Conduct Disorder: Diagnosis and Treatment in Primary Care H. RUSSELL SEARIGHT, PH.D., Family Medicine of St. Louis Residency Program, St. Louis, Missouri FRED ROTTNEK, M.D., Institute for Research and Education in Family Medicine, St. Louis, Missouri STACEY L. ABBY, PHARM.D., St. Louis College of Pharmacy, St. Louis, Missouri

Conduct disorder is a common childhood psychiatric problem that has an increased inci- dence in . The primary diagnostic features of conduct disorder include aggres- sion, theft, vandalism, violations of rules and/or lying. For a diagnosis, these behaviors must occur for at least a six-month period. Conduct disorder has a multifactorial etiology that includes biologic, psychosocial and familial factors. The differential diagnosis of con- duct disorder includes oppositional defiant disorder, attention-deficit/hyperactivity disor- der (ADHD), and intermittent explosive disorder. Family physicians may provide brief, behaviorally focused parent counseling, pharmacotherapy and referral for more intensive family and individual psychotherapy. (Am Fam Physician 2001;63:1579-88.)

onduct disorder is a psychiatric icians to refer patients to appropriate subspe- syndrome occurring in child- cialists. Third, conduct disorder increases the hood and adolescence, and is risk of several public health problems, includ- characterized by a longstanding ing , weapon use, teenage pregnancy, pattern of violations of rules and dropping out of school.3-5 Cand antisocial behavior. As listed in the Diag- Thus, it is important to identify conduct disor- nostic and Statistical Manual of Mental Disor- der and begin intervention as early as possible. ders, 4th ed. (DSM-IV),1 symptoms typically include , frequent lying, running Illustrative Cases away from home overnight and destruction of Patients with conduct disorder typically do property (Table 1). Approximately 6 to 16 per- not perceive their behavior as problematic. cent of boys and 2 to 9 percent of girls meet Similarly, parents and teachers often do not the diagnostic criteria for conduct disorder. consider longstanding conduct disorder when The incidence of conduct disorder increases attributing causes to children’s behavior. There- from childhood to adolescence. fore, symptoms of conduct disorder are not Family physicians who treat pediatric pa- usually a presenting concern in the office. The tients frequently encounter this disorder and following cases illustrate typical ways that con- should be knowledgeable about it for several dust disorder may present in family practice. reasons. First, family physicians are increas- ingly treating a broader array of psychiatric ILLUSTRATIVE CASE 1 conditions,2 including common pediatric Tim is a six-year-old boy brought to the problems. Second, primary care family medicine clinic for an initial visit. On physicians often serve as referral sources for entering the examination room, the physician mental health treatment. Thoughtful differen- observed Tim spinning in circles on the stool tial diagnosis of conduct disorder enables clin- while his mother pled,“If I have to tell you one more time to sit down…” Tim was not per- mitted to begin first grade until his immuniza- tions were updated. His mother explained that Symptoms of conduct disorder include aggression, frequent Tim had visited several physicians for immu- lying, running away from home overnight and destruction nization but was so disruptive that the physi- of property. cians and nurses always gave up. She hoped that with a new physician, Tim might comply.

