Or, the other disruptive behavior disorders Patrick Shea MD R3 Triple board

ODD is a pattern of behaviors that are:

Negativistic Hostile Defiant

It cant be accounted for by something else (generally CD, mood, psychosis, PDD)

manifested by at least four from below:

1. 2.

It causes significant distress and/or impairment

It needs to be present for at least 6 months

3.
4. 5. 6. 7. 8.

Frequent temper tantrums Frequent arguments with adults Active defiance/refusal to comply with adult rules and requests Often deliberately annoying/irritating others Often touchy or easily annoyed by others (reactive) Often blames others for his/her own mistakes and misbehavior Angry, resentful attitude Spiteful, vindictive (generally when crossed or corrected)

Once per month: Spiteful or vindictive behavior; caught blaming others for misbehavior Once per week: Loses temper, argues with adults, openly defiant. Nearly daily: Touchy, angry, easily annoyed, eager to annoy others.

Ricky comes in for a well-child visit. He is generally healthy and recently started 3rd grade. His mom reports that he is an extremely picky eater and she frequently has to fix him special meals. He does not get along with his sister and has frequent tantrums, but mom admits that she often ignores him or gives into his demands, such as to watch TV and drink soda during dinnertime, just to keep the peace. Bedtime is a nightly struggle and Ricky refuses to stay in his bed and is frequently discovered playing with toys as late as 11 or 12 at night. At school he does fairly well in most subjects, but occasionally has poor grades due to refusal to complete classwork. Mom also reports frequent calls from the Principals office as Ricky tells other children he hates them and overreacts to playground skirmishes, threatening to run away from the school.

On exam he is quite hostile, refusing to comply with even the least invasive parts without mom cajoling him. On the way out of the office he can be heard to say to Mom: youd better take me to Wendys after this! Geez!!

Alessas mom brings her in for an office visit for behavioral problems. She is generally healthy, but has a long history of having a quick temper and overreacting to everyday situations at school and at home. Mom is at her wits end with the daily homework battle, and Alessas tantrums have recently worsened in that she is now yelling, using curse words, and occasionally even breaking household objects (mainly dishes) when something sets her off. Mom is desperate for change at home and would really like to try medications. In talking with Alessa herself, she seems incredulous and states that I dont know what my moms all freaked out about. Shes just being weird. At a follow-up visit, review of her assessment scales from mom and teachers show a lot of defiant behavior, but she performs better than expected on tests and is able to sit still and concentrate when she isnt feeling angry.

Onset between age 3 and age 8. 15-20% of children meet criteria at some point, boys>girls Oppositionality is developmentally appropriate during terrible twos and again in early adolescence as part of normal individuation.

Temperament: Rigid, reactive, strong-willed Sick or traumatized children Family dynamics that set up a power struggle between one parent and the child Coercive parenting and unintentional reinforcement: increased parental attention, or withdrawal of requests in response to negative behaviors Modeling by parents who may themselves be overly reactive or unnecessarily aggressive in everyday situations

Child behavior Checklist (CBCL) and Connors Rating Scales considered more comprehensive for ODD symptoms Vanderbilt also includes a section for ODD symptoms AACAP practice parameters: Medication only for treatment of comorbidities, rather than ODD itself Standard treatment for ODD: Parent Management Training

AKA: Parenting classes Behavioral techniques to establish clear rewards/consequences. Avoids unintentional reinforcement Teaching parents not to emotionally escalate with the child during a tantrum Parental responses should be: Predictable (and consistent across adults in household), Contingent, and Immediate Reward prosocial behavior, negative consequences for disruptive behavior. Prioritization of behaviors is key (Sometimes, parents must decide what they will ignore/redirect).

Alessa came home from school one day, while her mom was doing the laundry.
Alessa noticed one of her favorite shirts and yelled at mom, I want to wear that shirt right now! Hurry up and wash it for me! Mom replied just for that, missy, Im not washing it until tomorrow. Alessa became angry and threw her glass of milk on the floor, breaking the glass. Mom yelled, You ungrateful little witch! Now Im not washing it at all! Wash your own *$&%ing shirt! and threw the shirt at Alessa. Later that evening, Alessa met her dad at the door as he came home from work to tell him how her mom had just totally flipped out when all I did was ask her how the laundry was going.

Alessa came home from school one day, while her mom was doing the laundry.
Alessa noticed one of her favorite shirts and yelled at mom, I want to wear that shirt right now! Hurry up and wash it for me! Mom replied, Ill let you know when Im finished with it. Right now, why dont you fix yourself a snack and get started on your homework? Alessa yelled at mom that she wanted the shirt washed RIGHT NOW and threw down the glass of milk, breaking it. Mom calmly replied that According to our plan, since you broke something, I guess this means you wont be able to watch TV tonight.

