Dr. Parry: Beyond 20 years of general child psychiatrist clinical experience, my current role is with a preadolescent child and family inpatient unit in a large pediatric hospital in Brisbane, Australia, where we specialize in disruptive behavior disorders.
CCPR: When people talk about disruptive disorders, what does that include?
Dr. Parry: In DSM terms, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). But, in practice, also comorbidities with autistic spectrum disorders (ASD), learning disorders (LDs), speech and language delays, attachment problems, developmental trauma, ongoing maltreatment, and family and school dynamics abound. Puberty often exacerbates disruptive behavior—even in normal children—let alone when there are other factors. Disruptive mood dysregulation disorder (DMDD) does not seem to be used in Australia, perhaps because pediatric bipolar disorder (BD) in children was never widely used either. Also, the Australian public health system uses ICD-10 codes, which don’t include DMDD. Funding is not directly tied to diagnostic labels in public or private health systems, so usually the focus is on a biopsychosocial diagnostic formulation rather than a specific diagnosis. Educational and welfare funding is tied to ASD diagnoses, and there is debate about overdiagnosis of ASD.
CCPR: How common are these disorders?
Dr. Parry: The DBDs are the most common preadolescent disorders in child psychiatry and behavioral pediatrics. In our unit, we have many pre-pubertal children with an array of oppositional, defiant, conduct, and inattention symptoms who may or may not be mildly to severely autistic. These children display highly disruptive behaviors. At the point we see them, their parents or foster caregivers cannot manage them, and their treating pediatricians, psychiatrists, and mental health services have reached some kind of impasse. They are often taking a considerable cocktail of medications. They come to us for diagnostic clarification and to review their medication regimens.
CCPR: How old are the children you’re working with?
Dr. Parry: We take kids starting at around age 5 up to late puberty, including developmentally “younger” 14-year-olds. We have some capacity to admit parents along with the child to work on parenting and family aspects.
CCPR: Could you talk a little bit about your sense of how disruptive disorders evolve with different age groups like the preschoolers, school age, early teens, and then adolescents?
Dr. Parry: In terms of inpatient child and adolescent psychiatry, the preschool- and school-age groups are mostly boys and some girls with the mixture of comorbidities I mentioned. With regard to our adolescent inpatient unit, there are two main groups: one involves suicidal risks and borderline personality dynamics, usually from an environment of trauma; the second is individuals with emerging and manifest psychosis.
CCPR: In the U.S., we would add to that CD kids, who certainly are in the disruptive disorder category but don’t quite fit into any of those you just mentioned.
Dr. Parry: We do have them in our child unit. But, in an adolescent inpatient setting, they can quickly disrupt the therapeutic milieu, so we endeavor to discharge them as soon as a brief suicidal crisis, sometimes with substance intoxication (the most likely reason for admission), has settled. We do have a trauma-informed forensic adolescent service to refer them to, particularly in the youth detention centers if they’ve been sentenced, but there is a need for more forensic adolescent resources.
CCPR: How do you go about diagnosing DBD in kids?
Dr. Parry: Our model is to focus on creating a full diagnostic biopsychosocial formulation. This requires a thorough developmental history, including a trauma history if relevant. We look at school guidance testing and psychometrics testing such as the Wechsler Intelligence Scale for Children (WISC). We have a speech pathologist on our unit and often find a speech and language assessment is valuable, because many of these children don’t have the language they need to understand or to express their emotions. We do ADHD scales as well and are fortunate to have a hospital school that provides further input from teachers. In community clinics, it can be too easy to make an ADHD diagnosis based on limited information from the parents and the behavior of the child in your office, which may not be typical of their overall behavior.
CCPR: How does this individualized approach help you plan treatment?
Dr. Parry: Once we have a comprehensive diagnostic formulation, the management plan becomes self-evident. You can see what proportion is medication oriented; what proportion is helping this child deal with perhaps more recent discrete loss or trauma through some psychotherapy; what proportion is child abuse and neglect, requiring us to notify child protection to assess whether the child is safe to return to his or her place of residence; what proportion warrants—and this is common—parent training or family therapy. Then we try to initiate the interventions their formulation suggests will be most helpful, while passing the diagnostic formulation on to their community-based clinicians for ongoing therapy.
CCPR: What medications do you find useful?
Dr. Parry: If we have a child who meets criteria for ADHD, we’ll try the stimulants in the inpatient environment; but, if the behavior has anxiety inputs from stress and trauma and a child does not actually have the genes or early neurodevelopment adversity that would have led to a more biological ADHD, we often find that stimulants don’t do much.
CCPR: What about other drugs such as antidepressants, anticonvulsants, and antipsychotics?
Dr. Parry: A lot of children these days in Australia are on SSRIs and antipsychotics, as is true also in the U.S. Very few are on anticonvulsants, unless they have epilepsy or are older adolescents with well-established manic episodes. Personally, I’ve only seen benefit using SSRIs with the DBDs if there’s a significant anxiety or obsessive-compulsive component that’s driving the disruptive behavior. I think SSRIs are overused particularly in milder adolescent depression. Consistent with the research, I’ve seen a number of adolescents develop increased suicidality, and their prescriber had oftentimes not warned them or parents of the risk. I also find the long-term risks of antipsychotics concerning.