• Subscribe
  • Register for free Content
  • Cart
  • Login
  • Browse by Topic
    • 13 Reasons Why
    • ABA
    • Abstinence
    • Acamprosate
    • Addiction
    • Addiction Treatment
    • Addyi
    • Adhansia
    • Adhansia XR
    • ADHD
    • ADHD Attention Deficit Hyperactivity Disorder
    • ADHD Rating Scale-5
    • ADHD-RS-5
    • Adherence
    • Adjunct treatment
    • adolescents
    • Aducanumab
    • Aduhelm
    • Adult ADHD
    • Adverse Childhood Experiences (ACES)
    • adverse events
    • affective disorders
    • Affordable Care Act (ACA)
    • aggression
    • Agitation
    • Aid to capacity evaluation (ACE)
    • AIMS test (Assessment of Involuntary Movement)
    • air pollution
    • Akathisia
    • Alcohol
    • alcohol abuse
    • alcohol dependence
    • Alcohol Poisoning
    • Alcohol related liver disease
    • Alcohol Use
    • Alcohol use disorder
    • Alcoholism
    • Alpha Agonists
    • Alternative treatments
    • Alzheimers
    • Amantadine
    • amino acids
    • amphetamine
    • Amphetamines
    • anabolic steroids
    • Andro
    • Androstenedione
    • Anorexia
    • Anorexia Nervosa
    • Anti-NMDA Receptor Encephalitis
    • Antibiotic
    • Anticholinergic burden scale
    • Anticholinergics
    • Antidepressant
    • Antidepressant Augmentation
    • Antidepressants
    • Antipsychotic
    • Antipsychotics
    • Anxiety
    • Anxiety Disorder
    • anxiety disorders
    • APA CE Post-Test
    • Applied Behavioral Analysis
    • Aptensio
    • Aripiprazole
    • ArModafinil
    • Asenapine
    • Assault
    • Assent
    • Assessment
    • asthma
    • atamoxetine
    • Athletic performance
    • Ativan Challenge Test
    • Atomoxetine
    • Atomoxetine (ATX)
    • Atropine
    • attention
    • Attention Deficit Hyperactivity Disorder
    • Atypical Antipsychotics
    • Austedo
    • Autism
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder autism spectrum disorder
    • Behavior therapy
    • Behavioral addiction
    • Behavioral therapy
    • Behavioral treatment
    • Belsomra
    • Benzodiazepine
    • Benzodiazepines
    • Benzphetamine
    • Beta-blockers
    • Billing
    • Bipolar Depression
    • Bipolar Disorder
    • Bipolar II
    • Black youth
    • Bleeding
    • Board Certification
    • Borderline Personality Disorder
    • Boredom
    • BPD
    • BPSD (behavioral and psychological symptoms of dementia)
    • Brain Devices
    • Breastfeeding
    • Brexpiprazole
    • Brief psychotherapy
    • brief pulse
    • Brief Strategic Family Therapy (BFST)
    • Bulimia Nervosa
    • Bullying
    • Bumetanide
    • Buprenorphine
    • Buprenorphine Induction
    • Bupropion
    • Bush-Francis Scale
    • Buspirone
    • C-Reactive Protein
    • Caffeine
    • CAM Treatments
    • Cancer
    • Cannabidiol
    • Cannabis
    • Capacity
    • Caplyta
    • Carbamazepine
    • Cardiovascular
    • Cariprazine
    • Catatonia
    • CATIE
    • CBT
    • CBTi
    • Central Alpha Agonists
    • CGI
    • Chantix
    • Child and adolescent
    • Child Psychiatry
    • Child Psychiatry
    • childcare
    • children
    • children and adolescents
    • Chlorpromazine
    • Chokroverty
    • Chromosomal Microarray
    • circadian system
    • Citalopram
    • Clinical Global Impressions
    • Clinical practice
    • Clinical Practice Guidelines
    • Clozapine
    • CME Post-Test
    • co-morbidities
    • Co-occurring disorders
    • Cocaine
    • Cognition
    • Cognitive Behavioral Therapy
    • Cognitive Behavioral Therapy for Insomnia
    • Cognitive Behavioral Therapy for Insomnia (CBTi)
    • Cognitive Decline
    • Cognitive functioning
    • cognitive impact
    • Cognitive impairment
