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Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in Children and Adolescents: Diagnosis and Treatment

by Jim Chandler, MD, FRCPC

Oppositional Defiant Disorder (ODD) 1

What is it? 1

Conduct disorder 6

Prognosis and Course of Conduct Disorder 9

Long term outcome of ODD/CD. 10

What can be done? 12

Non-Medical Strategies for ODD and CD. 12

Medical Interventions 15

Putting it all together 26

Oppositional Defiant Disorder (ODD)

What is it?

ODD is a psychiatric disorder that is really just the far end of the stubbornness spectrum. The line that divides being just difficult and stubborn from ODD is a set of diagnostic criteria.  The criteria for ODD are:

A pattern of negativistic, hostile, and defiant behavior lasting at least six 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 and resentful

8. is often spiteful and vindictive

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

How often is "often"?

All of the criteria above include the word "often". But what exactly does that mean? Recent studies have shown that these behaviors occur to a varying degree in all children. These researchers have found that the "often" is best solved by the following criteria.

Has occurred at all during the last three months-

8. is spiteful and vindictive
5. blames others for his or her mistakes or misbehavior

Occurs at least twice a week

6. is touchy or easily annoyed by others
1. loses temper
2. argues with adults
3. actively defies or refuses to comply with adults' requests or rules

Occurs at least four times per week

7. is angry and resentful
4. deliberately annoys people

Who gets it?

A lot of children! This is the most common psychiatric problem in children. Over 5% of children have this. In younger children it is more common in boys than girls, but as they grow older, the rate is the same in males and females.

 

ODD rarely travels alone - Comorbidity

It is exceptionally rare for a physician to see a child with only ODD. Usually the child has some other neuropsychiatric disorder along with ODD. The tendency for disorders in medicine to occur together is called comorbidity.

Common patterns of comorbidity

ODD plus ADHD

If a child comes to a clinic and is diagnosed with ADHD, about 30-40% of the time the child will also have ODD (1). Here are some examples of how this looks across ages.

Pre School Marianne

Marianne is now 4 years old. Her parents were very excited when she turned four that perhaps that would mean that the terrible twos were finally over. They were not. Her parents are very grateful that the Grandparents are nearby. The grandparents are grateful that Marianne's aunts and uncles live nearby. Marianne's Aunt is grateful that this is her niece, not her daughter. Why? Marianne requires an incredible combination of strength, patience, and endurance.

Marianne begins her day by getting up early and making noise. Her father unfortunately has mentioned how much this bothers him. So she turns on the TV, or if that has been mysteriously disconnected, bangs things around until her parents come out. Breakfast is the first battleground of the day. Marianne does not like what is being served once it is placed in front of her. She seems to be able to sense how hurried her parents are. When they are very rushed, she is more stubborn and might refuse it altogether. It would be a safe bet that she would tell her Mom that the toast tastes like poop. This gets her the first “time out” of the day.

In the mornings she goes to pre-school or goes off with her grandmother or over to her aunts. Otherwise Marianne's mother is unable to do anything. Marianne can not entertain herself for more than a few moments. She likes to spend her time purposefully annoying her mom, at least so it seems. Marianne will demand over and over that she wants something. For example, playdough. She knows it must be made first. So her mom finally gives in and makes it. Marianne plays with it about one minute and says, " Let’s do something" . Her mother reminds her that they are doing something, the very thing that Marianne has been demanding for the last hour. " No, Lets do something else"

So after Marianne's mother screamed so hard she was hoarse when her husband came home, Marianne gets to go out almost every morning. At preschool she is almost perfect, but will not ever do exactly what the teacher wants. Only once has she had a tantrum there. Marianne gets along with the other children as long as she can tell them what to do.

Her grandmother and Aunt all follow the same “time out” plan. This means she goes to a certain room until she calms down. The room is empty now at Marianne's grandmother. Marianne broke the toys, and they were removed. She banged the furniture around and it was removed. What sets Marianne off is not getting to do what Marianne wants. She screams, tells people she hates them, and swings pretty hard for a four old. After a half hour it is usually over, but not always. Marianne will usually tell her mom or Grandmother about these tantrums. The story is always twisted a little. For example, Marianne will tell her Grandmother that her mom locked her in her room because she was watching TV. Her grandmother used to believe these stories, and Marianne could tell the whole story of how she was watching this show, and her mom just came in and dragged her to her room. Now it turns out that Grandma doesn't think much of TV anyways, and so this made a certain amount of sense to her. This led to more than one heated argument between the Grandma and her mom. Of course there was almost no truth to this at all. It took the tables being turned for the Grandma to really believe that her Granddaughter could set up an argument like this. Marianne came home and told her mom that Grandma let her eat four cookies and an ice cream cone for a treat and that she was very full. Marianne's mom doesn't think much of treats, and could see how this might happen and thought she would have to talk to her mom. Finally they both realized what Marianne was doing.

