Unveiling Trauma's Connection to Anger & Conduct Disorder

Hey there, everybody, and welcome to this presentation on oppositional defiant conduct and impulse control, a trauma informed perspective. I'm your host, Dr. Donnellice Snipes. In this video, we're going to identify disorders in this category of impulse control disorders. And then we'll review the diagnostic criteria specifically for oppositional defiant conduct and intermittent explosive disorder as well as pyro and kleptomania. We'll briefly review differential diagnosis, we'll talk about suicidality risk, and then we will finish up by talking about current best practices from what we know right now to treat these disorders. In the DSM 5TR, the category is disruptive impulse control and conduct disorders. In this category is oppositional defiant disorder, intermittent explosive disorder, conduct disorder, pyromania, kleptomania, unspecified disruptive impulse control disorder, and antisocial personality disorder. Now you might be thinking, Dr. Snipes, antisocial personality disorder is in the personality disorders category. Yes, it is, but it is also in this one. So that's kind of an interesting little caveat that we have that some of these disorders occur in multiple categories. But we'll cover that when we get to personality disorders. Oppositional defiant disorder is characterized by a pattern of behavior with at least one person who is not a sibling lasting more than six months, as evidenced by four or more symptoms which are not developmentally appropriate for an individual's age, gender and culture. Straight out of the DSM5TR, I have concerns about indicating that certain behaviors may be more or less appropriate by gender. However, that's what's in there. So pointing out that the diagnostic criteria does highlight some very specific caveats. The other thing that I think is interesting in oppositional defiant disorder is it's a pattern of behavior with at least one person. So the symptoms, four or more symptoms are going to be present frequently for more than six months toward one person. Behavior is communication. Behavior changes when people have experienced trauma and we are going to learn that there's a very, very strong correlation. And in some cases they're stepping it up to even indicate that there may be causation, that trauma is one of the root causes for oppositional defiant disorder and potentially conduct disorders. And I think that is really important that when we're diagnosing, we don't misdiagnose oppositional defiant disorder for a trauma, Trauma caused disorder that may not rise to the level of PTSD. A lot of your adverse childhood experiences or your ACEs do not meet criteria for PTSD. So it could be an unspecified trauma related disorder as opposed to oppositional defiant Disorder. We really need to explore what the root cause is. Think about it just from a stigmatization and discrimination standpoint. And I hate to say it, but our culture, even in the medical communities, does tend to not look fondly upon people diagnosed with things like oppositional defiant disorder, conduct disorder, antisocial personality, or even borderline personality disorders. These disorders, which are in many cases understandable adaptations to traumatic events, communicate to people that don't know the patient. Hey, this person's a problem, and that's not okay. That is not okay. We need to start really examining behaviors from a communication standpoint and say, how did this behavior develop? In what way might this behavior have emerged to protect the person? Okay, so off my soapbox, four or more symptoms which are not developmentally appropriate for the individual. Now, I want you to remember that ODD is typically diagnosed in children and adolescents under 18. And when we make those diagnoses, when you think about children and people that are going through puberty, there is a lot of mood swings. There can be emotional turmoil. There can be a lot of these behaviors that emerge either in real life or online, especially in the past 20 years, as social media has crept up and it has become easier to be vindictive from a distance. I guess. However. So let's look at these criteria. Four or more, and there's a bunch of them. It takes up three slides. Angry or irritable mood. They often lose their temperature. They may be touchy or easily annoyed, and they're often angry and resentful. Now, remember, this is toward one particular person or many particular people. At least one particular person bears the brunt of these symptoms, which, again, I think we need to look at. What is it about that person that elicits these behaviors? Were they rewarded or reinforced in some way by that person? Was there some social learning that other people behaved this way toward that person and there were no negative consequences? So the identified patient learned that, hey, it's okay to behave that way. Or does that person somehow represent a threat and the identified patient is in some way trying to protect themselves from. From that person? Or a fourth option. Remember chronic stress, whether it's due to cptsd, and I know that's not actually a diagnosis yet, but chronic trauma, chronic stress leads to HPA axis dysregulation, or the stress response becoming dysregulated, which leads to emotional dysregulation. So we may see be seeing an individual who doesn't have adequate skills and tools to cope with emotional dysregulation. They