    • Cognitive Rehabilitation Therapy (CRT)
    • Collaboration
    • Collaborative care
    • Collateral data
    • Combination treatment
    • Combined Pharmacotherapy
    • Commitment
    • community trauma
    • Comorbidity
    • complementary medicine
    • Complementary treatments
    • Complimentary Medicine
    • Complimentary treatments
    • compulsions
    • Computer addiction
    • Computers in Psychiatric Practice
    • Conduct Disorder
    • Confidentiality
    • Connect
    • Connection
    • Connections
    • Consensual
    • Consent
    • Contagion
    • Contempla
    • contingency management
    • contraceptive services
    • control group
    • Coronavirus
    • Cosmetic pharmacology
    • Countertransference
    • court hearings
    • COVID-19
    • COVID19
    • craving
    • creatine
    • creatine monohydrate
    • Creativity
    • Crime
    • Criminal behavior
    • Crisis intervention
    • Crocus Sativus
    • CRP
    • Cultural Competence
    • Culture
    • custody agreement
    • Cymbalta
    • CYP2C19
    • CYP2D6
    • DASH diet
    • Dayvigo
    • De-escalation
    • Debriefing
    • Decisional Capacity
    • Degarelix
    • Deliberate foreign body ingestion
    • Delirium
    • Delusional Disorder
    • Dementia
    • Deplin
    • Deprescribing
    • Depression
    • Depressive Disorder
    • designer drugs
    • Detoxification
    • Deutetrabenazine
    • Developmental Relationship Based Intervention
    • DFBI
    • Diabetes
    • diabetes insipidus
    • Diagnosis
    • Diagnostic Testing
    • diet
    • Dietary Approaches to Stop Hypertension (DASH)
    • Diethylpropion
    • Diphenhydramine
    • Disaster
    • Discrepancies
    • Disparities
    • Dispositional capacity
    • Disruptive Mood Dysregulation Disorder (DMDD)
    • Disulfiram
    • Divalproex
    • Diversity
    • Divorce
    • DMDD
    • Dopamine
    • Dosage Timing
    • Dose Response
    • Dosing
    • double blind
    • DRBI
    • Drooling
    • Droperidol
    • drug misuse
    • Drug-assisted psychotherapy
    • DSM
    • Dual diagnosis
    • Duloxetine
    • duty to protect
    • duty to warn
    • Dyanaval
    • Dyslexia
    • Dysregulation
    • E-Cigarettes
    • Eating Disorders
    • eating restriction
    • eCigarettes
    • ECT
    • effect size
    • Effexor
    • efficacy
    • EHR
    • Electroconvulsive therapy
    • Electronic Health Records
    • electronic use
    • Emergency
    • Emergency Department
    • emergent suicidality
    • emotion dysregulation
    • Emotional dysregulation
    • Encephalitis
    • End of Life Care
    • Engagement
    • Equine Assisted Psychotherapy
    • Equine therapy
    • Escitalopram
    • Esketamine
    • Estrogen
    • Eszopiclone
    • eTNS
    • Evekeo
    • excessive exercise
    • Exercise
    • Existing marijuana
    • expressed emotion
    • extended dosing
    • extended-release
    • Falls
    • Family Separation
    • Fast-acting
    • FDA
    • FDA Warnings
    • Female hypoactive sexual desire disorder
    • Female Issues in Psychiatry
    • fentanyl
    • fetal effects
    • First Generation Antipsychotics (FGAs)
    • fluid restriction
    • Fluoxetine
    • Folate
    • Folic Acid
    • Fragile X
    • Free Articles
    • gabapentin
    • GAD
    • GAMC
    • Gastroenterology
    • GDD
    • Gender
    • Gender & Sexuality
    • Gender Affirming Medical Care
    • Gender Diverse
    • Gender Dysphoria
    • Gender Dysphoric Disorder
    • Gender Identity
    • Generalized Anxiety Disorder
    • Generics
    • GeneSight
    • Genetic Testing
    • Genetics and Psychiatry
    • Geriatric
    • Geriatric Psychiatry
    • Geriatrics
    • Ginkgo
    • Good Psychiatric Management
    • Guanfacine
