Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. 
   

   A pattern of negative, 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

   
   
   
   
   5. 
      

      often blames others for his or her mistakes or misbehavior

   
   
   
   
   6. 
      

      is often touchy or easily annoyed by others

   
   
   
   
   7. 
      

      is often angry or resentful

   
   
   
   
   8. 
      

      is often spiteful or vindictive

   
   
   
   
   • 
     

     Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

   
   
2. 
   

   The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

   
   
3. 
   

   The behaviors do not occur exclusively during the course of psychotic or mood disorder.

   
   
4. 
   

   Criteria are not met for conduct disorder, and, if the individual is 18 years or older, criteria are not met for antisocial personality disorder.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 American Psychiatric Association.)

General Considerations

As with conduct disorder and attention-deficit/hyperactivity disorder (ADHD) (described in previous chapter), with which it is often entangled, it is uncertain whether oppositional defiant disorder is a truly distinctive nosological category. Specifically, it is unclear whether oppositional behavior is better considered to be on a continuum between normal developmental limit-testing on the one hand and pathologically disruptive behavior on the other. The distinction between categorical disorders and dimensional psychopathology is more than a theoretical quibble. Valid categories delimit disorders that are likely to have a significantly biological (e.g., neurochemical) basis. Dimensional sets of behavior masquerading as categories may, in fact, obscure true categories that nest within their fictitious boundaries.

Oppositional defiant disorder, as defined in DSM-IV-TR, is manifest as age-inappropriate, persistent, intemperate, argumentative, defiant, deliberately annoying, irritable, resentful, vindictive behavior associated with the tendency of the subject to blame others for his or her own transgressions or omissions. The aggression of the oppositional child or adolescent is predominantly verbal rather than physical. The aggression tends to be reactive (e.g., in response to an unwelcome imposition of rules) rather than proactive (e.g., bullying), and overt (e.g., shouting) rather than covert (e.g., spreading malicious rumors).

Epidemiology

The prevalence of oppositional defiant disorder is uncertain, but it has been estimated at 5.7–9.9%. The average age at onset is 6 years. Oppositional defiant disorder is regarded by many researchers as a milder, precocious form of conduct disorder. The male-to-female sex ratio in childhood conduct disorder is 4:1. There is a clinical impression that childhood oppositional defiant disorder is more common among preadolescent males than females, however, the relative prevalence in females appears to rise in adolescence.

Etiology

The genesis of oppositional defiant disorder has not been studied separately from that of conduct disorder. Because conduct disorder often evolves from earlier oppositional behavior, and because the two disorders have similar risk factors, oppositional defiant disorder and conduct disorder are often discussed together.

Many young children who exhibit oppositional defiant behavior were, as infants, already temperamentally hyperreactive, irritable, difficult to soothe, and slow to adapt to new circumstances. Infants who exhibit disorganized attachment behavior are at risk of oppositional, disruptive behavior in middle childhood. Often the families of these children are highly stressed, as a result, for example, of marital discord, single parenthood, parental psychopathology, or socioeconomic disadvantage. Maternal depression may be particularly common. Preoccupied with their own problems, parents fail to provide these children with adequate praise and attention. When parents seek to set limits, they do so harshly and inconsistently. The children react defiantly, testing the limits, and the stage is set for repetitive cycles of escalating coerciveness, with shouting and mutual accusations, often terminated by harsh physical punishment or by the capitulation of one or other of the antagonists. Children’s aggressiveness is associated with how aggressive their parents were at the same age. Often parents respond to their children in the manner (and even with the same words) that their parents responded to them. In summary, a lack of positive reinforcement for acceptable behavior is associated with negative attention for oppositional behavior and with inconsistent, unpredictable, harsh punishment. Table 36–1 lists the characteristics of a coercive interaction. These factors can be targeted for therapeutic intervention (see “Treatment” section later in this chapter).

Genetics

The genetics of oppositional defiant disorder has not been studied apart from that of conduct disorder. Behavioral genetic studies of aggressive behavior in children have yielded inconsistent estimates of its heritability, probably because of variations in the measurement instruments used. Most studies suggest that the trait of aggressiveness has low heritability.