don't have adequate skills and tools to feel safe. So we want to look at attachment related traumas. We want to look at other adverse childhood experience related traumas as well that may have contributed to a feeling of unsafeness and disempowerment, maybe even prevented them from developing emotional intelligence and the ability to modulate, identify and modulate their own feelings and responses. Interestingly, with the angry and irritable mood category, the DSM 5TR Notes Temper loss need not always involve tantrum behavior and can be displayed by angry facial expressions, verbal expressions of anger and subjective feelings of anger that would not typically be considered a tantrum. So that makes this angry irritable mood pretty amorphous here. And I want you to think, if you raise teenagers like I have, how often there were periods where the children might go through, or adolescents might go through phases where they were trying to individuate so they would become irritable, they would become moody sometimes and they would roll their eyes. And I know, I remember very distinctly my children, I swear I could hear their eyes rolling even if I had my back turned to them. But that is developmentally appropriate. They are, in many cases they are learning how to individuate, they're learning how to become assertive. So we really need to look at the frequency, whether it's an ongoing issue and the magnitude of the irritability and oppositionality, if that's even a word. But remembering that According to the DSM 5TR, it doesn't even have to be a full out tantrum. The person can have a subjective feeling of anger and that qualifies another set of criteria that we can choose from for these four plus symptoms. Often argues with authority figures or actively defies or refuses to comply with requests from authority figures or with rules. This could be, as I mentioned before, something that has been reinforced in prior interactions with adults and authority figures where the child was told to do something and they didn't do it. They were like whatever. And then there were no consequences. So the child learned that there are no consequences for being oppositional. And so why should they do something if they don't want to? On the other hand, their trauma may have been at the hands of an authority figure or authority figures who were reticent to protect them from traumas. So they could have deep seated anger and hostility towards authority figures thinking well, why should I trust you? And I'm going to do what I think is going to keep me safe or make me happy. Obviously each individual is going to be different, but I really, in this presentation I really want you to start thinking about what is this behavior communicating, where might it have originated from? And is it the result of what in later life might be termed antisocial behavior, lack of empathy, or is it the result of a trauma response? The final two criteria in the category of argumentative defiant behavior is often deliberately annoys others and often blames others for his or her mistakes or behavior developmentally appropriate. Again, I remember when my children were younger, when they were in elementary school, they're four years apart and they would be sitting in the back of the car, we'd be going somewhere and one would deliberately start annoying the other and we would have this whole to do and it was almost a game. The annoyer was amused by being annoying. However, they both went back and forth doing it. They were siblings. So remember this has to be a non sibling that this behavior is engaged with, but it doesn't say it has to be an adult. So it so it can be a peer with whom they are being deliberately annoying. Often blaming others for their mistakes or misbehavior. This can be something that developed as a result of reinforcement. They learned that through either seeing others do it or through doing it and not experiencing punishment that they can blame others for behavior. Or it may have developed out of fear because the behavior was the punishment was so harsh that they are terrified of getting in trouble. So it is a safety or a survival standpoint mechanism to blame other people. They did it. I didn't do it in order to prevent the harsh discipline. The DSM5TR goes on to note, individuals with oppositional defiant disorder typically do not regard themselves as angry or defiant. They justify their behavior in response to unreasonable demands or circumstances. It is important to identify whether what the person's perception is if they are being argumentative or defiant in order to protect themselves because they're fearful, that could be a response from prior trauma. What you perceive as going on as the caregiver or the target of the oppositional defiant behavior may be very benign in nature. However, what the target perceives may be something that is very threatening or triggering to them. Again, it also could be something that just developed as a result of never experiencing consistent discipline or corrective measures when they were oppositional or defiant before. So now they perceive any demands upon them to be unreasonable and vindictiveness. The person has been spiteful or vindictive at least two times in the last six months. Now this is toward that identified person or persons. But as I mentioned earlier, unfortunately we have a plague of vindictiveness that seems to happen in our social media and, and