    • Hair loss
    • Haloperidol
    • Harm reduction
    • Head Trauma
    • Health Apps
    • Healthy aging
    • Hearing loss
    • Heart health
    • Heart rate
    • Hemorrhagic
    • Hepatitis
    • Heroin
    • Higher-calorie refeeding
    • HIPAA
    • Histamine
    • HIV
    • Hormone Replacement Therapy
    • Hospital policy
    • HRT
    • huffing
    • hydroxymethyl butyrate (HMB)
    • Hydroxyzine
    • hypersalivation
    • hypersexual behaviors
    • Hypnotics
    • Hypomania
    • Hyponatremia
    • IDEA
    • Incarceration
    • Inclusion
    • Inclusion strategies
    • Independent Educational Plan (IEP)
    • induction
    • infant
    • Inflammation
    • Ingrezza
    • Inhalants
    • Innovations
    • Inpatient Psychiatry
    • inquiry
    • Insomnia
    • Insulin resistance
    • Insurance
    • intermittent fasting
    • Internet
    • interpersonal stressors
    • Interpreter
    • Intervention
    • Intra-cerebral hemorrhage
    • Intra-nasal
    • involuntary civil commitment
    • Irritability
    • IV immunoglobulin therapy (IVIG)
    • Jornay PM
    • Keppra
    • Ketamine
    • l-methylfolate
    • Laboratory Testing in Psychiatry
    • lactation
    • Lamictal
    • Lamotrigine
    • Language
    • Lavender
    • Learning & Developmental Disabilities
    • Least Restrictive Environment
    • Legal issues
    • Lemborexant
    • Levetiracetam
    • Lewy Body Dementia
    • LGBT
    • LGBTQ+
    • Life coaching
    • Life expectancy
    • Light and Dark Therapy
    • Light therapy
    • Lightbox
    • Liraglutide
    • Literacy
    • Lithium
    • Longevity
    • lorazepam taper
    • Low calorie refeeding
    • Low libido
    • low sodium
    • Lumateperone
    • Lurasidone
    • Lyrica
    • maintenance ECT
    • Malingering
    • Malnourishment
    • Management
    • Mania
    • Mania on Antidepressants
    • MAOIs
    • Marijuana
    • MDMA
    • Media
    • Medical Comorbidities
    • Medical incapacity hold
    • Medication
    • Medication adherence
    • medication capacity hold
    • Medication for Opioid Use Disorder
    • Medication for Opioid Use Disorder (MOUD)
    • medication of opioid use disorder (MOUD)
    • medications
    • Melatonin
    • Memantine
    • memory loss
    • Mental Health
    • Meta-analysis
    • Metabolic syndrome
    • Metformin
    • Methadone
    • Methamphetamines
    • methylfolate
    • methylphenidate
    • Micronutrients
    • Mind-Gut Connection
    • Mindfulness
    • Minocycline
    • Minority
    • Mirtazapine
    • Mixed Features
    • Modafinil
    • Mood
    • mood disorders
    • Mood stabilizer
    • Mood Stabilizers
    • Mortality
    • Motivational Interviewing
    • MTA
    • MTHFR
    • muscle dysmorphia
    • Mydayis
    • Naloxone
    • Naltrexone
    • Narcolepsy
    • Natural Medications
    • natural treatments
    • Naturalistic Developmental-Behavioral Intervention
    • NDBI
    • Negative Symptoms
    • Negative symptoms of schizophrenia
    • Netflix
    • neuroleptic malignant syndrome
    • Neurology
    • Neuroscience in Psychiatry
    • Neurotoxicity
    • New York
    • newborn
    • News of Note
    • nicotine
    • Nightmares
    • NMDA
    • NNH
    • NNT
    • Nomogram
    • Non-pharmacologic
    • Non-suicidal self-injury
    • Norepinephrine
    • Nortriptyline
    • Novel drug
    • Novel Medications
    • Nuedexta
    • null hypothesis
    • number needed to harm
    • number needed to treat
    • Nuplazid
    • Nurses
    • Nutrition
    • Nuvigil
    • Obesity
    • observational study
    • obsessions
    • Obsessive Compulsive Disorder
    • Obsessive compulsive disorder/OCD
    • OCD
    • olanzapine
    • Omega-3
    • Online Learning
