Oppositional Defiant Disorder

1. Oppositional DefiantDisorder Dr Claude Jolicoeur

2. Oppositional Defiant Disorder • Statistical Manual of Mental Disorders (DSM IV), 4th edition, 1994, American Psychiatric Association • (update DSM IV-TR, and soon to be published2006-2007, DSM V)

3. Criterion A • Diagnostic FeaturesThe essential feature of Oppositional Defiant Disorder  is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months

4. Next 1 - and is characterized by the frequent occurrence of at least four of the following behaviors:

5. Criteria • A1- losing temper • A2- arguing with adults • A3- actively defying or refusing to comply with the requests or rules of adults • A4- deliberately doing things that will annoy other people

6. Next 1 • A5- blaming others for his or her own mistakes or misbehavior • A6- being touchy or easily annoyed by others • A7- being angry and resentful • A8- being spiteful or vindictive

7. Criterion B • To qualify for Oppositional Defiant Disorder, the behaviors must occur more frequently than is typically observed in individuals of comparable age and developmental level and must lead to significant impairment in social, academic, or occupational functioning

8. Criterion C • - The diagnosis is not made if the disturbance in behavior occurs exclusively during the course of a Psychotic or Mood Disorder

9. Negativistic and defiant behaviors are expressed by • . persistent stubbornness, . resistance to directions, . unwillingness to compromise, give in, . or negotiate with adults or peers.

10. Next 1 Defiance may also include . deliberate or persistent testing of limits, usually by ignoring orders, arguing, and failing to accept blame for misdeeds.

11. Next 2 • Hostility can be directed at adults or peers and is shown by deliberately - annoying others or by verbal aggression (usually without the more serious physical aggression seen in Conduct Disorder).

12. Diagnostic criteria • 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

13. next • (5) often blames other for his or her mistakes or behavior(6) is often touchy or easily annoyed by others(7) is often angry and resentful(8) is often spiteful or vindicative

14. Associated Features and Disorders • to be more prevalent among those who, in the preschool years, have problematic temperaments (e.g., high reactivity, difficulty being soothed) or • high motor activity. During the school years, there may be low self-esteem, mood lability, low frustration tolerance, swearing, and the precocious use of alcohol, tobacco, or illicit drugs.

15. next • There are often conflicts with parents, teachers, and peers. There may be a vicious cycle in which the parent and child bring out the worst in each other. • Oppositional Defiant Disorder is more prevalent in families in which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or neglectful child­rearing practices are common.

16. Specific Age and Gender Features • Because transient oppositional behavior is very common in preschool children and in adolescents, caution should be exercised in making the diagnosis of Oppositional Defiant Disorder especially during these developmental periods. The number of oppositional symptoms tends to increase with age.

17. next • The disorder is more prevalent in males than in females before puberty, but the rates are probably equal after puberty. Symptoms are generally similar in each gender, except that males may have more confrontational behavior and more persistent symptoms.

18. Prevalence • Rates of Oppositional Defiant Disorder from 2% to 16% have been reported, depending on the nature of the population sample and methods of ascertainment.

19. Course • Oppositional Defiant Disorder usually becomes evident before age 7 years and usually not later than early adolescence. • The oppositional symptoms often emerge in the home setting but over time may appear in other settings as well.

20. Next 1 • Onset is typically gradual, usually occurring over the course of months or years.

21. Next 2 • In a significant proportion of cases, Oppositional Defiant Disorder is a developmental antecedent to Conduct Disorder

22. Familial Pattern •     Oppositional Defiant Disorder appears to be more common in families in which at least one parent has a history of a Mood Disorder, Oppositional Defiant Disorder, Conduct Disorder, Attention-Deficit/Hyperactivity Disorder, Antisocial Personality Disorder, or a Substance-Related Disorder.

23. Next 2 • In addition, some studies suggest that mothers with a Depressive Disorder are more likely to have children with oppositional behavior, but it is unclear to what extent maternal depression results from or causes oppositional behavior in children.

24. Next 3 • Oppositional Defiant Disorder is more common in families in which there is serious marital discord.

25. Differential Diagnosis •     The disruptive behaviors of individuals with Oppositional Defiant Disorder are of a less severe nature than those of individuals with Conduct Disorder and typically do net include aggression toward people or animals, destruction of property, or a pattern of theft or deceit

26. Next 1 • Because ail of the features of Oppositional Defiant Disorder are usually present in Conduct Disorder, Oppositional Defiant Disorder is not diagnosed if the criteria are met for Conduct Disorder.

27. Next 2 • Oppositional behavior is a common associated feature of Mood Disorders and Psychotic Disorders presenting in children and adolescents and should not be diagnosed separately if the symptoms occur exclusively during the course of a Mood or Psychotic Disorder

28. Next 3 • Oppositional behaviors must also be distinguished from the disruptive behavior resulting from inattention and impulsivity in Attention-Deficit/Hyperactivity Disorder. • When the two disorders co-occur, both diagnoses should be made.

