BHIPP Bulletin

Volume 8, Issue 11

May 2023

This month's BHIPP Bulletin is a contribution from

Rick Ostrander, EdD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine,

Founder of Pediatric Medical Psychology Program at Johns Hopkins Children's Center and BHIPP Consultant.

As pediatric primary care providers, you may be the first to hear parents' concerns about their child's oppositional or defiant behaviors. This newsletter will provide information about assessing and diagnosing Oppositional Defiant Disorder (ODD), factors that increase the risk of children developing ODD, and common comorbid psychiatric disorders. By being aware of these oppositional and defiant concerns, you can assist families in addressing these concerns.

Introduction to the Diagnostic Criteria of ODD

ODD is a behavioral disorder comprised of a set of characteristics that have been a source of clinical concern for some time and have been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for over 40 years. This disorder is often mistaken for expected behaviors that are observed at one time or another by all children. After all, most children episodically argue, get angry, or sometimes fail to follow rules; however, only about 3% of children meet the criteria for ODD. It is the persistence, intensity, and/or the level of impairment noted across settings that distinguishes children with ODD from other children at a similar chronological age and developmental level.

The diagnosis of ODD was included in DSM-III in 1980; however, the core symptoms of ODD have undergone only modest changes since 1988. The symptoms have consistently included losing one’s temper, arguing, defying others, annoying others, blaming others, being touchy, being angry, and being spiteful. With the publication of DSM-5, the actual symptoms have not changed; however, the most recent diagnostic criterion for ODD reflects empirical support for the notion that ODD involves at least two groupings of symptoms that are highly related. As shown in the following table, the criteria for ODD in the DSM-5 include three subcategories: Angry/Irritable Mood, Argumentative/Defiant Behavior, and Vindictiveness. Rather than viewing all children with ODD as having the same clinical presentation, young people diagnosed with ODD can be more precisely characterized by the degree to which both chronic irritability and oppositional/defiant behaviors are represented.

Summary of DSM-5 Criteria for ODD

Definition:

Criteria:

The clinical utility of distinguishing between these 3 dimensions of ODD reflects increasing evidence denoting different outcomes for people diagnosed with ODD depending on their levels of irritability/anger. The risk of Conduct Disorders (CD) or antisocial tendencies is heightened by the high levels of oppositional/defiant behaviors that are typical of most children with ODD; however, the additional risk of developing internalizing psychopathology (i.e., anxiety, depression) is more likely when chronic irritability and anger are also prominent.

Notably, the diagnosis of ODD is not warranted when the onset of behaviors associated with ODD coincides with the onset of psychosis, substance use, bipolar disorders, or depressive disorders. The DSM-5 identifies severity based on the degree to which the symptoms are present across settings (i.e., home, school, and social).

As reflected in the following table, several diagnostic tools have been developed for identifying children with ODD and related disorders. The Behavioral Assessment Scale for Children (BASC) and the Child Behavioral Checklist (CBCL) represent two commercially available measures that offer separate child, parent, and teacher instruments and provide a valid means for evaluating a wide range of symptoms and disorders, including ODD (Biederman et. al., 2008; Doyle et. al., 1997; Ostrander et. al., 1998). Diagnostic tools for ADHD, such as the Swanson, Nolan, and Pelham Rating Scales, the Vanderbilt ADHD Diagnostic Parent Rating Scale, and the Conners 3 scales, have comorbidity screening scales that can help identify ODD (Steiner & Remsing, 2007; Becker et. al., 2012). One study of the Vanderbilt scale found that affirmative answers ("often" or "very often") to the items "Actively disobeys or refuses to follow adults' requests or rules" and "Is angry or bitter" had good sensitivity (55% to 88%) and specificity (85% to 94%) for diagnosing ODD (Becker et. al., 2012).

Rating Scales for Assessing ODD and Related Disorders

What Places Children at Risk for Developing ODD?