    • online therapy
    • Open Label
    • Opioid antagonist
    • Opioid epidemic
    • Opioid Use Disorder
    • Opioids
    • oppositional behavior
    • Oral Contraceptives
    • Orexin
    • Orthostasis
    • Osmolality
    • Osteporosis
    • Outcome tracking
    • Outcomes
    • Outpatient
    • Over the counter
    • Over the counter medication
    • Overdiagnosis
    • Overdose
    • Oxcarbazepine
    • p-value
    • Pain
    • pandemic
    • Panic Disorder
    • Parent Training
    • Parenting Strategies
    • Parents
    • Parkinson’s
    • Parkinson’s Disease
    • Paroxetine
    • Particulate matter
    • Patch
    • Patient relationship
    • pediatric
    • Pediatric Acute Onset Neuropsychiatric Syndrome (PANS)
    • Pediatric Autoimmune Neurologic Disorder Associated with Streptococcus (PANDAS)
    • Pedophilic Disorder
    • Performance Enhancing Substances
    • Perseveration
    • Perseverative Behavior
    • Personality Disorders
    • Pharmaceutical Industry
    • Pharmacogenomics
    • Pharmacology
    • Pharmacology Tips
    • Pharmacotherapy
    • Pharmacy
    • Phendimetrazine
    • Phentermine
    • phonemic awareness
    • Phonics
    • Physician assisted suicide
    • Pica
    • PICOT
    • Pimozide
    • Pitolisant
    • Podcast
    • polypharmacy
    • post traumatic stress disorder
    • post-exposure prophylaxis
    • Post-hoc Analysis ADHD Rating Scale-5
    • Post-menopausal
    • Post-stroke depression
    • Posterior Probability
    • Postpartum Depression
    • Potency
    • Practice management
    • Practice Tools and Tips
    • Practice Tools and Tips
    • Pramipexole
    • Prazosin
    • Pregabalin
    • Pregnancy
    • pregnancy testing
    • Prepubescent children
    • prescribing patterns
    • Prescription costs
    • prevalence
    • Prevention
    • Primary care
    • primary outcome
    • Prison
    • Privacy
    • Prodrome
    • Prolactin
    • Prolonged exposure
    • Promethazine
    • Promotoras
    • Pronouns
    • Provigil
    • Prozac
    • pseudobulbar affect
    • Psilocybin
    • Psychedelics
    • Psychiatric interviewing
    • Psychoanalysis
    • Psychodynamic therapy
    • Psychological First Aide
    • Psychopharm Myths
    • Psychopharmacology
    • Psychopharmacology Tips
    • Psychosis
    • Psychotherapy
    • Psychotherapy
    • Psychotic Agitation
    • Psychotic Depression
    • psychotic disorders
    • Psychotropic medication
    • PTSD
    • Public health
    • Qelbree
    • Quality of care
    • quality of life
    • Quetiapine
    • Quillivant
    • Race
    • Raloxifene
    • Randomized controlled trial
    • randomized discontinuation design
    • rapid naming
    • Rapid-acting
    • RCT
    • Reading
    • Reading disorder
    • Reading Disorders
    • Reading remediation
    • recovery time
    • Red Cross
    • Refeeding syndrome
    • Registered Articles
    • Relationships
    • Remediation
    • Repetitive Behavior
    • Repetitive behaviors
    • replication
    • reporting requirements
    • Research
    • Research Update
    • Research Updates
    • Respectful Care
    • restrictive dieting
    • retarded vs excited catatonia
    • retention
    • Retirement
    • retrograde amnesia
    • Riluzole
    • Risk
    • Risk Management
    • Risk of Addiction
    • Risperidione
    • Risperidone
    • Ritalin
    • rTMS
    • safety
    • Safety Planning
    • Saffron
    • SAMe
    • Samidorphan
    • Saphris
    • Schizoaffective disorder
    • Schizophrenia
    • School Phobia
    • School Refusal
    • screening
    • ScreeninGeg
    • Seasonal Affective Disorder
    • Second Generation Antipsychotics (SGAs)
    • secondary outcome
    • Secuado
    • Self-injury