Most of the afternoon with Marianne is spent chasing her around trying to wear her out. It doesn't seem to work, but it is worth a try. When she is at her aunts, she tries to wreck her cousin’s stuff. When is she good? When there are no other cousins around and she has the complete attention of her Aunt or Grandpa.

Marianne loves the bedtime battle. She also loves to go to the Mall. But she never gets to go there or hardly anywhere else. She acts up so badly that her family is very embarrassed. Her mother shops and visits only when Marianne goes to preschool. It is hard to know who is more excited about Marianne going to school next year, her mother or Marianne!

Elementary School Ryan

Ryan is 10. Ryan's day usually starts out with arguing about what he can and can not bring to school. His mother and his teacher have now made out a written list of what these things are. Ryan was bringing a calculator to school and telling his teacher that his mother said it was alright. At first his teacher wondered about this, but Ryan seemed so believable. Then Ryan brought a little (Ryan's words) knife. That lead to a real understanding between the teacher and Ryan's mother.

Ryan does not go to school on the bus. He gets teased and then retaliates immediately. Since it is impossible to supervise bus rides adequately, his parents and the school gave up and they drive him to school. It is still hard to get him there on time. As the time to leave approaches, he gets slower and slower. Now it is not quite as bad because for every minute he is late he loses a dime from his daily allowance. Once at school, he usually gets into a little pushing with the other kids in those few minutes between his mother's eyes and the teacher's. The class work does not go that badly now. Between the daily allowance which is geared to behavior and his medicine, he manages alright. This is good for everyone. At the beginning of the school year he would flip desks, swear at the teacher, tear up his work and refuse to do most things. Looking back, the reasons seem so trivial. He was not allowed to go to the bathroom, so he flipped his desk. He was told to stop tapping his pencil, so he swore at the teacher.

Recess is still the hardest time. Ryan tells everyone that he has lots of friends, but if you watch what goes on in the lunch room or on the playground, it is hard to figure out who they are. Some kids avoid him, but most would give him a chance if he wasn't so bossy. The playground supervisor tries to get him involved in a field hockey game every day. He isn't bad at it, but he will not pass the ball, so no one really wants him on his team.

After school was the time that made his mom seriously consider foster care. The home work battle was horrible. He would refuse to do work for an hour, then complain, break pencils and irritate her. This dragged 30 minutes of work out to two hours. So, now she hires a tutor. He doesn't try all of this on the tutor, at least so far. With no home work, he is easier to take. But he still wants to do something with her every minute. Each day he asks her to help him with a model or play a game at about 4:30. Each day she tells him she can not right now as she is making supper. Each day he screams out that she doesn't ever do anything with him, slams the door, and goes in the other room and usually turns the TV on very loud. She comes up, tells him to turn it down three times.  He doesn't and is sent to his room. She calculated that she has made about 1500 suppers since he was five years old. Could it be that they have gone through this 1500 times? She decides this is not a good thought to follow through. After supper Ryan's dad takes over and they play some games together and usually it goes fine for about an hour. Then it usually ended in screaming. So Ryan's grandmother had the bright idea of inviting them over for desert at about 8:00 pm most nights. But what about days when there is no school? Ryan's parents try very hard not to think about that.