it's not just with school children. We see it in adults as well, where they may troll one another or engage in flaming wars. I think that's what they still call it. And that can be perceived as vindictive. If you're trying to cancel somebody, that can be seen as vindictive. So has this person been vindictive toward their target? And at least twice in the last six months. You can see that a lot of this area, especially for children and adolescents whose prefrontal cortex is not fully developed yet, their executive control network is not fully developed yet. So they may tend to be more impulsive and reactive. They may not have all the skills of distress tolerance yet, so they may be more impulsive and reactive. You can see how a lot of these behaviors may occur relatively frequently in children and adolescents, which is why we need to explore what is developmentally and unfortunately culturally appropriate. And what do I mean by that before people start to get really upset? What I'm talking about is the. What I perceive as the current culture of online communication and flaming and canceling and doing all that kind of stuff in. Back in my day before computers existed, behaviors tended to be much more subtle. But a lot of these behaviors have become more normative now, and it pains me to see it. Does that mean we have an increase in odd or does that mean our culture has changed to be more accepting of angry, impulsive, oppositional and vindictive behavior? That's a question for you to answer. Frequency these behaviors, these four or more behaviors in children that are less than five years old. Now I want you to think about this. Two, three, four year old children are going to be oppositional sometimes. But for children who are less than five years old, the behavior occurs most days for at least six months. So that can be very exhausting. If the child is engaging in these behaviors, we really need to explore where that might be coming from. Do they have differences in their neural networking? Are they neuro atypical? Maybe the putting on those clothes that you want them to put on is painful, it's too itchy because they are hypersensitive. Maybe using the soap to wash their hair is the smell is too strong or the water that you draw for their bath feels fine to you is too hot for them, so they don't want to engage in these behaviors. And if they are sensitive to temperature, likely they're going to be sensitive to temperature in food as well as things like bath water. So you can see eating and bathing which are two things that we are still helping children do at this age may be very conflictual if we are not registering, if we are not understanding why the child is resistant to that behavior. So it's important to rule out any neurological differences. And it's not just people with autism spectrum disorder. We see sensory gating issues and sensory integration issues in people with adhd, which very commonly occurs with oppositional defiant disorder and people with schizophrenia and a fair number of other disorders. Therefore, we really need to ask, has this child experienced some sort of trauma or pain or unsafeness in their environment that we haven't recognized yet? For children that are over five years old, the behavior occurs at least once per week for at least six months. Okay, so one difference here is that when a child is over five years, a lot of times they are engaging in some of the behaviors that under five years, the parent used to be heavily involved in. Over five years, the child is starting to be more involved in. The child is starting to maybe run their own bath. Now, five may be a little bit young, but you see where we're getting away from as much parental involvement or caregiver involvement, which may mean less conflict because the interactions, the child is becoming more independent. Or it could be that the child has developed compensatory strategies to deal with this. The disturbance in behavior is associated with distress in the individual. So in the. In the child or adolescent or in significant others. So it's causing significant distress in caregivers or co workers or school chums, whomever the target of the behavior is, or it has a negative impact on other areas of functioning. If the individual is being oppositional defiant in the classroom, then it's having a negative impact on their learning. If they're being oppositional defiant in other settings, it may have a negative impact. If they're being oppositional and defiant with their peers, then it's going to be hard for them to form social connections. So it is important to examine if the behavior is causing them impairment. Significant impairment, even if it's not causing them distress. If they think I'm fine, it's everybody else who's overreacting. But if it's causing them significant impairment in developmental tasks or in activities of daily living, then you know it meets the criteria. Children with oppositional defiant disorder may have experienced a history of hostile parenting. Okay, so this is from the DSM 5TR, and I'll give you a hint. The American Academy of Family Physicians has some more research on it that we're going to talk about. But According to the DSM 5tr, children with ODD may have experienced a history of hostile parenting. It's impossible to determine if the child caused the parents to be hostile or if the parents hostility caused the child's problematic behavior, or both. I