APRIL 15, 2001 / VOLUME 63, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1579 The mother described a several-year history of TABLE 1 aggressive and destructive behavior, as well as DSM-IV Diagnostic Criteria for Conduct Disorder four school suspensions during kindergarten. He often becomes “uncontrollable” at home A. A repetitive and persistent pattern of behavior in which the basic rights of and has broken dishes and furniture. Last year, others or major age-appropriate societal norms or rules are violated, as mani- Tim was playing with the gas stove and started fested by the presence of three (or more) of the following criteria in the past a small fire. Tim frequently pulls the family 12 months, with at least one criterion present in the past six months: dog around by its tail. Tim’s older sisters Aggression to people and/or animals watched him in the past but have refused to do 1. Often bullies, threatens or intimidates others. so since he threw a can of soup at one of them. 2. Often initiates physical fights. Tim’s father is a long-haul truck driver who 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). sees Tim every three to four weeks. 4. Has been physically cruel to people. ILLUSTRATIVE CASE 2 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, Sharon, a 15-year-old girl, was brought to the extortion, armed robbery). office by her mother. Her mother explained 7. Has forced someone into sexual activity. that Sharon was suspended from school for Destruction of property assaulting a teacher and needed a “doctor’s 1. Has deliberately engaged in fire setting with the intention of causing evaluation” before she could return to class. serious damage. The history reveals that this is Sharon’s 10th 2. Has deliberately destroyed others’ property (other than by fire setting). school suspension during the past three years. Deceitfulness or theft She has previously been suspended for fighting, 1. Has broken into someone else’s house, building or car. carrying a knife to school, smoking marijuana 2. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” and stealing money from other students’ lock- others). ers. When asked about her behavior at home, 3. Has stolen items of nontrivial value without confronting the victim (e.g., shoplifting, but without breaking and entering; forgery). Sharon reports that her mother frequently “gets on my nerves” and, at those times, Sharon Serious violations of rules 1. Often stays out at night despite parental prohibitions, beginning before leaves the house for several days. The family age 13 years. history indicates that Sharon’s father was incar- 2. Has run away from home overnight at least twice while living in a parental cerated for auto theft and assault. Sharon’s or parental surrogate home (or once without returning for a lengthy period). mother frequently leaves Sharon and her eight- 3. Is often truant from school, beginning before age 13 years. year-old brother unsupervised overnight. B. The disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning. Clinical Features of Conduct Disorder C. If the individual is age 18 years or older, criteria are not met for antisocial Four types of symptoms of conduct disor- personality disorder. der are recognized: Specify severity: (1) Aggression or serious threats of harm to Mild: few if any conduct problems in excess of those required to make the people or animals; diagnosis, and conduct problems cause only minor harm to others. (2) Deliberate property damage or destruc- Moderate: number of conduct problems and effect on others intermediate tion (e.g., fire setting, vandalism); between “mild” and “severe.” (3) Repeated violation of household or Severe: many conduct problems in excess of those required to make the diag- nosis, or conduct problems cause considerable harm to others. school rules, laws, or both; and (4) Persistent lying to avoid consequences 1 Reprinted with permission from American Psychiatric Association. Diagnostic and or to obtain tangible goods or privileges. statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psy- DSM-IV1 emphasizes that there should be chiatric Association, 1994:90-1. Copyright 1994. at least three specific conduct disorder behav- iors present for at least six months to make the

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diagnosis. Isolated behaviors (e.g., shoplifting, experimentation with marijuana or alcohol) About 40 percent of children with conduct disorder will are common, and specific antisocial acts may grow up to be adults with antisocial personality disorder. occur in up to 80 percent of youth in the United States.6 By contrast, a diagnosis of con- duct disorder requires a persistent history of multiple problem behaviors. onset conduct disorder develops into adult Associated features of conduct disorder antisocial personality disorder.8 Adolescent include an inability to appreciate the impor- conduct disorder should be considered in tance of others’ welfare and little or social context. Adolescents exhibiting conduct about harming others. Adolescents disorder behavior as a part of gang culture or to with conduct disorder often develop skills in meet basic survival needs (e.g., stealing food) outwardly verbalizing remorse to obtain favor are often less psychologically disturbed than or avoid punishment, but do not experience those with early childhood histories of behav- any apparent guilt. Patients with conduct dis- ior disorders. Additionally, new-onset conduct order often view others as threatening or mali- disorder behavior, such as skipping school, cious without an objective basis. As a result, shoplifting or running away, in the context of a these children and adolescents may lash out family stressor, often remits if appropriate preemptively, and aggression may appear structure and support are provided. unprovoked. Physicians should be able to distinguish Etiology between normal adolescent risk-taking and The etiology of conduct disorder involves enduring antisocial behavior. In normal an interaction of genetic/constitutional, famil- experimentation, offenses do not typically ial and social factors. Children who have con- involve serious harm to individuals or prop- duct disorder may inherit decreased baseline erty and do not persistently recur. Isolated or autonomic nervous system activity, requiring acting-out episodes with a recent onset, par- greater stimulation to achieve optimal ticularly among adolescents without previous arousal.9-11 This hereditary factor may account adjustment problems, are often transient reac- for the high level of sensation-seeking activity tions to external stressors. This pattern of associated with conduct disorder.10 Current behavior should prompt physicians to inquire research focuses on defining neurotransmit- about recent parental conflict or separation, ters that play a role in aggression, with sero- geographic moves or school transitions.6 tonin most strongly implicated.11 Among children 10 to 14 years of age, several Parental substance abuse, psychiatric illness, health-related behaviors are red flags for con- marital conflict, and child abuse and neglect all duct disorder. These include cigarette smok- increase the risk of conduct disorder. Exposure ing, sexual activity, and alcohol or drug use.7 to the antisocial behavior of a caregiver is a particularly important risk factor.12 Children Subtypes of Conduct Disorder with conduct disorder, while present in all eco- Conduct disorder has two subtypes: child- nomic levels, appear to be overrepresented in hood onset and adolescent onset. Childhood lower socioeconomic groups.10 Another com- conduct disorder, left untreated, has a poorer mon feature appears to be inconsistent prognosis. Behaviors that are typical of child- parental availability and discipline.10,13 As a hood conduct disorder include aggression, result, children with conduct disorder do not property destruction (deliberately breaking experience a consistent relationship between things, setting fires) and poor peer relation- their behavior and its consequences. ships. In about 40 percent of cases, childhood- This early childhood pattern includes irri-