Clinical Findings

Signs and Symptoms

The persistent, recurrent aggressive and defiant behavior associated with oppositional defiant disorder may be restricted to the home or may be generalized as an antiauthoritarian attitude, for example, to teachers and other adults outside the home. It is usually evident before 8 years of age but may emerge for the first time in adolescence. Oppositional, hostile, limit-testing behavior disrupts family relationships and can interfere with learning. At school, oppositional children or adolescents may be moody, irritable, lacking in self-esteem, and often in conflict with teachers and peers. As a result, the oppositional child or adolescent often appears to have a “chip on his or her shoulder.” Oppositional adolescents may be solitary or inclined to gravitate to the company of others who regard themselves as outlaws. Precocious tobacco use is likely, as is alcohol and substance abuse.

Psychological Testing

Aside from questionnaires that are useful for assessing aggressive behavior (e.g., the Child Behavior Checklist and the Eyberg Child Behavior Inventory), a number of behavioral observation rating scales and questionnaires have been developed for the assessment of conflictual parent–child or family behavior (Table 36–2). These tests may be useful as monitors of the progress and effectiveness of treatment, in accordance with treatment goals and objectives.

Differential Diagnosis (Including Comorbid Conditions)

Oppositional defiant disorder should be differentiated from normal developmental limit-testing in toddlers and preschool children, and from the challenging confrontations that occur between parents and normal adolescents who are seeking to be more independent. Developmental oppositional behavior is transitory and causes no significant impairment.

Oppositional defiant disorder should be discriminated from ADHD, with which it frequently coexists, and from conduct disorder, which often succeeds it. An underlying mood disorder may be manifest, to the superficial observer, as sullen defiance. Premorbid schizophrenia or early schizophrenia is sometimes associated with negativism and marked contrasuggestibility. A comprehensive history and mental status examination will differentiate these two disorders.

Children with mental retardation, hearing loss, or impaired language comprehension are sometimes oppositional and defiant at school. Selective mutism often has oppositional features.

Oppositional defiant behavior often coexists with the following situations or conditions: Parental conflict, parental psychopathology (especially depression), physical or sexual abuse, conduct disorder, ADHD, and adolescent substance use disorder. In regard to the comorbidity of oppositional defiant disorder with ADHD and conduct disorder, it is unclear whether these disorders have mixed symptoms, whether they share risk factors, whether oppositional defiant disorder is a risk factor for other disorders, or whether it is an early manifestation of conduct disorder.

Treatment

Children

With children under 12 years of age, treatment is provided primarily through the parents. Whether as single parents, as parental dyads, or in parental groups, parents are educated concerning the origin and meaning of oppositional defiant behavior and are trained to replace coercive discipline with more effective child-rearing techniques. Table 36–3 describes the essentials of effective parenting.

The Positive Parenting Program (Triple P) contains all these elements and has been designed as a population-based intervention strategy. Triple P is a parenting and family support program that can be delivered in five levels: level 1 targets common, everyday behavior problems; level 2 targets oppositional defiant disorder; and levels 3–5 target severe behavior problems complicated by severe family psychopathology. The program can be delivered through parent information nights; through videotapes; by information and skills training delivered through individual, self-directed, and group programs; and through three levels of intensive family therapy (requiring specific training for the clinicians who implement the therapy). Table 36–4 lists the principles and objectives of the Triple P program.

Adolescents

In adolescent oppositional defiant disorder, a family therapy approach has had the most success. In the Problem Solving Communication Training (PSCT) program, the family is first assessed with regard to the issues described in Table 36–5. These issues can be described as molecular (i.e., family communication problems and poor problem solving) or molar (i.e., family structural and functional problems). Molecular issues provide the specific goals and objectives of therapy, whereas molar issues inform its strategy and tactics.

The treatment objectives of PSCT are listed in Table 36–5

Related posts:

Behavioral and Cognitive–Behavioral Interventions Psychiatric Epidemiology Schizophrenia Dissociative Disorders Anxiety Disorders in Children and Adolescents Psychological Reactions to Acute & Chronic Systemic Illness in Pediatric Patients

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