see a lot of finger pointing and blaming here, and that bothers me. But from a behavioral standpoint, when we start asking what is this behavior communicating, this gives us some insight. According to the DSM 5TR, it doesn't matter if hostile parenting or adverse childhood experiences caused the behavior. In terms of giving the diagnosis of oppositional defiant disorder, if the child meets that diagnosis. In the event that the child may be living in a particularly poor conditions where neglect or mistreatment may occur, clinical attention to reducing the contribution of the environment may be helpful. You think? I was aghast when I read that. So they're assuming that we would ignore neglectful or neglect or maltreatment and not assume that that is a treatment target and a significant contributing factor. I was a little appalled. According to the American Academy of Family Physicians, parental psychopathology, which means mood disorders, mental health issues, abuse, harsh punishment, and inconsistent discipline are common correlates of oppositional defiant disorder. Now these are other ways of naming what a lot of times we call adverse childhood experiences. Now, in a 2014 study with 731 subjects, it was found that parental behavior is likely causal rather than a response to the child's symptoms. Thought that was interesting. Now this may not occur in every situation. Remember, if the child is born and they are neuroatypical as an infant, they cannot communicate mom that's way too hot or dad that's way too hot or way too cold or it makes me itchy or that hurts when you do that. They can't communicate that. So normal caregiving behaviors like swaddling, diaper changes, bathing, feeding a lukewarm bottle may actually be painful to the child. So the caregiver has become associated with pain. The child is deemed fussy or high needs. And in reality they're just trying to communicate the only way they can at that point, through crying that hey, that hurts. So we do need to take a look at that and not just blame the parent and say parental behavior, it's your behavior that caused it. The parent may have been doing their very, very best trying to be a really good caregiver, but inadvertently traumatizing the child. So we do need to be sensitive to these things and be curious, but not condemning. The course and development of the behaviors. It's important to rule out psychotic disorders, substance Abuse, depressive, bipolar and disruptive mood regulation disorder. Obvious. Well, we're going to talk about differential diagnosis in a minute, but remember, disruptive mood dysregulation disorder is another disorder in a different category, but the individual, the child, is typically angry and moody most days. It's not just once a week. They're typically angry and moody most days. And we're gonna. I have the disruptive mood dysregulation disorder criteria in here that we're gonna take a look at in a minute, just to refresh your memory. It is not part of this category, but it is an important differential diagnosis. Specify current severity. If the ODD is confined only to one setting, such as home, school, or at work or with peers, then it is mild. That should tell you something. What is it about that one particular environment or the people in that one particular environment that is triggering or that elicits those behaviors and not the other situations? Get curious, figure out, you know what. What might be going on here? What's the behavior saying? Moderate. Some symptoms are present in at least two settings. So the child may have more difficulty with emotional dysregulation in multiple settings with multiple people. Severe. Some symptoms are present in three or more settings. So at home, at school and with peers, or at home at work and with peers, the individual has at least some symptoms of oppositional defiance. The first symptoms often present in preschool and definitely by adolescents. So you're going to see the first symptoms of this during the child's formative years, if you will. And again, I think that's important, really important to examine the child's behavior from a developmental standpoint. Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the provocation inconsistent with the developmental level that occur at least three times per week for at least one year in at least two of three settings. This is disruptive mood dysregulation. Remember this, Temper outbursts in oppositional defiant don't have to be severe. They can be subjective. So that's a different difference there. With disruptive mood dysregulation. The mood between temper outbursts is persistently irritable or angry, and there has not been a period of greater than three months without all of the symptoms. The diagnosis should not be made for the first time before age 6 or after age 18. Remember, oppositional defiant often appears in preschool years, so that's well before age 6. But if you're not seeing the child until after the age of six, you're going to have to really look very Carefully at differential diagnosis. Conduct disorder. Now, a lot of times, oppositional defiant precedes conduct disorder. Apparently, they can also be diagnosed comorbidly. Conduct disorder. In about 40% of the cases, the person goes on to meet criteria for antisocial personality disorder. In conduct disorder, there's a persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms are violated, as evidenced by three or more of