Conduct and oppositional disorders — multi-domain assessment and stepped care (MEQ)

(i) Assessment. Multi-informant history (child, parents, school, any youth justice/welfare). Map DSM ODD domains and CD criterion groups with timelines and settings; note childhood-onset features (defiance from early primary) and emerging CD behaviours (fighting with injury, shoplifting). Assess limited prosocial emotions / CU features (remorse, empathy, shallow affect, concern about performance) across relationships. Screen ADHD (restlessness, inattention, multi-setting ratings), learning, mood, anxiety, substances, trauma. Risk: violence recurrence, peer harm, absconding, exploitation, home safety, self-harm. Parenting style, maternal depression, peer network. Capacity/consent and mandatory reporting principles (jurisdiction-specific).^[2][6]

(ii) Formulation. Likely childhood-onset disruptive pathway with ADHD comorbidity and coercive family cycle, now escalating via antisocial peers — closer to life-course-persistent risk than pure adolescence-limited delinquency, especially if CU features are confirmed. Not mania. Strengths and protective factors must also be listed for balanced formulation.^[1][6]

(iii) Psychosocial plan. Psychoeducation; behavioural parent management training (clear commands, praise, consistent consequences; address maternal depression referral); school behaviour plan and attendance recovery; peer-network change work. If multi-domain severe CD with justice risk persists, consider MST-level ecological intensity (home-based, caregivers as change agents, fidelity-based) where available.^[3][4]

(iv) Medication. Optimise ADHD treatment first if ADHD confirmed. No antipsychotic for defiance alone. If severe residual aggression after psychosocial work, specialist time-limited low-dose risperidone pathway with weight/metabolic/EPS/prolactin monitoring and explicit review date (guideline-aligned adjunctive use).^[5]

(v) Prognosis talk. Elevated adult antisocial/SUD risk with early-onset CD, CU traits, ADHD and adversity — but not inevitable ASPD; ASPD is an adult diagnosis. Emphasise treatable drivers (parenting, ADHD, peers, school) and hope for desistance with sustained multiagency work.^[1][7]