Parents who report a child as having persistent and frequent problems with the behaviors associated with ODD often want to understand the underlying cause of this misbehavior. The explanation for why some children display ODD is multifactored and complex. There are genetic, neurological, and neurodevelopmental considerations that place children at risk of developing ODD. For example, pre-, peri-, and post-natal complications are associated with developing ODD. Children diagnosed with ADHD and Autism Spectrum Disorder are at particularly high risk of developing ODD. Neuropsychological considerations, including verbal or executive functioning deficits, have been found to increase risk of developing ODD as well (Burke et. al., 2017; 2021).

Although ODD is not exclusively attributed to parenting difficulties, ineffective parenting can exacerbate the underlying risk factors. While parenting behaviors can clearly affect children’s behaviors, the dynamic is bidirectional. The high rates of oppositionality, aggression, and irritability these children exhibit often prompt inconsistent, ineffectual, and coercive reactions from caregivers. Over time, this leads to an escalating cycle of negative parent-child interactions, engenders a high level of stress for everyone concerned, and contributes to a more pernicious psychiatric presentation (Burke et. al., 2017).

The Developmental Course of ODD

Most children that exhibit ODD are not going through a developmental phase; indeed, the behavioral manifestations of ODD are often stable over time and are maintained over broad developmental periods. Even though most children go through the "terrible twos," it is unusual for a young child to show four or more of the symptoms of ODD for 6 months or longer (the criteria for the disorder). As early as preschool, children with ODD are different from children who show typical oppositional behavior. Most children with oppositional tendencies may display one or two of these behaviors at the same time, or they might display clusters of ODD symptoms for a brief period (Burke et. al., 2017; 2021). In contrast, children with ODD display a persistent clustering of oppositional, irritable, and/or vindictive behaviors. Unlike the "terrible twos," the symptom cluster of ODD is not something that will resolve as development unfolds. Yet without a proper assessment, parents are often reluctant to seek out help; indeed, some studies have shown that the average period between when a parent first becomes concerned about behavior problems in their child and when they end up seeking help, is about four years (Burke et. al., 2017; 2021).

The Relationship Between ODD and DMDD

Disruptive Mood Dysregulation Disorder (DMDD) was included in the most recent version of the DSM (DSM-5, American Psychiatric Association, 2013) in order to distinguish a subset of chronically irritable youth who may be incorrectly diagnosed and/or treated for pediatric bipolar disorder (BPD). The core features of DMDD are "chronic, severe, and persistent irritability," which has two manifestations: "frequent temper outbursts" and "a chronic, persistently irritable or angry mood." Thus, the diagnostic symptoms for DMDD are nearly identical to the Irritability/Anger symptoms found in the diagnostic criteria associated with ODD. Given the high overlap of symptoms, distinguishing between DMDD and ODD has been difficult. Studies involving both clinical and community-based samples have reported that approximately 92% of children with DMDD had ODD, and 66% of children with ODD had DMDD symptoms (Mays et. al., 2016; 2017). Taken together, these findings indicate that it is unlikely to have DMDD symptoms without ODD, but that ODD can sometimes occur without DMDD symptoms. Yet, the DSM-5 exclusionary criteria state that a diagnosis of DMDD precludes a diagnosis of ODD. As a result, there is the possibility that providers may lose sight of how the interrelated emotional and oppositional features typically associated with ODD should be addressed. In line with this consideration, recent research would suggest that a diagnosis of DMDD promotes the use of antipsychotics and mood stabilizers; indeed, these medications are used more frequently with children diagnosed with DMDD than they are with children diagnosed with bipolar disorder (Findling et. al., 2022). In turn, this may lead to less clinical focus on the behavioral therapies and alternative medications that have proven to be effective at treating the interrelated irritability and oppositional tendencies that characterize ODD. This has led some to argue that ODD and DMDD are indistinguishable and that the diagnostic and treatment approaches relevant to ODD and related disorders should be commonly provided to children diagnosed with DMDD (Burke et al., 2017; 2021; Gupta & Gupta, 2022; Mays et. al., 2016; 2017)

