Intro to Oppositional Defiant Disorder and Conduct Disorder

Intro to Oppositional Defiant Disorder and Conduct Disorder John Sommers-Flanagan, Ph.D. University of Montana On behalf of Western Montana Addiction Services – 5/15/14 Email: John.sf@mso.umt.edu Blog: 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

Intro to Oppositional Defiant Disorder and Conduct Disorder