the following symptoms in the past 12 months and at least one criterion in the past six months. Aggression to people and animals. The person often bullies, threatens or intimidates others. Remember, in oppositional defiant there may be some anger outbursts, but it's generally I'm going to do what I want to do. It's not overtly aggressive. They often initiate physical fights. They use weapons that can cause physical harm. They've been physically cruel or violent to people or animals and may have stolen while confronting a victim. Now, three of the symptoms, and we're not finished with all the symptoms in the past 12 months and at least one in the past six months. Destruction of property. They've deliberately engaged in fire setting which with the intent of causing serious damage or deliberately destroyed other people's property other than by fire setting, by smashing it, spray painting it, whatever deceitfulness or theft has broken into someone else's property, house, building or car, often lies to obtain goods or favors or avoid obligations or has stolen items of non trivial value without confronting a victim. Shoplifting, for example, or stealing somebody's car when they're not in it. Serious violation of rules. They may often stay out at night despite parental prohibitions beginning before the age of 13 years. Thirteen years, depending on the child, is either eighth grade, ninth grade, right in there. So when they're in middle school or younger, they are going leaving at night, whether it's climbing out the window or staying out past curfew. Has run away from the home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. Lengthy period is not clearly defined, but we're going to assume they mean more than 24 hours, maybe a little bit longer if the child is in their mid to late teens or is often truant from school beginning before the age of 13. So we see serious violation of rules and not respecting adults or societal norms beginning before the age of 13 years. In most of these symptoms, the disturbance in behavior causes clinically significant impairment. They may not experience clinically significant distress. They may not have a problem with their behavior or the situation. But it causes clinically significant impairment in family functioning, in school functioning if they are runaway and they're living on the streets in health functioning if the individual is age 18 years or older. Criteria are not met for antisocial personality disorder. This can be diagnosed in people over the age of 18. If we rule out antisocial personality, we want to specify whether it's childhood onset type where the person shows at least one symptom prior to age 10, or adolescent onset type where they show no characteristic symptoms prior to age 10. That also should perk your little spidey senses up. If they were trotting along just fine up to age 10, then all of a sudden they went from being a model student or a model individual to conduct disorder. What the heck happened? What happened to precipitate the development of these behaviors? Conduct disorder can be diagnosed in people who are in children who are in preschool through adults, according to the DSM 5tr. So remember, oppositional defiant disorder can also be diagnosed beginning in preschool. And it's important to note the difference. Conduct disorder. The symptoms are significantly more severe, significantly more aggressive towards other people. Conduct disorder notes it's often preceded by oppositional defiant disorder, but not always. People with conduct disorder frequently misperceive the intentions of others as more hostile and threatening and respond with what they perceive as reasonable and justified aggression. This again may be indicative of a person who has experienced chronic trauma and their HPA axis has become dysregulated. They go from feeling steady state or numb or whatever they're feeling. You notice I'm not saying safe or content because a lot of times they don't feel that way to raging. And in other videos I've called this the flat to the furious. And that is a result of their stress response system turning down its sensitivity so things don't bother them too much. That may normally have bothered them. Their nervous system says, you know, I just can't get upset about everything. I don't have the energy. But when something does trigger them for some reason, there is a tsunami of stress chemicals. We need to respect the individual's perception of the situation. If they perceive the situation as much more hostile and threatening than the victim, I guess we'll use that word perceived it. We want to understand what was the difference. Why did they perceive it so much more hostile and threatening? And I would venture to guess that we can probably trace it back to them. Traumatic experiences that were triggered by something that the person did said a smell in the air, a situation that that triggered that trauma schema within within their bodies. And remember. Van der Kolk says that a lot of times trauma memories, especially traumas from early childhood, may not be memories that we can see with pictures or words. They may be experienced as sensations and that that sensation would be one of intense fear. People with opposite conduct disorder often have negative emotionality and irritability, poor self control, poor frustration tolerance, suspiciousness, insensitivity to punishment, thrill seeking and recklessness. Now