APRIL 15, 2001 / VOLUME 63, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1581 TABLE 2 Differential Diagnosis and Treatment of Conduct Disorder and Related Conditions

Diagnosis Distinguishing features Treatment

Conduct disorder Persistent pattern of violating others’ Family therapy, behavior modification, rights; aggression and illegal acts pharmacotherapy Oppositional defiant Chronic argumentativeness; refusal Family therapy, behavior modification disorder to comply with adult requests Attention-deficit/ Hyperactivity; behavior ; Pharmacotherapy (stimulants), behavior hyperactivity disorder inattention and distractibility modification Substance abuse/ Pattern of substance use associated Specialized multimodal treatment, dependence with adverse social/personal including group, individual and family consequences or physiologic therapies; medical detoxification and tolerance or withdrawal inpatient treatment Major depression and Dysphoric, irritable mood; sleep Pharmacotherapy (SSRIs), individual and dysthymic disorder and appetite disturbance; family therapy anhedonia; Bipolar mood disorder Depressive symptoms coexist or Pharmacotherapy (lithium, selected alternate with periods of excess anticonvulsants) energy and/or thought racing; or hypomania may include hallucinations, Intermittent explosive Sudden, unpredictable physically/ Pharmacotherapy (anticonvulsants, disorder verbally aggressive outbursts clonidine, lithium, SSRIs), cognitive behavior therapy

SSRIs = selective serotonin reuptake inhibitors.

tability, inconsolability and impaired social cate the situation. These children are also more responsiveness.14,15 Caregivers, particularly susceptible to the rise in peer group influence those with psychiatric conditions and sub- that typically occurs in later elementary stance abuse problems, may respond to these school. children coercively and inconsistently. In addi- tion, these family groups often experience Differential Diagnosis and financial distress, which may further compli- Several common childhood psychiatric conditions have features similar to those of conduct disorder, and comorbid conditions are also common.11 The differential diagnosis The Authors should include attention-deficit/hyperactivity H. RUSSELL SEARIGHT, PH.D., is director of behavioral medicine in the Family Medicine disorder (ADHD), oppositional defiant disor- of St. Louis Residency Program, St. Louis, Mo., and adjunct associate professor of com- munity and family medicine at St. Louis University School of Medicine. Dr. Searight is der, mood disorder (major depression, dys- also adjunct professor of psychology at St. Louis University. thymia, ), substance abuse FRED ROTTNEK, M.D., is director of community services for the Institute for Research and intermittent explosive disorder (Table 2). and Education in Family Medicine, St. Louis, Mo. Dr. Rottnek is also physician coordi- The growing public awareness of ADHD nator for Community Health in Partnership Services (CHIPS), Covenant House Missouri and its relative treatability with stimulant med- and area indigent care clinics. He received his medical degree from St. Louis University School of Medicine and completed a residency at Family Medicine of St. Louis. He also ication may contribute to its confusion with served a faculty development fellowship at University of North Carolina at Chapel Hill conduct disorder. ADHD’s features of disinhi- School of Medicine. bition, inattention and distractibility should be STACEY L. ABBY, PHARM.D., is a clinical pharmacist on the faculty at the Family Med- distinguished from lying, serious aggression icine of St. Louis Residency Program and assistant professor of pharmacy practice at and illegal behaviors. When evaluating a new St. Louis College of Pharmacy. Dr. Abby is also clinical assistant professor of commu- nity and family medicine at St. Louis University School of Medicine. patient with suspected ADHD, questions such as those presented in Table 3 will help differen- Address correspondence to H. Russell Searight, Ph.D., Family Medicine of St. Louis Res- idency Program, Forest Park Hospital, 6125 Clayton Ave., St. Louis, MO 63139. tiate ADHD from conduct disorder. Reprints are not available from the authors. Oppositional defiant disorder may be diffi-