    • Self-Regulation
    • Semaglutide
    • Separation
    • Separation Anxiety
    • SERM (Selective Estrogen Receptor Modulator)
    • Serotonin
    • Serotonin Norepinephine Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors (SSRIs)
    • Sertraline
    • Sex offenders
    • Sex Therapy
    • Sexual Abuse
    • Sexual Dysfunction
    • sexual intercourse
    • Sexual Side Effects
    • SIADH
    • Side Effects
    • Silexan
    • Skype
    • Sleep
    • Sleep Apnea
    • Sleep Disorders
    • Sleep Onset Insomnia
    • Smoking Cessation
    • Smoking Cessation Agents
    • smoking cessations
    • SNRIs
    • Social Anxiety
    • Social Anxiety Disorder
    • social cohesion
    • sodium supplementation
    • Somnambulism
    • Special populations
    • Specific Phobia
    • SSRIs
    • statistical significance
    • Statutes
    • Stereotypical Behavior
    • steroids
    • STI screening
    • Stigma
    • stimulant
    • Stimulant Medications
    • Stimulant treatment
    • Stimulant use disorder
    • Stimulants
    • Stroke
    • structured literacy
    • Suboxone
    • Substance Abuse
    • Substance Abuse
    • Substance Use
    • Substance Use Disorder
    • Substance use disorders
    • Suicidality
    • Suicide
    • Sundowning
    • Supplements
    • Surrogate decision-maker
    • Suvorexant
    • Swallowing
    • Symptom Assessment
    • Symptom Management
    • Systematic review
    • Tags
    • Tantrums
    • Tarasoff
    • Tardive dyskinesia
    • Technology
    • Teen
    • teens
    • Telehealth
    • Telemed
    • Telemedicine
    • Telepsychiatry
    • test cme quiz
    • testifying
    • Tetrabenazine
    • TFCBT
    • TGD
    • Therapy during medication appointment
    • Therapy with Med Management
    • tics
    • TMS
    • Tobacco
    • tobacco research
    • Tobacco use disorder
    • Top 10 Podcasts of 2021
    • Topiramate
    • Toxic Stress
    • Transcranial Magnetic Stimulation
    • Transdermal
    • Transgender
    • Translator
    • Trauma
    • Trauma Informed Care
    • Traumatic Brain Injury (TBI)
    • Trazodone
    • treatment
    • treatment efficacy
    • treatment pediatric
    • Treatment planning
    • Treatment-Resistant Depression
    • Trigeminal Nerve Stimulation
    • Trintellix
    • unblinded
    • Understanding Psychiatric Research
    • unilateral vs bilateral
    • urinary difficulties
    • urine toxicology
    • Valbenazine
    • Valproate
    • Vaping
    • Varenicline
    • Venlafaxine
    • verbal de-escalation
    • videogaming addiction
    • Viloxazine
    • Violence
    • Vitamin B6
    • Vitamin D
    • Vitamin E
    • VMAT2 Inhibitors
    • Vortioxetine
    • Vyleesi
    • Waist circumference
    • Wakix
    • water intoxication
    • water restriction
    • Weed
    • Weight gain
    • Weight Loss Medications
    • Weiss Functional Impairment Rating Scale-Parent (WFIRS-P)
    • Wellbutrin
    • whey protein powders
    • Whole Genome Sequencing
    • Wilderness Therapy Programs
    • Withdrawal
    • Women's Issues in Psychiatry
    • Women’s Issues in Psychiatry
    • Working With Families
    • workplace
    • Xenazine
    • Youth
    • Zenzedi and ProCentra
    • Ziprasidone
  • HOME
  • STORE
  • CME CENTER
  • Blog
  • Podcast
  • NEWSLETTERS
    • The Carlat Psychiatry Report
    • The Carlat Child Psychiatry Report
    • The Carlat Addiction Treatment Report
    • The Carlat Hospital Psychiatry Report
    • The Carlat Geriatric Psychiatry Report
  • Archive
  • Archive
  • Archive
  • Archive
  • Archive
  • The Carlat Child Psychiatry Report
  • Conduct Disorder in Children and Adolescents (April)
  • Conduct Disorder and Oppositional Defiant Disorder: A Primer