that's really interesting and those are great treatment targets for something with conduct. For someone with conduct disorder, the negative emotionality and irritability communicates to me that there is a disruption in their neurotransmitters. But it also communicates to me that likely they are hypervigilant, they are not feeling safe. So they are constantly in this fight or flight mode and they're perceiving things from a threat based standpoint, which contributes to irritability. And the poor frustration tolerance and poor self control goes along with HPA axis dysregulation. Suspiciousness seems to be a reasonable response when you've been betrayed, traumatized or victimized in the past. Insensitivity to punishment may develop as a result of the abuser being harshly dealing out harsh punishments. Whether it is verbal abuse or physical abuse, the individual learns how to check out. They learn how to dissociate and become insensitive to the punishments and thrill, sinking and recklessness. Those are dopamine driven behaviors. Those are behaviors that are not uncommon to see in people who want to feel pleasure. They want to feel escape, they want to feel something. And for someone who is flat most of the time, that may be the only way they can trigger enough of a excitatory response to feel pleasure. Remember, our excitatory neurochemicals can be associated depending on their balance, can be associated with fight, flee or fun, if you will. Conduct disorder should not be diagnosed in individuals in settings where patterns of disruptive behavior are viewed as near normative, such as in very threatening high crime areas straight out of the DSM 5 TR. This is another important thing to note. So look at the person in front of you. If they are living or if they are coming from an environment that is characterized as threatening or high crime, then conduct disorder would not be diagnosed. Intermittent explosive disorder is another common diagnosis that we see in Intermittent explosive disorder. Recurrent behavioral outbursts are grossly disproportionate to the provocation. So that sounds a lot like dysregulation, which represents a failure to control aggressive impulses and causes marked distress or impairment as Manifested by one or both of the verbal or physical aggression toward property, animals or people more than twice a week for at least three months. The physical aggression does not result in damage, destruction or injury. So the person has these explosive outbursts more than two times a week for at least three months. Or they have three or more outbursts that involve damage or destruction of property and or physical injury against animals or people within 12 months. It is possible and actually not that uncommon to see people with both of these criteria where they have these outbursts that are non destructive, non damaging, no less threatening, but non damaging a couple of times a week with regularity. But they have these other episodes, other outbursts interspersed where they go even further and there is destruction of property or physical injury. Outbursts are not premeditated and are not committed to achieve some tangible objective that differentiates intermittent explosive disorder from antisocial personality disorder. For example, the person doesn't think can I intimidate this person to get their wallet to get their car? This is a non premeditated outburst. Chronological age is at least six years. And symptoms are not better explained by another mental disorder, medical condition or the physiological effects of the substance. This diagnosis can be made in addition to the diagnosis of adhd, conduct disorder, oppositional defiant disorder or Autism spectrum disorder. And I also mentioned in the write up in people with dementia when recurrent outbursts exceed what is usually seen with those disorders. So if they have meet criteria for one of those other disorders that does have behavioral outbursts as part of them, that's fine. But if the outbursts are significantly severe so as to become a focus of clinical attention, then you can concurrently diagnose intermittent explosive disorder, pyromania and kleptomania. Multiple episodes of deliberate and purposeful fire setting in pyromania or failure to resist impulses to steal unnecessary objects in kleptomania. For both of these disorders there is a tension release. The tension builds up. They feel this need, this urge to either set a fire or to steal something that they see. And they experience intense pleasure when they follow through with the action. That's their only motivation. It's not to destroy property. It's not to injure or be vindictive in any way. This is attention release behavior. In pyromania, the person may have fascination with fire and its consequences. And these behaviors are not better explained by another mental disorder. The DSM5TR does note that fire setting behavior alone is not sufficient for a diagnosis of pyromania. If somebody is an arsonist, if they are not doing it for tension release in order to produce pleasure. And if they don't have this fascination with fire and its consequences, then they are not going to meet the criteria Prevalence Oppositional Defiant disorder ranges from 2% to 11% and yes, I checked multiple resources and multiple resources had this wide swath. The reason given is due to difficulties in differential diagnosis and quality. Cultural insensitivity in differential