1582 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 8 / APRIL 15, 2001 Conduct Disorder TABLE 3 Interview Questions for Assessing Conduct Disorder

1. Have you had any run-ins with the police? If yes, what were the circumstances? 2. Have you been in physical fights? If yes, what were the circumstances? How many? 3. Have you been suspended or expelled from sions in this regard. Early (i.e., at 10 to 13 years school? If yes, what were the circumstances? of age), repeated use of alcohol or illicit drugs 4. Have you ever run away from home? Overnight? is a red flag for the development of other How many times? behaviors associated with conduct disorder. 5. Do you smoke, drink alcohol or use other Additionally, substance use is likely to further drugs? If yes, what is the frequency and dura- tion of your use? Which drugs?* reduce impulse control and increase contact 16 6. Are you sexually active?* with deviant peers. Intermittent explosive disorder, featuring *—For questions 5 and 6, age should be taken into unprovoked, sudden aggressive outbursts, can account. only be correctly diagnosed when the child’s behavior does not meet the criteria for con- duct disorder. Patients with intermittent cult to distinguish from conduct disorder. Key explosive disorder deny plans to harm anyone features of oppositional defiant disorder but report that they “snapped” or “popped” include argumentativeness, noncompliance and, without realizing it, assaulted another with rules and negativism. While these fea- person. In children and adolescents with tures partially overlap with those of conduct intermittent explosive disorder, these episodes disorder, there are important distinctions. are the only signs of behavior disturbance. Children with oppositional defiant disorder, Other than unplanned acts of aggression, although argumentative, do not display signif- patients with intermittent explosive disorder icant physical aggression and are less likely to do not engage in repeated violations of other have a history of problems with the law. Par- rules or in illegal behavior such as theft or ents of children with oppositional defiant dis- running away from home. order are more likely to have mood disorders than the antisocial pattern common among Intervention parents of children who have conduct disor- Family physicians are often the first profes- der. Oppositional defiant disorder may, with sionals who are consulted by families of chil- time, develop into conduct disorder. dren with conduct disorder. During these vis- Significant acting out frequently occurs its, physicians should emphasize the among children and adolescents with major seriousness of the patient’s behavior and the depression and dysthymic disorder. Patients possibility of a poor long-term prognosis if with early-onset bipolar disorder may exhibit there is no significant parental intervention. impulsive violations of rules and aggression. Parents of children with conduct disorder are However, mood disorders typically include more likely to exhibit depression, substance disturbances of sleep and appetite and pro- abuse and/or antisocial personality traits. nounced affective symptoms, as well as signif- These parental disorders influence children’s icant alterations in energy and activity levels behavior problems associated with inconsis- not found among children with conduct dis- tency, harsh discipline, impaired attachment order. The coexistence of major depression and minimal supervision.17 While parents of with conduct disorder increases the risk of children with conduct disorder often have legal impulsive suicidal behavior. and social difficulties of their own, they usually Substance abuse may also overlap with the do not want their children to have a similar life symptoms of conduct disorder. A key issue in course. Basic intervention guidelines for family assessing substance use in adolescents is the physicians are summarized in Table 4. distinction between experimentation and Conduct disorder has varying degrees of abuse or dependence. The frequency and severity. Parental abuse, onset of problem duration of substance use are helpful dimen- behavior in early childhood, financial hardship

