Intro to Oppositional Defiant Disorder and Conduct Disorder

Intro to Oppositional Defiant Disorder and Conduct Disorder

John Sommers-Flanagan, Ph.D.University of MontanaOn behalf of Western Montana Addiction Services – 5/15/14Email: [email protected]: johnsommersflanagan.com

Today’s Plan

Define Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)

Place both of these mental disorders within their historical and cultural contexts

Review etiology, base rates, differential diagnosis, and key diagnostic signs

Discuss diagnostic challenges and conundrums

Today’s Plan (continued)

Describe how youth with ODD and CD typically act and look during an initial interview and MSE

Describe specific diagnostic interviewing procedures

Provide closing comments and a preview of next month

Some History and Context

ODD first appeared in the DSM in 1980 (DSM-III) as Oppositional Disorder

ODD is a widely criticized diagnosis Critics complain it’s a label for normal

childhood independence-striving ODD symptoms may overlap with

ADHD and CD symptoms

Disruptive Disorders

ODD and CD are categorized together in DSM-5 under “Disruptive, Impulse Control, and Conduct Disorders”

One problem is cultural and contextual Who decides who is disruptive to whom? Parents, teachers and other authority

figures determine who is disruptive

The ODD Response

Clients with ODD symptoms would likely complain about this particular labeling system and say:

“That’s not fair!”

And, of course, they would be correct Prototype for ODD = Calvin

ODD – DSM-5 Description

Oppositional defiant disorder (ODD) is a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories (the interaction must be with at least one individual who is not a sibling*).

There are Three Categories and Eight Possible Symptoms

Category 1: Angry/irritable mood Often loses temper Is often touchy or easily annoyed Is often angry and resentful

Note: DSM says it’s not unusual for individuals to present with the behavior symptoms, but not the mood symptoms

ODD Categories/Symptoms

Category 2: Argumentative/defiant behavior Often argues with authority figures Often actively defies or refuses to

comply with requests from authority figures or with rules

Often deliberately annoys others Often blames others for his or her

mistakes or misbehavior [Externalizing]

DSM-III Language

“The most striking feature is the persistence of the oppositional attitude even when it is destructive to the interests and well-being of the child or adolescent” (p. 63)

ODD Categories/Symptoms

Category 3: Vindictiveness Has been spiteful or vindictive at least

twice within the past 6 months

Does this fit you?

ODD Prevalence and Risk Factors

About 3.3% of population Males 1.4:1 > Females Difficult infant toddler emotional

regulation Family risks: harsh, inconsistent, or

neglectful parenting

Comorbidity and Course

ADHD ODD Symptoms overlap with disruptive

mood dysregulation disorder, but the two cannot coexist!

ADHD – ODD - CD

ODD Diagnostic Challenges

What the DSM considers “Often” is somewhat subjective . . . But they provide guidelines: Under 5 years “Often” means “most

days” 5 years and older “Often” means “at

least weekly” But these are just guidelines

ODD Diagnostic Challenges II

“Other factors should also be considered. . .” This refers to a general DSM diagnostic

rule that a diagnosis shouldn’t be provided if the behavior pattern is explained by developmental level, gender, or cultural context

Can you see any problems with diagnosing ODD given these contexts?

ODD Diagnostic Challenges III

There must be distress in the individual or others OR social, educational, occupational impairment

The symptoms don’t warrant a diagnosis if they occur during a psychotic, substance, depressive, or bipolar dx. . and disruptive mood dysregulation dx trumps ODD

Questions and Comments

Now is a good time for you to pose questions or make comments

CD – DSM-5 Description

Conduct disorder (CD) is a repetitive and persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated. At least three of the 15 CD criteria (in four categories) are needed over the past 12 months.

CD Symptoms (quickly . . .)

Category 1: Aggression to People and Animals Often bullies, threatens, or intimidates Often initiates physical fights Has used a weapon (e.g., bat, brick, broken

bottle, knife, gun) Has been physically cruel to animals Has been physically cruel to people Has stolen while confronting a victim Has forced someone into sexual activity

CD Symptoms II

Category 2: Destruction of Property Has deliberately engaged in fire-setting with

the intention of causing serious damage Has deliberately destroyed others’ property

(other than by firesetting)

CD Symptoms III

Category 3: Deceitfulness or Theft Has broken into someone’s house, building,

or car Often lies to obtain goods or favors or to

avoid obligations (i.e., conning) Has stolen items of non trivial value without

confronting a victim (shoplifting, forgery)

CD Symptoms IV

Category 4: Serious Violations of Rules Often stays out at night despite parental

prohibitions (beginning before age 13) Has run away from home overnight at least

twice while living in the parental/surrogate home . . . Or once without returning for a lengthy period

Is often truant from school, beginning before age 13

Specifiers

ONSET: Childhood onset (one symptom pre-10-

years-old); Adolescent-onset (No symptoms before

10-years); Unspecified (not enough information)

Specifiers II

With Limited Prosocial Emotions: Lack of remorse or guilt Callous—Lack of empathy Unconcerned about performance Shallow or deficient affect

Specifiers III

SEVERITY: Mild: Few and minor conduct problems Moderate: Intermediate conduct

problems Severe: Many problems that can cause

considerable harm to others.

ODD and CD Differential Diagnosis

Unlike CD, children with ODD are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit.

Prevalence and Risk Factors

About 4% of population Males > Females Difficult infant temperament Lower verbal IQ scores Family risks: parental rejection,

neglect, inconsistent discipline, physical or sexual abuse, lack of supervision, parental criminality

Comorbidity

ADHD ODD Substance-related disorders Specific learning disorders Depressive or bipolar disorders Anxiety disorders?

CD Diagnostic Challenges

Diagnostic challenges are similar to ODD, but also: Gang related neighborhoods, war zones,

etc., can explain CD behaviors Client deceit and minimization are

problematic For more info, see

johnsommersflanagan.com for two articles in pdf format

Initial Interview and MSE

Historical info from parents, school, and probation officer is essential

Tell the youth what you know (secret-keeping will activate resistance)

Your reaction is important to detecting client attitude (e.g., do you feel anxious, intimidated, or something else?)

Initial Interview and MSE II

Gather developmental history information

Use projective assessment methods Pick a fight; million dollars; house party

Use multi-rater, multi-method approaches to gather data from different settings (e.g., teacher, parent, client, in school and at home)

Specific Diagnostic Interviewing

You can use a direct approach to asking about DSM symptoms, but you’re likely to get dishonest answers

You’re better off doing an indirect aggression history and activate the client’s ego investment in being powerful, in control, and intimidating

Previewing Next Month

Next month I will focus mostly on treatment options

Resources

http://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=ntt_dp_epwbk_1

http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_4?s=books&ie=UTF8&qid=1400173275&sr=1-4