diagnosis, the differentiating it from what is normal age, developmentally appropriate for a child, or differentiating it from other disorders becomes difficult for all the reasons that we mentioned and cultural insensitivity. Unfortunately, some culturally unaware clinicians may over diagnose certain groups of people I'm trying to choose my words carefully. Certain groups of people over diagnose them with oppositional defiant disorder when in reality, or conduct disorder when in reality. It is a they may be demonstrating a trauma oriented response or they may be acting Remember that clause for conduct disorder? You can't diagnose it if the person is coming from a traumatic environment or one where there is high crime. And how many of the people that have been diagnosed with ODD are in that category? Intermittent explosive disorder the one year prevalence is 2.6% and the 4% and the lifetime prevalence is 4% for the overall population. However, it's been found that Intermittent Explosive disorder is diagnosed 33% more often among African American and Caribbean Black adolescents. We again need to look at whether there are some cultural insensitivity going on in our diagnosis or what the causative factors might be, because 33% for this very limited group is a very, very high group. Risk Factors Adverse Childhood Experiences I've said that repeatedly. Adverse childhood experiences. You can go to ACES Too High, which is the website, but adverse childhood experiences include physical abuse, mental abuse, emotional abuse, sexual abuse, neglect living in a household where one or more people has a mental health or an addiction issue being in a situation in which caregivers disappear, where there's abandonment, they either go to jail or they go to get cigarettes one day and never come home or whatever the case may be. Those are the big adverse childhood experiences that are highly correlated with the development of mental health and physical health issues later in life. So in this category, risk factors for the development of these disorders as identified in the DSM 5TR include pretty much all of those A history of child abuse or neglect a caregiver who has a mood or addictive disorder. Think about how that affects their parenting and their ability to form a secure attachment with the infant, toddler or child. It's pretty difficult. If that mood or addictive disorder is uncontrolled exposure to violence, this can be from caregivers or it can be domestic violence, or it can be in their own neighborhood where they don't feel safe going to sleep at night. Inconsistent discipline and a lack of adult supervision. Family instability, poverty or or frequent changes in caregivers. Those are all risk factors identified for the disorders in this category. Oppositional defiant disorder, as I mentioned before, tends to be more defiant. It's not aggressive. It's not overt. It's not in your face most of the time with the exception of maybe trying to annoy somebody. But it's not physically aggressive. Whereas conduct disorder is much more physically and verbally aggressive. Disruptive mood dysregulation disorder is given instead of oppositional defiant disorder. If the person meets criteria in disruptive mood dysregulation, the symptoms tend to be more severe and the irritability and anger more persistent. In ptsd, a connection between behavior and trauma must be able to be articulated, even for children, which leaves us really at a loss since complex PTSD is not a DSM 5tr diagnosis. We end up being at a loss because we know that complex trauma as a result of ACES is common, extremely common in these particular disorders. So are we really talking about a conduct disorder or a traumatic response? And again, I know I already said it. How pathologizing? How much are we actually harming the person by giving them a conduct disorder diagnosis? My opinion not in the dsm. How much are we harming the person by giving them a conduct diagnosis as opposed to a trauma related diagnosis? ADHD is often comorbid. Honestly, when I went in to look for treatment strategies, it is so commonly comorbid with oppositional defiant disorder that I could not find anything, literally could not find any best practices for treating standalone oppositional defiant disorder. It was always ADHD with oppositional defiant or conduct disorder. In adhd, symptoms only occur in response to sustained effort, attention or stillness. If it occurs in other situations, then you may have comorbid ODD or conduct disorder. Substance abuse. The behaviors occur exclusively during a period of intoxication or withdrawal, depression or bipolar disorder. The diagnosis of oppositional defiant disorder is not made if oppositional defiant behaviors are exclusively seen during a mood episode. Reactive Attachment Disorder. This was not mentioned anywhere in the right up in this chapter. However, I think it's important to note because these aces this problem in parenting probably resulted in attachment issues and they did note as a risk factor having frequent changes of caregivers, which is one of the criteria for reactive attachment disorder. However, in reactive attachment disorder, the criteria are that the person has to be inhibited and emotionally withdrawn following extremely insufficient care. So it's a little bit different. They're not necessarily as oppositional defiant as they are withdrawn and resigned. Language disorder. We need to rule out