APRIL 15, 2001 / VOLUME 63, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1583 and lack of supervision are all associated with ceptible to peer influences such as smoking, more severe conduct disorder.10,18 Additionally, sexual risk-taking, and alcohol or other sub- a poorer prognosis is associated with an stance abuse. Organized, supervised activities, increase in the number and severity of specific such as sports, Scouting, the arts or recre- DSM-IV criteria.10 Risk also increases with ational programs provided by churches, comorbid ADHD and substance abuse.10 These schools or agency youth clubs often protect dimensions should guide treatment. Subclini- teenagers from negative peer influences.18 cal conduct disorder symptoms or those of recent onset may be amenable to physician- COUNSELING PARENTS ABOUT CLEAR parent counseling. However, more serious, COMMUNICATION longstanding behavior involving aggression, A reasonable initial intervention for family illegal acts, substance abuse or other harmful physicians is parental instruction in commu- acts should prompt referral to a mental health nication for achieving improved compliance. specialist. With comorbid substance abuse, the Parents should communicate clear, direct and focus of initial treatment should be cessation of specific requests (“I would like you to set the drug use and may include medical detoxifica- table for dinner now.”). Importantly, requests tion before rehabilitation. should not be negative or qualified (“Don’t Monitoring of children’s activities and waste all your life in front of the television. whereabouts by adult caregivers is critical. Maybe you could be useful and help with din- Compliance with the evening curfew is essen- ner.”). If the requested activity is not initiated tial. For working parents, telephoning to check within five seconds, a verbal reminder should on the child or having another responsible follow. When the request is made for a third adult ensure that the child is in an appropriate time, a clear, reasonable consequence should setting during nonschool hours is important. be added (“If you have not finished setting the Monitoring becomes particularly important table in fifteen minutes, you will lose one-half during early adolescence when peer group hour of free time with your friends tonight.”). influences increase. Vulnerable youth are sus- The chosen consequences should be restric- tions that the parent can realistically imple- ment rather than those that are vague and TABLE 4 unenforceable (“You never do what I ask; you Practical Interventions for Management of Patients just love to make me mad. Well, you’re with Conduct Disorder grounded for the rest of the year.”).

REINFORCEMENT OF POSITIVE BEHAVIOR Assess severity and refer for treatment with a subspecialist as needed. Treat comorbid substance abuse first. While adverse consequences may be neces- Describe the likely long-term prognosis without intervention to caregiver. sary periodically, parent-child interactions Structure children’s activities and implement consistent behavior guidelines. should also include rewards. Positive rein- Emphasize parental monitoring of children’s activities (where they are, who forcement for desirable behavior will reduce they are with). Encourage the enforcement of curfews. reliance on punishment. Importantly, rewards Encourage children’s involvement in structured and supervised peer activities (e.g., should be concrete, specific and always pro- organized sports, Scouting). vided promptly when the child meets the cri- Discuss and demonstrate clear and specific parental communication techniques. Help caregivers establish appropriate rewards for desirable behavior. teria (“If you set the table by 6 p.m. each night Help establish realistic, clearly communicated consequences for noncompliance. this week, you can choose a video to rent on Help establish daily routine of child-directed play activity with parent(s). Saturday night.”). Parents of children with Consider pharmacotherapy for children who are highly aggressive or impulsive, conduct disorder typically rely on inconsistent or both, or those with mood disorder. coercion, rather than reinforcement, in a fam- ily climate high in negative exchanges.

