria)
   • Breaking and entering, "conning" others, theft without confronting victim
4. Serious rule violations (3 criteria)
   • Staying out at night before age 13, running away from home, truancy before age 13

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SLIDE 7: SUBTYPES OF CONDUCT DISORDER

• Mild - few criteria beyond minimum; minor harm (lying, truancy)
• Moderate - intermediate between mild and severe
• Severe - many criteria or considerable harm (weapons, forced sex, cruelty)

• Lacks remorse/guilt, callous/lacks empathy, unconcerned about performance, shallow/deficient affect
• Associated with callous-unemotional (CU) traits - stronger genetic influence, reduced physiologic arousal, poorer prognosis

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SLIDE 8: TYPE 3 - INTERMITTENT EXPLOSIVE DISORDER (IED)

• Aggression is grossly out of proportion to any precipitating stressor
• Episodes appear within minutes to hours and remit spontaneously
• Genuine regret or guilt after each episode
• No signs of generalized impulsivity between events
• Must be ≥6 years of age
• Not better explained by another disorder

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SLIDE 9: TYPES 4 & 5 - KLEPTOMANIA AND PYROMANIA

• Recurrent failure to resist impulse to steal objects not needed for personal use or monetary value
• Increasing tension immediately before the theft
• Pleasure, gratification, or relief at the time of committing the theft
• Stealing is NOT to express anger or vengeance, NOT in response to delusion/hallucination
• Not better explained by CD, mania, or ASPD
• Treatment: SSRI (e.g., citalopram), naltrexone, cognitive-behavioral therapy, 12-step support groups

• Deliberate and purposeful fire-setting on ≥2 occasions
• Tension or affective arousal before the act
• Fascination, interest, curiosity, or attraction to fire and related phenomena
• Pleasure, gratification, or relief when setting fires or witnessing/participating in the aftermath
• NOT for financial gain, concealing crime, expressing anger, or improving living circumstances
• Not better explained by CD, mania, ASPD, psychosis, or impaired judgment

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SLIDE 10: CLINICAL FEATURES - ODD

• Frequent temper tantrums disproportionate to the situation
• Persistent arguing with adults/authority figures
• Deliberately annoying others and being easily annoyed
• Blaming others for own mistakes
• Active defiance and refusal to comply with rules or requests

• Angry, resentful baseline mood
• Vindictiveness
• Low frustration tolerance

• Symptoms typically begin at home (parents, siblings), later generalize to school settings
• Difficulties with peer relationships
• Academic performance problems

• Prevalence: 3.3% (range 1-11%)
• More common in males before puberty; equal post-puberty
• Mean age of onset: 6 years
• ~50% resolve within 3 years; some progress to CD

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SLIDE 11: CLINICAL FEATURES - CONDUCT DISORDER

• Bullying, threatening, initiating fights
• Use of weapons (bats, knives, guns)
• Physical cruelty to people and animals
• Robbery, assault, rape

• Arson, vandalism

• Breaking and entering, shoplifting
• "Conning" and lying repeatedly

• Truancy (before age 13), running away, staying out at night

• Callousness, lack of empathy (in CU subtype)
• Risk-taking behavior, substance use, sexual acting out
• Low self-esteem masked by toughness
• Early onset of sexual behavior, smoking, alcohol/drug use
• High rates of accidents, STIs in adolescence

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SLIDE 12: CLINICAL FEATURES - ETIOLOGY AND RISK FACTORS

• Genetic: ~50% variance in CD due to genetic influence (twin/adoption studies)
• MAOA gene polymorphism + childhood abuse = doubled risk for CD
• CU subtype: reduced autonomic arousal, reduced startle response, blunted skin conductance
• Non-CU subtype: hyper-reactivity, reactive aggression

• Negative attributional bias (hostile intent attribution)
• Poor emotional regulation
• Impaired executive function
• Low frustration tolerance
• Inconsistent discipline history

• Coercive parent-child cycles
• Parental psychopathology, substance abuse, criminality
• Poverty, overcrowding, neighborhood violence
• Domestic violence, peer rejection
• Exposure to violent media

• ADHD (most common), anxiety disorders, depression, substance use disorder, learning disabilities

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SLIDE 13: DIAGNOSIS - GENERAL PRINCIPLES

1. Comprehensive psychiatric assessment:
   • Detailed history from child, parents, teachers
   • Developmental, family, and social history
   • School and behavioral records
2. Key diagnostic pointers:
   • Symptom count, duration, frequency, and settings
   • Must cause clinically significant impairment in social, academic, or occupational function
   • Rule out organic/medical causes first
3. Rating Scales:
   • Child Behavior Checklist (CBCL)
   • Conners' Rating Scale
   • Disruptive Behavior Disorders Rating Scale (DBD-RS)
   • Strengths and Difficulties Questionnaire (SDQ)
4. Multi-informant approach is mandatory:
   • Child self-report + parent report + teacher report
   • Behaviors may vary across settings
5. Medical workup:
   • EEG (if seizure disorder suspected)
   • Thyroid function, metabolic workup
   • Neuroimaging if neurological signs present