High School Tasha

Tasha is 15. She is in ninth grade and from her marks, you would say there is no big problem. She is passing everything, but her teachers always comment that she is capable of much more if she tried. If they gave marks for getting along with others, it would be a different story. Tasha's best friend is currently doing a 6 month sentence for vandalism and shoplifting. Tasha and Sylvie have been friends since fall, if you can call it that. Since Tasha has almost no other friends, she will do anything to be Sylvie’s friend. At least that is what her parents think. Tasha thinks it is "cool" that Sylvie is at the Secure Treatment Youth Centre. One sign of this friendship was that Tasha almost always gave her lunch money to Sylvie. Why? Because Sylvie wanted it. Tasha thought that Sylvie was her friend, but everyone could see that Sylvie was just using her. What seemed saddest to Tasha's parents is that Tasha could not see this at all. But this was nothing new. She would make a friend, smother them with attention, and that would be the end of it. Or, the friend would not do exactly what Tasha wanted and there would be a big fight, and it would be over. But mostly Tasha complained that everyone bugged her. What seemed to save Tasha was the nursing home. Somewhere along the way Tasha got involved working there. To hear the staff there talk about her, you would never guess it was the same girl. Helpful, kind, thoughtful - they couldn't say enough good about her. In fact her parents joked that maybe if they all moved to the nursing home, it would stop the fighting at home. They figured it out when another teenager volunteered to help one of the same afternoons as Tasha. Unfortunately the "other" Tasha came out. She was tattling, annoying, disrespectful and hard to get along with. Tasha could get along with any one, as long as they weren't her age, a teacher, or a relative!

 These examples stress some of the common features of this comorbid combination. Extremely major social problems with relatively little academic problems are not uncommon. Recent research suggests that all things being equal, girls with ODD plus ADHD have significantly worse social problems than boys with ODD plus ADHD (2). Tasha in the above example illustrates this.

ODD plus Depression/Anxiety

This is the other common combination with ODD. If you look at children with ODD, probably 15-20% will have problems with their mood and even more are anxious. (1) Here are some examples of how this can present

Preschool -Arriane

Arriane is 4. She has not been an easy child. Her mom does not like to compare children, but it is hard not to! Her brother is easy to get along with, excited, and energetic. She expected to have arguments with Arriane about doing a chore or task, but she ends up having an argument with Arriane about doing something fun! Arriane's first response to almost any activity is "No, I don't want to". Her mother has learned that if she can get Arrianne out the door and to pre-school, for example, she does quite well once she is there. That is, as long as everything is going her way. It does not take much of a problem for Arriane to lose her temper. Two days ago she was called to preschool when another boy bumped Arriane and she dropped her cheese and cracker on the carpet. Arriane belted the child and screamed "I hate you, I hate this place, I hate it!" until her mother came. Of course the next day she was back again and things were going alright. Arriane's mother has some unusual memories, or at least she thinks so. She remembers last fall when they took Arriane horseback riding for the first time. Arriane's face showed true joy for a whole hour. Her mother did not know whether to cry or not, as she could not remember such an expression on her child's face before for more than a few moments. That memory makes her hopeful that somehow she can bring that joy back to Arriane.

It is not an easy task. The combination of being irritable and oppositional tests everyone's patience. She did not realize how stressful it was until she started bringing Arriane to a babysitter so she could go out and visit her friends. Finally she did not have to be thinking about how to keep Arriane from losing it every minute. She is finally coming to the decision that try as she might, she can not make Arriane's life as smooth as Arriane wants it.

Elementary School Rick

Ricky is 11 years old. Ricky spends a lot of time in his room doing legos and making models. Then, all of a sudden there is a scream and stuff gets thrown around. If his parents are so unwise as to go up there, they will get to hear Ricky say that he hates this world, hates legos, and hates this stupid model. Then he will usually look up and say something awful to his parents. That is why they just leave him up there. He comes home from school crabby and throws his homework down and goes up plays in his room. His parents realize that he needs to get out and do something, but the only thing they can ever get him to do is go lift weights at the YMCA. Ricky's father has absolutely no interest in lifting weights, but he has done a pretty good job of convincing Ricky that he likes to go. That gets him out of the house about three times a week. As far as playing with other kids, unless his cousins come over, he won't play with anyone. His parents used to ask why and the answer was because no one likes me. Sad to say, it is not hard to figure out why Ricky would have that idea. When a friend comes over, he is so demanding and insists that the child do things just the way Ricky wants. Usually Ricky ends up sulking part of the time when he doesn't get his way. So now, his mom invites friends over for Ricky, but she plays right along side of the friend and Ricky. At least they aren't scared off that way. At school, it is even worse. Everyone seems to know how easy it is to get Ricky to loose his temper. It happens almost every day. He bangs the desk, takes a swing at someone, swears, or kicks them. He is usually caught, and since he is so irritable anyway, the teachers hear a fair amount of defiance. Amazingly, he does pretty well in school once he gets going on something. This year he has changed classes. His old teacher was humble enough to admit that Ricky had pushed her too far and she could not take it any longer. She said she just could not remain professional. Ricky's mom knows how that could happen. Sometimes she just takes off for a walk when Ricky is driving her nuts. She knows she shouldn't leave him alone at home, but she figures if she doesn't go out in the woods for a walk there would be far greater dangers awaiting Ricky at home than if he was there alone. Ricky mostly wishes people would just stop bugging him. Once in awhile, right before bed, Ricky will ask him mom if it hurts to die or what it is like to be dead. She can't tell if he means it or is just saying that to bug her. She is afraid to even think about it.