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Because television, movies and video games are reinforcing to many children and adoles- A reasonable initial intervention for family physicians is to cents, they are often used as rewards. Children teach parents clear, direct and specific communication who are at risk for conduct disorder, however, techniques to use with children who have conduct disorder. may be more likely to exhibit aggressive behavior in response to viewing violence.10,19 Therefore, access to these reinforcers should occur with parental supervision. STIMULANTS In two-parent households or other family Dextroamphetamine (Dexedrine) and situations in which multiple adults set rules, methylphenidate (Ritalin) are the most consistency between caregivers is particularly promising agents used in the treatment of important. In single-parent households, par- conduct disorder. However, there is no con- ticularly those with multiple children, parental sensus concerning stimulant efficacy in con- availability and energy may be limited. Physi- duct disorder. Stimulants evaluated in rela- cians should inquire about the availability of tively small studies have been shown to be other responsible adults to assist with carrying effective in reducing aggression, primarily in out rules under the parent’s guidance.20 patients with ADHD as a comorbidity, when A useful directive to improve the emotional compared with placebo.24,25 climate in families with preteens and younger children is to set aside 15 minutes every day ANTIDEPRESSANTS for parent and child to play together. The child One small, open-label trial26 evaluating the chooses a cooperative activity each day (e.g., efficacy and toxicity of bupropion (Well- playing catch, reading or drawing together). butrin) in attention-deficit disorder (ADD) Structuring such exchanges ensures regular and conduct disorder demonstrated parental- reinforcing contact between parent and rated and self-rated improvement in conduct. child.21 This study suggested that bupropion was safe and effective for use in this population. How- Pharmacotherapy ever, controlled double-blind studies are Pharmacotherapy may be considered as an needed for further evaluation. Fluoxetine adjunct treatment for conduct disorder and (Prozac) also was associated with a significant comorbid conditions. While there are no for- reduction in impulsive-aggressive behavior in mally approved medications for conduct dis- adults with personality disorder.27 While some order, pharmacotherapy may help specific controversy exists, there is concern about the symptoms. Further studies are needed to eval- cardiotoxic effects of tricyclic antidepressants uate the role of pharmacotherapy for conduct in children.28 The selective serotonin reuptake disorder. Commonly used medications are inhibitors (SSRIs) may be particularly helpful summarized in Table 5. in treating children with conduct disorder and By improving attention and increasing comorbid major depression. inhibitory activity, medication may improve children’s capacity to benefit from other psy- LITHIUM AND ANTICONVULSANTS chosocial intervention.22 The majority of pub- Lithium is a psychoactive agent with anti- lished studies involve patients with conduct aggressive properties. Results of several studies disorder and comorbid conditions, such as have demonstrated reduction of aggres- ADHD or major depression. Stimulants, anti- sion.29,30 However, lithium requires regular depressants, lithium, anticonvulsants and blood level monitoring to assess possible toxi- clonidine (Catapres) have all been used in the city. Lithium levels should be checked twice treatment of conduct disorder.23 weekly until clinical status and levels are sta-

APRIL 15, 2001 / VOLUME 63, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1585 TABLE 5 Pharmacotherapy for Conduct Disorder

Medication Dosage range Common adverse effects Monitoring/special considerations

Stimulants Methylphenidate For children six years and older: Anorexia, nervousness, sleep Periodic CBC with differential and (Ritalin) 2.5 to 5.0 mg per dose given delay, restlessness, dysrhythmias, platelet count, blood pressure, before breakfast and lunch to palpitations, tachycardia, height, weight, heart rate maximum dosage of 2 mg per kg anemia, leukopenia Tolerance or dependence can per day or 60 mg per day occur. Additional dose of 2.5 mg may Drug holidays should be be required, not to be given considered. after 4 p.m. Dextroamphetamine Amphetamine therapy is not Anorexia, dependence, CNS activity, height, weight, (Dexedrine) recommended for children hyperactivity, sleep delay, blood pressure younger than three years. restlessness, talkativeness, Tolerance or dependence can 3 to 5 years: 2.5 mg per day; palpitations, tachycardia occur. increased by 2.5 mg at weekly Do not discontinue abruptly. intervals (not to exceed 0.5 mg per kg per day) > 6 years: 5 mg three times daily; increase by 5 mg at weekly intervals; maximum dosage of 40 mg per day Antidepressants Bupropion 50 to 150 mg every day Agitation, anxiety, confusion, (Wellbutrin)* Adolescents and children older headache/migraine, than six years: 1.4 to 6.0 mg per insomnia, seizures, kg per day in divided doses arrhythmias, nausea, vomiting Fluoxetine (Prozac) 5 to 20 mg per day: dose should be Anxiety, dizziness, drowsiness, Drug interactions (metabolized titrated slowly; maximum dosage fatigue, headache, insomnia, by the CYP450 pathway) in adults is 80 mg per day; no nervousness, tremor, anorexia, dosage information in children diarrhea, dyspepsia < 5 years Anticonvulsants Phenytoin (Dilantin) 5 mg per kg per day in 2 to 3 divided Dizziness, psychiatric changes, Serum concentrations, CBC with doses to a maximum of 300 mg slurred speech, gingival differential, liver enzymes per day hyperplasia, constipation, Drug interactions nausea, vomiting Carbamazepine < 6 years: 10 to 20 mg per kg per Ataxia, drowsiness, constipation, CBC with platelet count, liver (Tegretol) day in 2 to 3 divided doses; diarrhea, nausea function tests maximum dosage of 35 mg per kg per day 6 to 12 years: 100 mg twice daily; increase by 100 mg at weekly intervals; maximum dosage of 1,000 mg per day Valproic acid 10 to 15 mg per kg per day in 1 to 3 Drowsiness, sedation, Liver function tests, bilirubin, (Depakene) divided doses; increase by 5 to constipation, diarrhea, CBC with platelet count 10 mg per kg per day at weekly heartburn, nausea, intervals vomiting, rash