ODD and Comorbidity

ADHD is one of the most common comorbid conditions with ODD, occurring in 14-40% of children with the disorder (Nock et. al., 2007). In particular, a diagnosis of the combined subtype of ADHD often contributes to the defiant and headstrong symptoms of ODD (Burns and Walsh, 2002; Crystal et. al., 2001). Sometimes the oppositional and defiant characteristics of ODD transform into a pattern of aggression, property destruction, and deceitfulness that typify a diagnosis of CD; still, most children with ODD do not go on to develop CD. Retrospective studies estimate that CD is comorbid in up to 42% of people with ODD (Burke et. al., 2017; 2021; Connor, Steeber, & McBurnett, 2010). Those with comorbid ADHD and ODD, or CD and ODD, tend to have more severe and persistent behavioral problems and are more likely to have additional comorbid mood disorders. They are also at higher risk of problematic substance use (Connor, Steeber, & McBurnett, 2010).

Anxiety and depression are commonly associated with ODD, developing as early as preschool age (Nock et. al., 2007). One study found that up to 14% of people with ODD also have anxiety, and 9% have a depressive disorder (Angold, Costello, & Erkanli, 1999). A later study found even higher rates, with at least 50% of individuals with ODD having a comorbid anxiety or depressive disorder (Nock et. al., 2007). Recent findings indicate that individuals with ODD, particularly those with prominent angry and irritable symptoms, are at higher risk of comorbid mood disorders, whereas those with high levels of argumentative, defiant, and vindictive symptoms are at higher risk of developing CD (Burke, Johnston, & Butler, 2021).

The Negative Social Outcomes Associated with ODD

The collateral damage engendered by children with ODD is not limited to their interpersonal relationships with parents, who typically bear the brunt of such behavioral transgressions. Not surprisingly, children with ODD are often viewed negatively by their peers, and as a result, they experience more peer rejection and struggle with friendships. Because they are rejected by many children, they are more likely to affiliate with other children with similar problems. This limits opportunities for engaging with peers who provide adaptive role models. These problems often continue through adolescence and may explain why students with ODD are more likely to drop out before completing high school. During the young adult years, they also have more problems in social and romantic relationships (Burke et. al., 2017; 2021).

Gender Differences

The relative rates of ODD illustrate that this is a similar problem for both boys and girls. In childhood, ODD is evident more often in boys than in girls, but these small differences diminish in adolescence in large measure due to the increase in ODD among girls. When it is present, it shows up in the same ways for both genders, with no differential effect on functioning or outcomes. The assessment and treatment approaches are the same for boys and girls (Burke et. al., 2017; 2021).

Conclusions

While screening for ODD involves an appraisal of the manifest symptoms of ODD, the combination of direct clinical inquiry and the use of various rating scales can facilitate this process. However, the complexity associated with the etiology, overlapping comorbidity, diagnostic ambiguity, developmental course, and functional impairment would suggest any child diagnosed with ODD would benefit from a comprehensive mental health evaluation in order to design a treatment approach for treating the whole child.

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

BHIPP Announcements

Register for the last BHIPP ECHO Clinic Core Foundations Series Session!

The American Academy of Pediatrics is now recruiting for two ECHO programs launching in June and July 2023

This ECHO program will focus on supporting pediatric primary care providers to increase their knowledge, competence, and confidence in providing behavioral and mental health care to pediatric patients and their families. The emphasis will be placed on pediatric PCPs to develop and implement effective strategies to foster long-term relational health and healthy mental development as well as identify, treat, and manage mental and behavioral health concerns in the primary care setting.

This 6 session ECHO will be held on the 2nd and 4th Wednesday of the month at 12:00pm. ECHO sessions will be held on: June 28, July 12, July 26, August 9, August 23, September 13.

Questions? Contact Lisa Brock, Program Manager, ECHO Initiatives at lbrock@aap.org.  

Primary care practices are invited to participate in an ECHO telementoring program related to youth suicide prevention. During the program, participants will increase their knowledge and self-efficacy regarding best practices to support youth at risk for suicide.

This 8 session ECHO program will be held on the 3rd Friday of the month at 1:00pm from July 2023 through February 2024.

For more information, please contact Jessie Leffelman, Program Manager, at jleffelman@aap.org.