High School Justin

Justin is now 18. Things are going great for Justin this year. He is back in school, off drugs, and actually is getting along with his parents. In fact, he actually missed them when they went away. He has been helping his Dad put up dry wall after school. Both he and his parents are grateful for his recovery, but they wished they could have picked it up earlier, like when he was 12 or 13. That's when things really started to get worse. Justin had always had a hot temper and still does, but then it was unreal. At age 12 his parents would not let him go to a dance. He broke all the windows in their car. He lasted two months in 8th grade before he was suspended for fighting. Justin lost the few friends he had by getting kicked off the hockey team. He swore at a judge during a probation hearing and got two months in the Youth Centre which was extended to six months after he tried to attack a guard. All the while he was so irritable and never happy. When he came home from the Youth centre he wanted to be able to drive. They said no, and he decided that was it and went out to hang himself in the barn. His parents still remember those words, "You'll all be f-ing better off without me and if you come after me I'll f-ing kill you, too". That horrible day was the turning point. It took five mounties to get him to go to the hospital. It took a careful evaluation to figure out that he wasn't just oppositional , stubborn, and hot headed. He was very depressed, too. Now after 6 months of medical and non-medical interventions, he is 100% better. Justin admits that if he had to go back to living the way he was, he'd start thinking of suicide.

These examples show how very difficult the combination of ODD and depression can be for the family and the child. Often the depression gets mixed in the midst of dealing with the aggression and defiance. I commonly run across children like Justin who have been oppositional and depressed but no one ever notices the depression until they make a suicide attempt. Looking for depression in ODD youth is very important, (see treatment section)

What happens to children who have this when they grow up?

ODD can be divided into different symptoms and recent research (27) suggests that certain symptoms of ODD lead to different psychiatric problems.

Irritable group of symptoms

Irritable

had temper outbursts?

been touchy or easily annoyed?

been angry and resentful?

This group of symptoms is more closely related to getting depression or anxiety when you are older

Headstrong

argued with grown-ups?

taken no notice of rules, or refused to do as she/he is told?

seemed to do things to annoy other people on purpose?

blamed others for his/her own mistakes or bad behavior?

This group of symptoms is more closely related to ADHD and Conduct Disorder

Hurtful

been spiteful?

tried to get back at people?

Along with the headstrong symptoms, this is more closely related to Conduct Disorder (see below)

 

There are three main paths that a child will take.

First, there will be some lucky children who outgrow this. About half of children who have ODD as preschoolers will have no psychiatric problems at all by age 8.(19)

 Second, ODD may turn into something else. About 5-10 % of preschoolers with ODD will eventually end up with ADHD and no signs of ODD at all. (19) Other times ODD turns into conduct disorder (CD). What predicts a child with ODD getting CD? A history of a biologic parent who was a career criminal, and very severe ODD.

 Third, the child may continue to have ODD without any thing else. However, by the time preschoolers with ODD are 8 years old, only 5% have ODD and nothing else.

Fourth, They continue to have ODD but add on comorbid anxiety disorders, comorbid ADHD, or comorbid Depressive Disorders. By the time these children are in the end of elementary school, about 25% will have mood or anxiety problems which are disabling. (14) That means that it is very important to watch for signs of mood disorder and anxiety as children with ODD grow older.

Will children with ODD end up as criminals?

Unfortunately, severe and early onset ODD does predict getting conduct disorder in adolescence, and some of those become criminals. In other words, if you take 100 children in grade 1 with ODD, roughly 30 will have conduct disorder as teenagers, and about 10 will be criminals as adults. (31)

What is the difference between ODD and ADHD?

ODD is characterized by being oppostional, but not impulsiveness. In ODD people annoy you purposefully, While it is usually not so purposeful in ADHD. ODD signs and symptoms are much more difficult to live with than ADHD. Children with ODD can sit still.