Table 5 continues

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TABLE 5 (continued) Pharmacotherapy for Conduct Disorder

Medication Dosage range Common adverse effects Monitoring/special considerations

Other Lithium Children: 15 to 60 mg per kg per Dizziness, drowsiness, fine hand Drug interactions day in 3 to 4 divided doses tremor, headache, hypotension, Serum lithium concentrations prior Adolescents: 600 to 1,800 mg per anorexia, diarrhea, dry mouth, to next dose, monitor biweekly day in 3 to 4 divided doses nausea, vomiting, polyurea until stable then every 2 to 3 months; serum creatinine, CBC, urinalysis, serum electrolyte, fasting glucose, echocardiogram, TSH Clonidine (Catapres) 0.05 mg per day; increase every Dizziness, drowsiness, sedation, Blood pressure, heart rate 3 to 7 days by 0.05 mg per day constipation, dry mouth Do not discontinue abruptly or to 3 to 5 µg per kg per day in withdrawal symptoms may 3 to 4 divided doses occur. Maximum dose: 0.3 to 0.4 mg per day

CBC = complete blood count; CNS = central nervous system; TSH = thyroid-stimulating hormone. *—Data on pediatric safety are not extensive.

ble, with monthly checks thereafter. Monitor- that contribute to or limit treatment of the ing and the toxicity associated with lithium patient’s problem. Therefore, family therapy is treatment may limit the use of this agent. the treatment of choice. In addition to behav- Anticonvulsants have also been used to reduce ior management, effective therapy requires aggression.31 The side effect profile and mon- parental consistency and reduction of marital itoring requirements provide similar limita- or intergenerational conflict.12,35 Empowering tions to the anticonvulsants. parents to take charge of discipline and rule setting is often difficult because of adults’ own CLONIDINE self-focus or concurrent . Several studies have demonstrated a signifi- Table 2 summarizes the key features of the dif- cant reduction in and aggressive ferential diagnosis of conduct disorder and outbursts with clonidine.32-34 Side effects treatment implications. include drowsiness, low blood pressure, brady- In managed health care systems, primary care cardia and depression. The first three effects clinicians are often the gatekeepers to mental may be limited by reducing the dosage. Patients health care.6 By accurately diagnosing these taking clonidine should be closely monitored children and determining the degree of risk to for symptoms of depression and oversedation. self or others, while noting resources available in the patient’s natural environment, family physi- Referral for Specialized Treatment cians can more effectively advocate the appro- While mild and early-stage cases of conduct priate level of service these patients require. disorder may be effectively managed by family When adult caregivers are unavailable or unable physicians, many children and adolescents to provide the degree of structure and supervi- with conduct disorder will require specialized sion required, residential treatment may be nec- mental health treatment. Typically, patients essary. Family physicians who prescribe medica- with conduct disorder are not distressed by tion for conduct disorder or comorbid their behavior; furthermore, there are almost conditions should maintain regular contact always major family issues and dysfunctions with other professionals treating the child.

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1588 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 8 / APRIL 15, 2001