What is the appropriate diagnosis for a 14-year-old female with a history of aggression, robbery, and elopement presenting to a psychiatric mental health nurse practitioner for the first time?

Diagnostic Approach for a 14-Year-Old Female with Aggression, Robbery, and Elopement

This patient's presentation of robbery (theft) and aggression strongly suggests Conduct Disorder (CD) rather than Oppositional Defiant Disorder (ODD), as robbery represents a serious violation of rules and rights of others that exceeds the criteria for ODD. 1

Distinguishing Between ODD and Conduct Disorder

The key differentiating factor here is robbery, which is a CD-specific behavior involving violation of others' rights and property through theft. The AACAP guidelines explicitly note that "more severe, persistent cases of ODD eventually meet diagnostic criteria for CD" and that youth with ODD may have specific CD behaviors such as aggression 1.

Critical Diagnostic Features to Assess:

For Conduct Disorder diagnosis, you need at least 3 symptoms in the past 12 months, with at least 1 present in the past 6 months 2. The behaviors fall into four categories:

• Aggression to people/animals (present in this patient)
• Destruction of property (assess for this)
• Deceitfulness or theft (robbery confirms this)
• Serious rule violations (elopement suggests this)

Elopement (running away from treatment facilities or home) represents a serious rule violation and is associated with psychosocial issues and the patient's attitude toward treatment 3. This further supports CD over ODD.

Essential Comorbidity Assessment

Before finalizing the CD diagnosis, you must systematically rule out or identify comorbid conditions, as aggressive and oppositional behavior complicates a wide range of other diagnoses 1:

Priority Screening:

• ADHD: Most common comorbidity; treatment of ADHD with stimulants often improves oppositional behavior 1
• Mood disorders (depression, bipolar disorder)
• Anxiety disorders
• Substance use disorders (critical in adolescents with CD) 1
• Trauma history (physical/sexual abuse, domestic violence exposure) 2
• Psychotic symptoms (hallucinations, delusions, disorganized thinking) 4

Risk Factors to Document:

• Poverty/low socioeconomic status
• Parental substance use or criminal behavior
• Maternal smoking during pregnancy
• History of abuse or domestic violence 2

Common Diagnostic Pitfalls

Do not diagnose ODD when CD criteria are met. The guidelines are clear that robbery and serious aggression push the diagnosis into CD territory 1. ODD is characterized by oppositional, vindictive, and negativistic behavior but does not include serious violations like theft or robbery.

Avoid premature closure: Aggression is a symptom, not a diagnosis. It can present in ADHD, mood disorders, psychosis, autism spectrum disorder, substance use, and medical conditions 5, 6, 7. The robbery and elopement pattern, however, specifically points toward CD.

Provisional Diagnosis

Conduct Disorder is the most appropriate primary diagnosis given the triad of aggression, robbery (theft), and elopement (serious rule violation). Document the specific CD behaviors present, their duration, and functional impairment in social, academic, or occupational domains 1, 2.

However, complete your assessment by:

1. Screening for ADHD symptoms (inattention, hyperactivity, impulsivity)
2. Assessing mood symptoms (depression, mania)
3. Evaluating substance use
4. Documenting trauma exposure
5. Checking for psychotic symptoms

The final diagnosis may be CD with comorbid conditions, which is common and significantly impacts treatment planning 1.