5/2/2017. By Pamela Pepper PMH, CNS, BC. DSM-5 Growth and Development

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1 By Pamela Pepper PMH, CNS, BC DSM-5 Growth and Development The idea that diagnosis is based on subjective criteria and that those criteria should fall neatly into a set of categories is not sustainable, especially for diagnosis in children, for whom symptoms are fluid. 1

2 Many of the symptoms that define the disruptive impulse control and conduct disorders are behaviors that occur to some degree in typically developing individuals. Thus it is critical that the frequency, persistence, pervasiveness across situation, and impairments associated with the behaviors indicative of the diagnosis be considered relative to what is normative for the person s age, gender, and culture when determining if they are symptomatic of a disorder. DSM-5 Disruptive impulse control and conduct disorders Conduct disorder-behavior issues Intermittent Explosive disorder-emotional issues Odd midway between the two A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least 4 symptoms from any of the following categories and exhibited in interactions with at least 1 individual who is not a sibling. 2

3 Often loses temper Is often touchy or easily annoyed Is often angry and resentful Often argues with authority figures or for children and adolescents with adults Often actively defies or refuses to comply with requests from authority figures or with rules Often deliberately annoys others Often blames others for his or her mistakes or misbehaviors Has been spiteful or vindictive at least twice in the past 6 months 3

4 The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 the behavior should occur on most days for a period of at least 6 months. For individuals 5 and older the behavior should occur at least once a week for at least 6 months. The frequency and intensity of behaviors are outside a range that is normative for the individuals developmental level, gender, and culture. The disturbance in behavior is associated with distress in the individual or others such as family, peer, work or it impacts negatively on level social, educational, occupational or other important areas of function. The behaviors do not occur exclusively during the course of psychotic, substance abuse, depressive or bipolar disorder. Also the criteria are not met for disruptive mood dysregulation disorder (DMDD). 4

5 Mild-1 setting Moderate- 2 settings Severe- 3 settings Major Depressive Disorder-depressed mood most of the day nearly every day. note: In children and adolescents can be an irritable mood ADHD Manic episode of bipolar- abnormally and persistently elevated, expansive or irritable mood Conduct disorder- ODD is usually less severe, less aggressive but may have more emotional dysregulation-more anger irritability IED-high rate of anger, aggression more prominent Intellectual disability-the developmental level is the person s mental age Language disorder- failure to follow directions due to not comprehending Social anxiety disorder-defiant due to fear of negative evaluation by others Needs to be at least 6 years old but less than 18 years old. Symptoms started before age 10 Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the provocation Inconsistent with developmental level occurs 3 or more times a week Between outburst mood is irritable or angry most of the day Has been going on for at least 12 months 5

6 1-11% Before adolescents slightly more prevalent in males 1.4:1 At adolescence there is no difference However in psychiatric clinics the prevalence may be up to 50% Temperament qualities such as emotional reactivity, poor frustration tolerance Environmental qualities such as harsh inconsistent or neglectful child rearing practices It is often hard to determine if the child s behavior caused the parents to act in a more hostile manner toward the child or if the parent s hostility led to the problem behaviors, or if there was a combination of the two. 6

7 Lower heart rate, lower skin conductance, reduced basal cortisol reactivity, abnormalities in the prefrontal cortex and amygdala have all been associated with ODD. Parental history of ADHD, ODD, conduct disorder Parental mood disorder, bipolar, depression Parental substance abuse Smoking during pregnancy Exposure to toxins Poor nutrition Poor relationship with 1 or more parents Neglectful or absent parent Difficulty processing social cues Poverty Inconsistent discipline Family instability Rarely develops after adolescence May appear in preschool May progress to conduct disorder Increase risk for anti social behaviors, impulse control problems, substance abuse, anxiety, and depression 7

8 Parent training programs Family therapy Problem solving skills training Social skills programs Medication-EVERYTHING IS OFF LABEL Behind the Wall by Widdifield and Widdifield What good memories do I hold from my child s infancy and childhood? What qualities of my child are dear to me? Can I access these memories during trying times? Am I able to separate behaviors associated with ODD from the person my child really is? Do I blame myself for my child s illness? Do I have reliable people in my life to support me? In what specific ways do I take care of myself? Always build on the positives, give the child praise and positive reinforcement when he shows flexibility or cooperation. Take a time-out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if he decides to take a time-out to prevent overreacting. Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child a time-out in his room for misbehavior, don t add time for arguing. Say your time will start when you go to your room. Set up reasonable, age appropriate limits with consequences that can be enforced consistently. Maintain interests other than your child with ODD, so that managing your child doesn t take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child. Manage your own stress with healthy life choices such as exercise and relaxation. Use respite care and other breaks as needed 8

9 Training the kids in social, cognitive, and emotional management skills such as making friends, communication skills, problems solving, anger management, recognizing and understanding feelings. May be best done in school based programs. Often problems learning a skill in therapy and then transferring this skill to school so school based programs may be more successful. Psychodynamic therapy Play therapy Group therapy- kids tend to learn new problem behaviors from one another Psychodynamic based family therapy One time or short lived therapies such as boot camps, tough love camps, or scare tactics (of note I have seen arrest, juvenile detention and probation be very effective for some kids and not at all effective for others) Stimulants and atomoxetine (strattera) may help with aggression if ADHD is also present. If there is just ODD without ADHD stimulants not helpful. 9

10 Clonidine has been found effective for aggression in conduct disorder in both open label and controlled trials to 0.4 mg/day. Start at HS and may go up to qid. Kapvay, time released clonidine is another option. Guanfacine (tenex) or the time relased, intuniv may help but I haven t found studies on it for aggression. Both are used for the hyperactive part of ADHD. SSRIs first choice when using antidepressants in youth Remember there is a black box warning for youth and young adults for all antidepressants and for medications chemically similar to antidepressants such as Strattera. Due to side effect profile think long and hard before prescribing these Risperdal is the most studied in this category but besides the risk of metabolic syndrome there is also the risk of prolactin elevation 10

11 three controlled studies support the use of lithium for the treatment of explosive anger in youth, two controlled studies indicated no effectiveness. Valproic acid had 2 positive studies for conduct disorder with aggression Carbamazepine was not found effective in one controlled study 67% of children diagnosed with ODD who received treatment were symptoms free 3 years later 33% of children diagnosed with ODD go on to develop conduct disorder 10% of children diagnosed with OD will eventually develop a more lasting personality disorder such as antisocial personality disorder Some children eventually outgrow ODD, but not all do 11

12 Diagnostic and Statistical Manual of Mental Disorders, fifth edition, American Psychiatric Association, ODD A Guide for Families, American Academy of Child & Adolescent Psychiatry, Behind the Wall The true Story of Mental Illness as Told by Parents, by M Widdifield and E Widdifield, Langdon Street Press, Pediatric Psychopharmacology Fast Facts, by D Conner & B Meltzer, W.W. Norton & Company, Facts for Families, by American Academy of Child and Adolescent Psychiatry, #72, July Strengthening social and emotional competence in young children-the foundation for early school readiness and success by C Webster-Stratton and M Reid in Infants and Young Children, vol17, #2, pp , Lippincott, Williams, and Williams,