the person being oppositional defiant, irritable, frustrated because they don't understand instructions. Whether it's because they can't understand the language or they can't hear clearly. We want to rule out hearing issues, vision issues, and other communication issues. Social anxiety would be diagnosed instead. If the defiance is associated only with fear of negative evaluation, they are compliant at home. They're compliant with friends, for example, in small groups, but they become defiant in large groups of children or, for example, at school when the teacher calls on them or when they might be in a position to be negatively evaluated. And we want to rule out antisocial or borderline personality in these personality disorders. According to the dsm, there are lower intensity outbursts than in intermittent explosive disorder. And antisocial personality can also not be diagnosed until the age of 15 years. With regard to suicidality, Intermittent explosive disorder, comorbid with ptsd, was associated with a markedly elevated rate of lifetime suicide attempt, 41%. Now, what have I been saying throughout this whole class? The chance that somebody's emotional dysregulation, that their intermittent explosive disorder was precipitated by complex PTSD or PTSD is likely pretty good. Therefore, I wonder whether that rate is even higher if you factor in complex ptsd, not just traditional post traumatic stress disorder criteria. All disorders in this category are associated with a higher risk of suicidal ideation, though, and that makes sense. People who are struggling with their mental health and struggling with interpersonal relationships likely will feel more angry, more unsafe, more disempowered, which can lead to more suicidal ideation treatment. Parent management therapy targets decreasing unintentional reinforcement of unwanted behaviors, positive reinforcement or negative reinforcement, which means reinforcing unwanted behaviors by providing undue attention, or reinforcing unwanted behaviors by not responding to them at all, just fine, whatever. Help parents identify appropriate consequences for disruptive behaviors. Many times parents may have evolved over the years trying to figure out how to interact with this child in a way that's become dysfunctional. So we need to back up, examine what the behavior means, you know, again, rule in or out neurological differences, rule in or out language difficulties, and then restructure the discipline ladder, if you will, and help parents learn how to make their responses timely, predictable, and appropriate. So there's consistency. Children crave consistency and discipline or correction is much more effective if it is timely, if it's proximal to when the behavior occurred as opposed to the child getting in trouble for it four, five, six hours later. Parent child interaction training has also been shown to be helpful at improving the relationship and dynamics between the child and caregiver in terms of child focused therapy. Individual child therapy helping them develop attachment, security, self esteem and emotional intelligence, including emotional awareness, distress tolerance, and problem solving have all been found to be helpful in working with people who have disorders that are in this category. Unfortunately, there was a surprising, in my mind, surprising lack of research on effective treatment strategies for dealing with conduct and impulse control disorders, which again makes me wonder whether this category has been stigmatized so much that the researchers are reticent to even study it. I'm just hypothesizing, but it was shocking to me how little information there was on best practices in terms of medication. Stimulants have been shown to be effective with comorbid adhd. However, the more pronounced the symptoms are, the less impact, according to this particular study, the less impact the stimulants had on the oppositional defiant behavior, which could mean the more profound the symptoms are, the more traumatized the person might be. So it may not be neurochemical ADHD impulse related stuff, it may be trauma HPA axis related stuff. So it makes sense that a stimulant's not going to do the job because it's a whole different causative factor. In terms of atypical antipsychotics, only one that's risperdone was found to be somewhat helpful with oppositional defiant behavior. However, some studies that I looked at indicated that medications which address comorbid mental health issues may tangentially also help with the oppositional defiant behaviors, which makes sense. If the person's symptoms of their other mental health issues are more controlled, they may feel more empowered, they may feel more safer, or be better able to use their distress tolerance and emotion regulation tools, free screening tools, the Vanderbilt ADHD Diagnostic Parent Rating Scale and the Swanson, Nolan and Pelham Teacher and Parent Rating Scale. Obviously they're designed to assess for adhd, but they also have subscales for oppositional defiant and conduct disorder. Oppositional defiant disorder is a relatively common diagnosis in children and adolescents, up to 11%. Since there's a high correlation between ACES and the development of oppositional defiant and conduct disorder, it's important to consider the functions of the behaviors and accurately differentially diagnosed from PTSD and specified or unspecified trauma and stressor related disorders.