Conduct Disorder and Oppositional Defiant Disorder: A Primer

The Carlat Child Psychiatry Report, Volume 7, Number 3, April 2016
https://www.thecarlatreport.com/newsletter-issue/ccprv7n3/

From The Carlat Child Psychiatry Report, April 2016, Conduct Disorder in Children and Adolescents

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Child Psychiatry | Cognitive Behavioral Therapy | Free Articles | Practice Tools and Tips | Psychotherapy

Print Friendly, PDF & Email

Michael B. Kelly, MD

Clinical assistant professor and the assistant director for the Program in Psychiatry and the Law, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine

Dr. Kelly has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity

Vignette:
Richie was a 15-year-old boy referred for evaluation after multiple run-ins with the police for drug possession, fighting, and shoplifting. Richie was the oldest of three boys and looked up to a gang-involved cousin who was in prison for drug trafficking. The patient was enrolled in multisystemic therapy (MST) for both treatment and further evaluation. Richie’s MST therapist met with his family 3 to 4 times per week over the first three months of treatment. The therapist encouraged the family to increase their level of supervision over their boys, prevent Richie from smoking marijuana at home, and limit his access to problematic peers. Over the course of treatment, Richie’s parents established regular communication with teachers and helped him get involved with a local boxing team after school. Richie’s therapist reduced the frequency of visits over the final two months of treatment. At the conclusion of treatment, Richie was meeting curfew consistently, completing school assignments, and no longer testing positive for marijuana. Richie’s younger siblings also began doing their school work more consistently and behaving better on the playground.

What is conduct disorder? Are there different types? And more importantly, how can we best treat these patients?

This month’s Q & A with Dr. Marsh touches on these issues, and I recommend you read that interview first to give you a basic foundation. In this article, I’ll go through the topic in a more structured and systematic way, so that you can get a lay of this complicated land.

Defining terms: Conduct disorder and oppositional defiant disorder
Both conduct disorder (CD) and oppositional defiant disorder (ODD) are under the larger umbrella category of “disruptive behavior disorders.”

ODD is defined by a pattern of angry, argumentative, irritable, defiant, and/or vindictive behavior for 6 months or greater. In order to meet full DSM-5 criteria for the disorder, a young person must display 4 or more cardinal symptoms that relate to mood, defiance, and retaliatory behavior (see the table “DSM-5 Criteria for Oppositional Defiant Disorder and Conduct Disorder” on page 4).

In contrast to ODD, CD is identified on the basis of behaviors that often violate the rights of others and break social rules—as opposed to simply being defiant and angry. In order to meet DSM-5 criteria for conduct disorder, a person must meet 3 of 15 diagnostic criteria spanning four separate domains (see the table on page 4). DSM-5 further divides conduct disorder into two subtypes based on age of onset (ie, before or after 10 years of age). Youth who develop conduct disorder prior to age 10 tend to have a less favorable long-term prognosis.

Finally, DSM-5 also includes a “with limited prosocial emotions” specifier for youth with CD who have 2 or more of the following traits: lack of remorse or guilt, callousness or lack of empathy, absence of concerns about performance, and a shallow or deficient affect. Like early age of onset, this specifier implies a poorer prognosis. The limited prosocial emotions specifier is often more colloquially termed psychopathic traits, and these are not unique to CD. Psychopathic traits also occur in ODD and, as in CD, are correlated with worse treatment outcomes.

According to the Centers for Disease Control, around 3.5% of youth between the ages of 3 and 17 years have a behavioral problem such as ODD or CD at any given time. Disruptive behavior disorders are more common in boys than girls by a margin of roughly 2:1 (Perou R et al, MMWR Surveill Summ 2013;62(Suppl 2), 1–35). About 40% of youth with ODD go on to develop CD (Loeber R et al, J Am Acad Child Adolesc Psychiatry 2000;39(12):1468–1484).

CD and ODD rarely occur as isolated conditions. Most kids with either diagnosis have at least one other psychiatric disorder, the most common being learning disorders, depression, bipolar disorder, anxiety disorders, substance use disorders, and attention-deficit/hyperactivity disorder (ADHD) (Maughan B et al, J Child Psychol Psychiatry 2004;45(3):609–621). The combination of ADHD and CD is especially troublesome, since it’s associated with substance use disorders and persistent antisocial behavior in adulthood. By the way, adults can also have either CD or ODD—with the provision that those who meet criteria for antisocial personality disorder can’t also have CD.