Alessa stormed off to her room, but further escalation was avoided.

Per AACAP parameters, the role of medication in ODD is to treat comorbidity. 40% of children with AD/HD will also have ODD or CD (not the other way around) Many (15-20%?) also have mood and anxiety symptoms but numbers hard to pin down. Screen for depression/anxiety and AD/HD and treat if these are present. Treatment is the same as first-line therapies for patients who dont have ODD. Important to know whats being treated.

Most (70%) will no longer meet criteria for ODD after 3 years. 30% develop Conduct Disorder Some controversy exists over whether ODD and CD should be one spectrum diagnostically but most recent studies find that there is a meaningful difference in terms of symptom severity and outcomes. One study suggested a higher prevalence of Personality disorders (15%) in later life, but this considered ODD and CD together. Poorer outcomes observed in patients who also meet criteria for AD/HD, and in patients who are diagnosed at earlier ages (generally higher rates of progression to CD).

1.

Persistent behavior pattern which violates:

basic

rights of others major age-appropriate societal norms and rules. is manifest by 3 of 4 categories:

2.

3.

4.

Severe aggression: Physical cruelty to people and/or animals, initiating physical fights with others, using weapons, forcing others into sexual activity, theft while confronting a victim. Serious property destruction: Fire setting or deliberate property destruction. Deceitfulness/Theft: Breaking and entering, lies to con others into favors, stealing items of nontrivial value. Serious rule violations: Staying out at night or truancy before age 13. After 13, running away from home overnight at least twice.

Clinically significant impairment Not explainable by another diagnosis (particularly ASPD if older than 18) Need the 3 of 4 criteria over a span of 12 months Specify child (before 10 y/o) or adolescent onset.

Relay is a 17 year old boy presenting for psychiatric admission after an Amitriptyline overdose. Relay had been selling and using cocaine for the past year and a half, and had recently stolen $15,000 from his mothers checking account and grandmothers money market account in order to finance some deals that had gone bad, and in order to pay off a higher level dealer for cocaine that Relay had flushed down the toilet when authorities were about to raid the home in which he was staying. He claimed that the TCA overdose was an attempt at a recreational high, rather than suicide or self-harm. Due to trouble he was in for the theft of the money, he had run away from home 2 weeks prior to this admission and was found in a girlfriends apartment; she called EMS after discovering Relay unconscious. He had a relatively long criminal record for his age including drug possession and sales as well as multiple violent altercations and weapons charges in association with his drug distribution.

Estimates from 1-10% of the population meet criteria at some point Male>Female at a 7:1 ratio Males have an earlier onset on average Higher prevalence among children of parents with Personality disorders and Substance use disorders.

Much more studied than etiology of ODD (presumably due to link with criminality) Parental factors: chaotic homes, aggressive parenting (incl. abuse), neglect. Controversial: Divorce vs persistence of hostility. Old-school: Psychodynamic idea that the child is acting out the parents secret antisocial wishes. Socioeconomic deprivation: Hard to isolate from family chaos and substance abuse among parents. Psychological factors: Impulse control issues, less empathy development (modeling?) Neurobiological factors: Decreased noradrenergic function, decreased serotonergic function Well known risks: Abuse, mentally ill/substance abusing parents, AD/HD.

Child behavior checklist and other assessment tools useful for identifying particular behaviors/instances Unfortunately, often first presents to clinical attention via criminal justice system Also can come to attention via the inpatient mental health system: Suicidality, aggression, or homicidal threats.

Behavioral programs: Similar to ODD with regard to structure and consequences, but removal from family (at least for some period) is more often indicated Individual therapy (but beware of pitfalls if they truly lack empathy) Treat any comorbidities. Substance abuse and AD/HD are the most common but mood disorders as well.

Again, treating comorbidities, such as AD/HD, bipolar, MDD Aggression: Antipsychotics and Depakote have been shown helpful in controlled studies Evidence mixed for Tegretol and Clonidine. In treating aggression, meds always far more helpful for impulsive aggression. Unclear (if any) efficacy for cold aggression.

20-25% will progress to meet criteria for Antisocial Personality Disorder as adults Factors predictive of worse outcome: Earlier onset, significant substance abuse, AD/HD, frankly assaultive behavior, parental criminality. Better outcomes for: Later diagnosis, no substance issues, higher IQ, more skilled in some way, attachment to adult figure (parental or not), more prosocial behavior. Important: Diagnosis of CD, in and of itself, is NOT predictive of later imprisonment.

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