Oppositional Defiant Disorder & Conduct Disorder

DSM IV Criteria for ODD ICD-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.

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

Background on ODD Lower income homes 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 > 2 SD below mean on rating scales for social adjustment Higher rates in: Boys Lower income homes

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

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.

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.)

Tools for Diagnosis NICHQ Vanderbilt Assessment Scale SNAP-IV14 Web site: http://www.nichq.org/NICHQ/Topics/ChronicConditions/ADHD/Tools/ SNAP-IV14 Web site: http://www.adhdcanada.com/pdfs/SNAPIVTeacherParetnRatingScale.pdf Pediatric Symptom Checklist15 Web site: http://www.massgeneral.org/allpsych/PediatricSymptomChecklist/psc_english.pdf

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

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

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

Conduct disorder

DSM-IV Criteria Conduct 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  Continued on next page

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. 

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

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

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

Early treatment is key for both disorders! Success rates are higher with earlier implementation of interventions