Hot vs. cold aggression
While not incorporated into DSM-5, recent research has found that there are two types of aggression: hot vs. cold. Understanding this distinction will help you in your treatment of patients with CD.

Hot aggression has a defined trigger and is essentially losing one’s temper. It is also referred to in the literature with the mnemonic RADI: Reactive, Affective, Defensive, and Impulsive. A good example from popular culture of hot aggression is the Incredible Hulk. Bruce Banner is a mild-mannered scientist who morphs into “the Hulk” whenever he is threatened or becomes angry. The Hulk’s rage is nearly impossible to control.

Cold aggression, by contrast, is more similar to what many people think of as psychopathic aggression. A common mnemonic for it is PIP: Planned, Instrumental, and Predatory. An extreme portrayal of cold aggression is Dr. Hannibal Lecter from the book and movie Silence of the Lambs. Dr. Lecter coldly calculates and plans violence of all sorts to satisfy his desires, and he is devoid of empathy and remorse.

Youth with a propensity for cold aggression often have reduced biologic reactivity to dangerous and stressful situations. They also tend to be less biologically responsive when observing fearful facial expressions in others and are relatively undeterred by punishment. Cold aggression identifies youth who qualify for DSM-5’s specifier, “limited prosocial emotions.” Other terms often used for these kids include “callous-unemotional” or “psychopathic” personality traits.

Youth with CD often display mixtures of hot and cold aggression. Understanding a patient’s aggression profile is important in terms of your treatment decisions. Youth with CD and hot aggression are more responsive to therapy and medications (Steiner H et al, Child Adolesc Psychiatry Mental Health 2011;5:21). Those with cold aggression usually need structured, longer-term, intensive services—a type of care that generally is hard to find.

Risk factors for CD and ODD
While causes of CD of ODD are far from established, there are certain well-known risk factors. These include those you would suspect—poverty, growing up in dangerous neighborhoods with increased risk of exposure to trauma and abuse, inconsistent parenting practices, lack of appropriate supervision, parental incarceration, and associating with delinquent peers. For both CD and ODD, evidence suggests that temperamental factors such as poor emotional regulation during infancy and early childhood are key, especially with inconsistent or ineffective parenting with ODD and harsh, punitive parenting with CD (Manglio R, Trauma Violence Abuse 2015;16(3):241–257).

Treatment of CD and ODD
The main treatments available for CD and ODD involve psychosocial interventions and, in some cases, medication for symptom relief. We’ve put together a table, “Potential Treatments for Conduct Disorder and Oppositional Defiant Disorder,” below outlining these interventions.

Psychosocial interventions
Parent management training (PMT) aims to empower parents to retake the reins within the family system, set clear expectations, and incentivize appropriate behavior, all while providing healthy doses of positive reinforcement. In PMT, parents are initially tasked with observing their children’s behavior closely so they can create explicit goals and then monitor progress. Parents learn to incentivize positive behaviors through social reinforcers (eg, praise, hugs) and tokens (eg, gold stars, points) that can be exchanged for special activities (such as going out for ice cream or to a baseball game). Parents learn to provide discipline promptly, calmly, and consistently in this approach. PMT has been shown to be quite effective for ODD and ADHD and somewhat effective for CD. This approach works best with school-aged children, although it has been used effectively in conjunction with individual approaches in teens.

Multisystemic therapy (MST) is an approach designed for a subset of conduct-disordered youth who are entrenched in the juvenile justice system and often also have comorbid substance use problems. The technique targets environmental factors that perpetuate juvenile delinquency and substance abuse. MST therapists are on call 24 hours a day to help families stay on track. Over a typical four- to five-month treatment course, MST teaches parents how to better monitor their kids for problematic behaviors. MST therapists also help parents work effectively with teachers, probation officers, case workers, etc. to ensure that the benefits of MST continue after treatment is terminated. MST has been shown to reduce recidivism and substance abuse and also appears to reduce the likelihood of conduct problems in the siblings of MST clients (Wagner DV et al, J Consult Clin Psychol 2014;82(3):492–499).

Table: Potential Treatments for Conduct Disorder and Oppositional Defiant Disorder


Click here to view table as full-sized PDF.

