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