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SLIDE 14: DSM-5-TR DIAGNOSTIC CRITERIA - SUMMARY TABLE

1. Often loses temper 2. Often touchy or easily annoyed 3. Often angry and resentful
2. Often argues with authority figures 5. Often defies rules/requests
3. Often deliberately annoys others 7. Often blames others for mistakes
4. Has been spiteful/vindictive ≥2x in last 6 months

• Recurrent behavioral outbursts (2x/week x3 months OR 3 major outbursts/year)
• Out of proportion to provocation; not premeditated
• Not explained by other mental/medical/substance disorder; age ≥6

• ODD/CD: Mild / Moderate / Severe
• CD: Childhood-onset / Adolescent-onset; With/without LPE specifier
• IED: Not applicable for age <6 years

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SLIDE 15: DIFFERENTIAL DIAGNOSIS

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SLIDE 16: MANAGEMENT - OVERVIEW AND PSYCHOSOCIAL INTERVENTIONS

• Parents attend without the child; learn limit-setting, consequence management
• Practice withstanding demanding/defiant behavior
• Build parental self-control and united front among authority figures
• Evidence: strong RCT support, especially for preschool and school-age

• Specifically designed for preschool children (2-6 years) with ODD
• Focuses on building the positive parent-child relationship through therapist coaching

• 30 clinical trials demonstrating effectiveness

• Also used in mild child physical abuse contexts

• Problem-solving skills training (PSST)
• Anger management techniques
• Social skills training
• Modification of hostile attribution bias

• For adolescents with CD + delinquency (juvenile justice involvement)
• Intensive: 3-4 contacts/week over 4 months; small therapist caseloads
• Addresses family, school, peer, and community systems simultaneously
• Proven to reduce recidivism and delinquency

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SLIDE 17: MANAGEMENT - PHARMACOLOGICAL

• Medications alone are rarely sufficient
• Always combine with behavioral/family therapy
• Monitor for side effects: metabolic (atypical antipsychotics), cardiovascular (stimulants)
• Regular reassessment of diagnosis and medication need

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SLIDE 18: MANAGEMENT - SCHOOL AND COMMUNITY-BASED INTERVENTIONS

• Individualized Education Plans (IEPs) for academic difficulties
• Classroom behavioral management plans
• Fast Track Preventive Intervention Program (evidence: reduces CD development across childhood)
• Social skills groups within school settings
• Teacher training in de-escalation techniques

• Mentoring programs for high-risk youth
• After-school structured programs
• Vocational training for older adolescents
• Juvenile justice diversion programs

• Reserved for severe CD unresponsive to outpatient interventions
• Maintains intensive therapy + structured environment
• Family involvement remains critical even in residential settings

• Early childhood home visitation programs
• Parent education programs in at-risk families
• Addressing poverty, violence exposure, and parental psychopathology

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SLIDE 19: QUALITY OF LIFE (QoL) AND INTEGRATIVE APPROACHES

1. Strength-based assessments - identify positive traits, interests, and skills
2. Therapeutic alliance - non-blaming, collaborative approach with child and family
3. Trauma-informed care - address ACEs (adverse childhood experiences)
4. Mindfulness-based interventions - emotional regulation, impulse control
5. Physical activity programs - structured sports, martial arts (evidence for aggression reduction)
6. Family cohesion - restoring warm parent-child relationships as foundation of all treatment
7. Coordination of care - pediatrician, child psychiatrist, school counselor, social worker

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SLIDE 20: PROGNOSIS AND TAKE-HOME MESSAGES

1. These are among the most prevalent childhood psychiatric disorders seen in pediatric practice
2. Early identification and intervention significantly improve long-term outcomes
3. Multi-modal, integrative treatment (behavioral + pharmacological + school + family) is always superior to single-modality treatment
4. Comorbidities (especially ADHD) must be identified and treated
5. The family relationship is the foundation - parent training is the single most evidence-based intervention
6. Quality of life across academic, social, physical, and legal domains must be monitored

• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 11e
• Kaplan & Sadock's Synopsis of Psychiatry
• The Harriet Lane Handbook, 23e (Johns Hopkins)
• DSM-5-TR (APA, 2022)

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APPENDIX: QUICK REFERENCE - DSM-5-TR DIAGNOSTIC CRITERIA MNEMONICS

• Angry, Touchy, Resentful (Angry/Irritable cluster - 3 symptoms)
• Argues, Defies, Deliberately annoying, Blames, Vindictive (Argumentative/Defiant + Vindictive cluster - 5 symptoms)

• Aggression to people/animals (7 criteria)
• Destruction of property (2 criteria)
• Deceitfulness/theft (3 criteria)
• Rule violations (3 criteria)

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Summary of All 20 Slides

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• ODD and CD are developmentally linked - most children who develop CD begin with ODD symptoms, but ~50% of ODD cases resolve without progressing
• The LPE (Limited Prosocial Emotions) specifier in CD (callous-unemotional traits) is the most important prognostic marker - strongest genetic influence, reduced emotional arousal, least responsive to standard punishment-based interventions
• Parent-Child Interaction Therapy (PCIT) has >30 RCTs for preschool ODD and is considered the gold standard for ages 2-6
• Multisystemic Therapy (MST) is the gold standard for adolescents with CD and delinquency
• For ODD without ADHD, no medication has proven direct benefit - psychosocial therapy is the only evidence-based intervention
• When both ODD and DMDD criteria are met, only DMDD is diagnosed