Oppositional Defiant Disorder
Heather Walter
Phillip Hernandez
Krista Kircanski
I. Description of the problem. Many children go through oppositional stages including angry outbursts, arguing, vindictiveness, and disobedience, generally directed at authority figures (such as parents and teachers) (see Chapter 59). Their behaviors will normally present in all children and adolescents from time to time, particularly during the toddler and early teenage periods, when autonomy and independence are developmental tasks. Reports suggest that most oppositional symptoms peak between 8 and 11 years of age and then decline in frequency.
Oppositional behavior becomes a concern when it is intense, persistent, and pervasive, and when it affects the child’s family, social, and academic functioning to a significant degree. The pediatric clinicians’ role is to differentiate children whose oppositional behaviors are more severe and persistent so that they can refer them to a mental health clinician.
Estimates of the prevalence of oppositional defiant disorder (ODD) vary depending upon the methodologic characteristics of the study. Recent surveys using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria suggest a point prevalence approximating 3% of children aged 6-18 years, and a lifetime prevalence approximating 10%.
II. Making the diagnosis.
A. Signs and symptoms. The DSM-IV-TR describes specific criteria for this diagnosis listed in Table 60-1. Disruptive behavior disorder, not otherwise specified (subsyndromal disruptive behavior) is diagnosed when some symptoms of ODD are present, but not enough to meet full diagnostic criteria.
B. Differential diagnosis. Although ODD shares a number of characteristics with conduct disorder (CD), ODD can be distinguished from CD by the absence of severe forms of antisocial behavior, such as physical assault, destruction of property, theft, and other serious violations of societal norms. When the youth’s pattern of behavior meets the criteria for both ODD and CD, the diagnosis of CD takes precedence. Other diagnoses to consider in the differential include attention-deficit/hyperactivity disorder (ADHD), bipolar, pervasive developmental, anxiety, mood, psychotic, and communication disorders, in which anger and disruptive behavior can be associated symptoms.
C. Comorbidity. The most frequent comorbidities with ODD are ADHD (about 10 times more often than expected), major depression (about seven times), and substance abuse (in adolescents, about four times). Other less commonly co-occurring disorders are bipolar, anxiety, posttraumatic stress, impulse control, somato form, adjustment, learning, and communication disorders. Comorbidities can exacerbate the symptoms of ODD by increasing negative parent-child interactions.
D. History: key clinical questions.
Does your child have trouble controlling his anger or behavior?
Why is this child not completing schoolwork? Is the work too difficult (always a possibility), or is the child too difficult? Ruling out a potential comorbid learning problem is an important facet of the work-up.
Does your child have friends?
How does your child respond to correction from adults?
How often does your child lose his or her temper, argue with adults, act defying or refuse to follow rules, deliberately annoy others, blame others for his or her mistakes, is easily annoyed, get angry and resentful, and be spiteful and vindictive?
III. Management.
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