PANCE Blueprint Psychiatry (7%)

A child is referred to your office for unusual animal cruelty and bullying at school

• A repetitive pattern violating the basic rights of others or major age-appropriate norms — four categories: aggression to people/animals · destruction of property · deceitfulness or theft · serious rule violations
• Often the precursor to antisocial personality disorder (not diagnosable before age 18)
• vs ODD: ODD children are defiant but not aggressive to people/animals, destructive, or deceitful

DX: DSM-5 — ≥ 3 of 15 criteria in the past 12 months (from any of the four categories), with ≥ 1 in the past 6 months

• Examples: bullying/fights/weapon use/cruelty · fire-setting/property destruction · breaking in/lying/stealing · staying out at night, running away, truancy before age 13
• Specify childhood- vs adolescent-onset and "with limited prosocial emotions"; rule out substance use and abuse as drivers

TX: Multimodal psychosocial treatment integrating individual, school, and family settings

• Parent management training has the best evidence; multisystemic therapy for severe cases
• Treat comorbid ADHD, depression, and substance use — no medication treats conduct disorder itself

"Oppositional defiant disorder is a less intense form of conduct disorder. Children who continue with the chronic behavior are at risk of developing conduct disorder. This disorder is most often seen in boys, with problems being worse at school. The behavior can occur at home and with peers."

A child is found to backtalk and resist following instruction from parents or authorities

• Three symptom clusters: angry/irritable mood · argumentative/defiant behavior · vindictiveness
• vs conduct disorder: no aggression to people/animals, no property destruction, no theft or deceit

DX: DSM-5 — ≥ 4 symptoms for ≥ 6 months, exhibited with ≥ 1 individual who is not a sibling

• Often loses temper · easily annoyed · angry/resentful · argues with authority · defies rules · deliberately annoys · blames others · spiteful ≥ 2× in 6 months

TX: Psychosocial treatment first-line — parent management training (best evidence), CBT for anger and problem-solving, family therapy

• No medication is approved for ODD itself — treat comorbid ADHD (stimulants often improve oppositional behavior); risperidone/aripiprazole reserved for severe, refractory aggression