Medications
There are no FDA-approved medications for the treatment of CD or ODD. However, there’s some evidence for the effectiveness of valproic acid, especially for curbing hot aggression (Padhy R et al, Child Psychiatry Hum Dev 2011;42(5):584–593). Atypical antipsychotic medications are also effective in reducing hot aggression when used judiciously, while stimulants can improve both CD and ODD when they are comorbid with ADHD (Connor DF and Doerfler LA, J Atten Disord 2008;12(2):126–134). There are no hard-and-fast dosing guidelines for treating hot aggression. In general, medications should only be used when behavioral interventions aren’t enough. As always in child and adolescent psychiatry, we recommend that you “start low and go slow” when initiating meds on kids, especially those prone to hot aggression. However, medications don’t seem to touch kids with cold aggression.

Conclusion
In sum, CD and ODD are serious, often chronic disorders that can produce major problems for the individual, family, and society more broadly. Too often, individuals with these diagnoses are dismissed as “bad apples” and may well end up in the legal system, where effective treatment is unlikely to be available. Accurate diagnosis and intervention, especially of ODD and some subtypes of CD, can be life-changing.

Suggested Articles

  • The Best and Worst Antipsychotics for Mania - Part 2 October 25, 2021 In the final episode of our 3-part series on antipsychotics, you’re going to find out…
  • When Psilocybin was a Psych Med September 13, 2021 Phase III clinical trials are beginning to roll out for psychedelic medications like like psilocybin…
  • How to Use Nortriptyline August 30, 2021 Nortriptyline + lithium is one of the top combos for keeping patients well after ECT,…
  • Antidepressants in Bipolar II: What the Experts Do April 19, 2021 18 experts weigh in on how they use antidepressants in bipolar II. Sleep onset latency…

Powered by Contextual Related Posts

Michael B. Kelly, MD

Clinical assistant professor and the assistant director for the Program in Psychiatry and the Law, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine

Dr. Kelly has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Share this page!
Subscribe
Register for free content

Register For Free Articles

Register to receive free email newsletters with concise, practical advice for busy clinicians. You will also have access to select article content on the website and you will receive notifications of new books and special discount offers.




Courses and Book CME
Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Genetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • ADHD in Children and Adolescents (April/May/June)
  • Assessment in Children and Adolescents (January/February/March)

2021

  • Overarousal in Children and Adolescents (Oct/Nov/Dec)
  • Substance Use in Children and Adolescents (Jul/Aug/Sep)
  • Autism in Children and Adolescents (April/May/June)
  • Clinical Complexity With Children and Adolescents (Jan/Feb/Mar)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Joshua D. Feder, MD

Dr. Joshua Feder studied mathematics and medicine at Boston University, Psychiatry at Naval Regional Medical Center San Diego, serving the first gulf war in child and adolescent psychiatry fellowship at Tripler Army Medical Center in Honolulu, and eventually becoming Chief of Child Psychiatry at the National Naval Medical Center in Bethesda, MD. Dr. Feder now practices in Solana Beach, California and serves as Medical Director at Positive Development, providing relationship-based support for families, with research at UCSD, SDSU, Fielding Graduate University, An Najah National University, Quicksilver Software, Autism Is inclusion program, and Programmatic Lead for the International Networking Group on Peace Building with Young Children, with projects in the US, Northern Ireland, and the Middle East. Dr. Feder co-authored the first American Academy of Child & Adolescent Psychiatry Practice Parameter on Autism and serves on the Disaster & Trauma Committee and the Resource Group on Youth at the Border. Dr Feder was founding policy chair for the California Association for Infant Mental Health, and advocates worldwide on access to care, climate policy, and peacebuilding. His recent books include Child Medication Fact Book for Psychiatric Practice (2018) and Prescribing Psychotropics (2021).

Full Editorial Information

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Subscriptions
  • Books
  • Online Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Child Psychiatry Report
  • The Carlat Hospital Psychiatry Report

Contact

  • info@thecarlatreport.com
  • 866-348-9279
  • PO Box 626, Newburyport MA 01950

Follow Us

© 2022 Carlat Publishing, LLC and Affiliates, All Rights Reserved.

Please see our Privacy Policy and the Hardware/Software Requirements to view our website.

×