Oppositional Defiant Disorder

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Oppositional Defiant Disorder Conduct Disorder
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DSM IV Criteria for ODDICD-9 313.81

• A. A pattern of negativistic, hostile, and
  defiant behavior lasting at least 6 months,
  during which four (or more) of the following are
  present (1) often loses temper (2) often
  argues with adults (3) often actively defies or
  refuses to comply with adults' requests or
  rules (4) often deliberately annoys people (5)
  often blames others for his or her mistakes or
  misbehavior (6) is often touchy or easily
  annoyed by others (7) is often angry and
  resentful (8) is often spiteful or vindictive  
• B. The disturbance in behavior causes clinically
  significant impairment in social, academic, or
  occupational functioning. 
• C. The behaviors do not occur exclusively during
  the course of a Psychotic or Mood Disorder. 
• D. Criteria are not met for Conduct Disorder,
  and, if the individual is age 18 years or older,
  criteria are not met for Antisocial Personality
  Disorder.

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Objectives

• Be familiar with the diagnostic criteria for
  Oppositional Defiant Disorder and Conduct
  Disorder
• Know how to screen for these disorders
• Understand the treatment modalities that can be
  implemented

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Background on ODD

• 3 of children meet DSM criteria
• studies show wide variance associated with
  differences in the criteria used, age at
  assessment, and number of informants used,
  resulting in prevalence estimates of 1-16
• Significant social impairment
• gt 2 SD below mean on rating scales for social
  adjustment
• Higher rates in
• Boys
• Lower income homes

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Natural History

• 40 of kids with ADHD also meet diagnostic
  criteria for ODD
• 2x rate of depression bipolar d/o
• 30 of kids with ODD develop conduct disorder
• 40 develop antisocial personality disorder in
  adulthood

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Example Case

• Lisa is a five-year-old girl whose parents asked
  their physician to see her
• because of their increasing concern about her
  temper tantrums in the home.
• The parents indicated that Lisa often becomes
  enraged and argumentative with
• them, refusing to follow rules or take direction.
  In particular, they report difficulty
• getting her to transition from playing with her
  toys to coming to the dinner
• table. After Lisa ignored her parents repeated
  prompts, her father became
• frustrated and told her that she had lost her
  dessert privilege. Lisa became
• aggressive and destructive, breaking her toys and
  smashing food and water
• from the dinner table into the carpet. Her
  parents described similar scenarios
• at bedtime, bath time, and when getting dressed
  in the morning. They
• described her as irritable in these situations
  and they felt she was deliberately
• ignoring or trying to annoy them.

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Screening Questions

• Has your child in the past three months been
  spiteful or vindictive, or blamed others for his
  or her own mistakes?(Any yes is a positive
  response.)
• How often is your child touchy or easily annoyed,
  and how often has your child lost his or her
  temper, argued with adults, or defied or refused
  adults requests? (Two or more times weekly is a
  positive response.)
• How often has your child been angry and resentful
  or deliberately annoying to others? (Four or more
  times weekly is a positive response.)

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Tools for Diagnosis

• NICHQ Vanderbilt Assessment Scale
• Web site http//www.nichq.org/NICHQ/Topics/Chroni
  cConditions/ADHD/Tools/
• SNAP-IV14
• Web site http//www.adhdcanada.com/pdfs/SNAPIVTea
  cherParetnRatingScale.pdf
• Pediatric Symptom Checklist15
• Web site http//www.massgeneral.org/allpsych/Pedi
  atricSymptomChecklist/psc_english.pdf

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Diagnosis of ODD

• Given the wide range of normal oppositional
  behavior during the preschool years, caution
  should be exercised in diagnosing this disorder
  in the preschool age child
• The assessment should include information
  gathered from multiple sources (e.g., preschool,
  teachers) as well as history obtained from the
  child directly
• The behavior must be considerably more frequent
  than is typically observed in persons of
  comparable age and developmental level

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Referral

• Pre-school age children developmental
  pediatrician
• School age children Psychologist or
  psychiatrist trained in the assessment of
  children with behavioral disorders

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Medication

• Studies in ADHD patients with comorbid ODD
  stimulants and atomoxetine have shown to be
  beneficial
• Studies have not demonstrated that stimulants
  reduce the symptoms of oppositional defiant
  disorder when ADHD is absent

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Conduct disorder
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DSM-IV CriteriaConduct Disorder (312.8)

• A repetitive and persistent pattern of behavior
  in which the basic rights of others or major
  age-appropriate societal norms or rules are
  violated, as manifested by the presence of three
  (or more) of the following criteria in the past
  12 months, with at least one criterion present in
  the past 6 months 
• Aggression to people and animals 
• (1) often bullies, threatens, or intimidates
  others (2) often initiates physical fights (3)
  has used a weapon that can cause serious physical
  harm to others (e.g., a bat, brick, broken
  bottle, knife, gun) (4) has been physically
  cruel to people (5) has been physically cruel to
  animals (6) has stolen while confronting a
  victim (7) has forced someone into sexual
  activity 

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• Destruction of property 
• (8) has deliberately engaged in fire setting
  with the intention of causing serious damage (9)
  has deliberately destroyed others' property
  (other than by fire setting)
• Deceitfulness or theft 
• (10) has broken into someone else's house,
  building, or car (11) often lies to obtain goods
  or favors or to avoid obligations (i.e., "cons"
  others) (12) has stolen items of nontrivial
  value without confronting a victim (e.g.,
  shoplifting, but without breaking and entering
  forgery) 
• Serious violations of rules 
• (13) often stays out at night despite parental
  prohibitions, beginning before age 13 years (14)
  has run away from home overnight at least twice
  while living in parental or parental surrogate
  home (or once without returning for a lengthy
  period) (15) is often truant from school,
  beginning before age 13 years 
• B. The disturbance in behavior causes clinically
  significant impairment in social, academic, or
  occupational functioning. 
• C. If the individual is age 18 years or older,
  criteria are not met for Antisocial Personality
  Disorder. 

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Background on Conduct Disorder

• 2-4 of children diagnosed with d/o
• Prior to 10 years old
• recurrent behavior in any one of these categories
  is sufficient to diagnose conduct disorder.
• After 10 years old
• must exhibit behaviors in 3 of 4 categories to
  warrant the diagnosis.
• More common among boys

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Treatment

• Identify and treat common comorbid conditions,
  including ODD, ADHD, anxiety disorder,
  depression, and psychosis
• Involve entire family in behavioral therapy
• Parent management training (PMT) is a structured
  program that empowers caregivers to provide the
  child with positive feedback, logical
  consequences, and on rare occasions, brief and
  specific punishment
• Coordinate therapy with other sources of support
  from the school and the community
• may include social skills training, academic
  tutoring, a mentoring program, special
  accommodations for a learning disability, and
  individual counseling

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Presentation

• Preschool present as irritable temperament,
  inattentiveness, and poor maternal-child
  attachment
• Elementary School exhibit quick, angry
  temperaments poor social skills and a tendency
  to blame the victim in cases of physical
  aggression
• Middle and High School commonly break rules,
  overreact emotionally, and fail to take
  responsibility for their actions

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Early treatment is key for both disorders!

• Success rates are higher with earlier
• implementation of interventions