29. Disruptive Behavior disorder Not Otherwise Specified, 312.9 • This category is for disorders characterized by conduct or oppositional defiant behaviors that do not meet the criteria for Conduct Disorder or Oppositional Defiant Disorder.

30. next • For example, include clinical presentations that do not meet full criteria either for Oppositional Defiant Disorder or Conduct Disorder, but in which there is clinically significant impairment.

31. Melissa, 7 y.o. • Mélissa se refuse aux routines, dès le matin, • de s’habiller, • de préparer sa toilette, • de déjeûner, • mais veut seulement jouer, • regarder la télé

32. Suite 1 • La jeune mère de 27 ans se dévalorise, au point de menacer de quitter la maison et tout laisser au père seul, • Pour lui, c’est surtout la mère qui aurait du mal à se faire écouter, trop douce, incapable de tenir son bout comme lui.

33. Suite 2 • Dans la crise, « la chaise revolle, • elle donne des coups de pieds, de poings », à la mère surtout. • Le soir, ne veut pas aller au lit • Exige sur le champ, sans délai d’attente

34. Suite 3 • Elle aime grimper, sauter. • Elle n’a « peur de rien », • Mélissa bouge pas mal, depuis la tendre enfance: elle aurait même déboulé les escaliers d’estrade du Parc Jarry à 3 ans, par imprudence

35. Conners- parents, (enseigants) • Évaluation questionnaire Conners parents : père (mère) :Opposition : 85 (126); inattention : 72 (63) ; hyperactivité : 86 (101); anxiété : 47 (86); • perfectionnisme : 55 (69); manque de sociabilité : 62 (55 ); psychosomatique : 65 (nil); • ADHD index : 79 (97); • CGI impulsivité : 84 (97); CGI labilité émotive : 57 (113); CGI total : 77 (110) • DSM-IV : parents (prof).inattention: 72 (75); hyperactivité- impulsivité: 84 (96); DSM-IV total : 83 (93)

36. Suite 4 • En classe, elle dérange, mais serait influencée par une autre gamine très active qui l’excite, selon le père qui est contre la médication. • Lui-même était turbulent, opposant, • Abandonne l’école en sec. 1 • Se fait expulsé de chez lui à 15 ans

37. Suite 5 • Mais reprend les études à 23 ans • Termine secondaire • Fait cours des matériaux composites • Travaille dans fibre de verrs • Mère fait actuellement le sec. 2.

38. Jonathan, 11 ans • Il a beaucoup de misère à se concentrer, selon la jeune. • Il a de la misère à comprendre; il ne peut accorder ses verbes. • Et de plus, il refuse de faire des exercices.

39. Suite 1 Jonathan • Pour les devoirs, « c’est la guerre ». • Cette année, il se fait expulser de l’aide aux devoirs, après l’école, pour induscipline. • Dans la classe, « il parle, il rie fort, il lit un libre, il fait des blagues », et devient ainsi populaire parmi ses pairs.

40. Suite 2 Jonathan • Le prof le place à l’avant et lui demande de ne pas bouger, de cesser sa danse constante du pied.

41. Suite 3 Jonathan • Excelle dans le sport, comme hockey • Récemment il refuse d’alterner, aux minutes, son temps de glace comme les autres. • Il est très mauvais perdant

42. Suite 4 Jonathan • Jonathan est peu organisé dans ses affaires, et manifeste un grand désordre dans sa chambre. • Le patient fait des oublis à répétition; il perd des chandails, souliers, des tuques, mitaines, crayons, etc. Il égare ses jeux favoris dans la maison. Il ne remplit pas son agenda et il ne connaît pas les devoirs à faire. • À la maison, il envahit vite la conversation des adultes, et donne son opinion sur tout, sans retenue. « Lui

43. Suite 5 Jonathan • En classe, il se distrait, dérange les autres, parle fort, fait des blagues, refuse de travailler, de suivre les consigne. • Il fait des erreurs d’attention, il ne se donne pas la peine de corriger ses fautes. Il perd facilement le fil des idées du prof. ne peut suivre la dictée et saute des lignes

44. Suite 1 Jonathan, fabulation • Il change facilement sa version des faits, à quelques minutes de distance

45. Suite 1 Jonathan: Insomnie, immaturité • Il s’endort mal le soir et se réveille souvent en pleine nuit, puis s’occupe jusqu’au matin ou se lève tôt vers 5-6 heures. Alimentation limitée sur les légumes. • Petit, il pleurait souvent et ne fait pas ses nuits avant 24 mois.

46. Conners parents (enseigants) • Évaluation questionnaire Conners parents (ens) :Opposition : 80 (88); inattention : 85 (78) ; hyperactivité : 100 (79); anxiété : 74 (75); • perfectionnisme : 54 (59); manque de sociabilité : 76 (48); psychosomatique : 66 ( nil ); • ADHD index : 83 (80); • CGI impulsivité : 87 (80); CGI labilité émotive : 70 (91); CGI total : 85 (89) • DSM-IV : parents (prof).inattention: 81 (78); hyperactivité- impulsivité: 97 (83); DSM-IV total : 90 (84)