What difference does it make if you have ADHD or ADHD plus ODD?

A lot! Children and adolescents with ADHD alone do things without thinking, but not necessarily oppositional things. An ADHD child may impulsively push someone too hard on a swing and knock the child down on the ground. She would likely be sorry she did this afterward. A child with ODD plus ADHD might push the kid out of the swing and say she didn't do it.

My child has been diagnosed with ODD. I don't like to say this, but no one can stand him. Is this common?

Unfortunately, it is quite common. In comparison to ADHD alone, children and adolescents with ODD plus ADHD or just ODD are much more difficult to be with. The destructiveness and disagreeableness are purposeful. They like to see you get mad. Every request can end up as a power struggle. Lying becomes a way of life, and getting a reaction out of others is the chief hobby. Perhaps hardest of all to bear, they rarely are truly sorry and often believe nothing is their fault. After a huge blow up, the child with ODD is often calm and collected. It is the parents who look as they are going to lose it, not the child. This is understandable. The parents have probably just been tricked, bullied, lied to or have witnessed temper tantrums which know no limits.

My father in law says the whole problem is my husband and I. My daughter convinced him that she is a victim of uncaring parents. How often does this happen?

Too often! Children and adolescents with ODD produce strong feelings in people. They are trying to get a reaction out of people, and they are often successful. Common ones are: inciting spouses to fight with each other and not focus on the child, making outsiders believe that all the fault lies with the parents, making certain susceptible people believe that they can "save" the child by doing everything the child wants, setting parents against grandparents, setting teachers against parents, and inciting the parents to abuse the child. I frequently see children with ODD in which teachers and parents and sometimes others are all fighting amongst each other rather than with the child who is causing all the turmoil in the first place.

Conduct disorder

In some ways, conduct disorder is just a worse version of ODD. However recent research suggests that there are some differences. Children with ODD seem to have worse social skills than those with CD. Children with ODD seem to do better in school. (1). Conduct disorder is the most serious childhood psychiatric disorder. Approximately 6-10% of boys and 2-9% of girls have this disorder.

Here is the Definition.

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major society rules are violated. At least three of the following criteria must be present in the last 12 months, and at least one criterion must have been present in the last 6 months.

Aggression to people and animals

often bullies, threatens, or intimidates others

often initiates physical fights

has used a weapon that can cause serious physical harm to others (a bat, brick, broken bottle, knife, gun)

physically cruel to animals

physically cruel to people

has stolen while confronting a victim ( mugging, purse snatching, extortion, armed robbery)

Destruction of property

has deliberately engaged in fire setting with the intention of causing serious damage

has deliberately destroyed other's property other than by fire setting

Deceitfulness or theft

has broken into someone else's house, building or car

often lies to obtain goods or favors or to avoid work

has stolen items of nontrivial value without confronting a victim (shoplifting, forgery)

Serious violations of rules

often stays out at night despite parental prohibitions, beginning before 13 years of age

has run away from home overnight at least twice without returning home for a lengthy period

often skips school before age 13

B. The above problem causes significant impairment in social , academic, and occupational functioning.

So how are ODD and CD related?

Currently, the research shows that in many respects, CD is a more severe form of ODD. Severe ODD can lead to CD. Milder ODD usually does not. The common thread that separates CD and ODD is safety. If a child has CD there are safety concerns. Sometimes it is the personal safety of others in the school, family, or community. Sometimes it is the safety of the possessions of other people in the school, family or community. Often the safety of the child with CD is a great concern. Children with ODD are an annoyance, but not especially dangerous. If you have a child with CD disorder in your home, most likely you do not feel entirely safe. Or, you do not feel that your things are entirely safe. It is the hardest pediatric neuropsychiatric disorder to live with as a sibling, parent, or foster parent. Nothing else even comes close. It is worse than any medical disorder in pediatrics. Some parents have told me that at times it is worse than having your child die.

Conduct Disorder and comorbidity

It has been common in the past for people to think that conduct disorder is just the beginning of being a criminal. Up until the last few years, children with conduct disorder were often "written off". It is now clear that this is true only with a minority of cases. It is very easy to focus on the management of the CD child and forget to check the child out for other neuropsychiatric disorders. A careful examination of children with CD almost always reveals other neuropsychiatric disorders. Some of the most exciting developments in this area of medicine involve understanding these phenomena. It is called comorbidty, that is the tendency for disorders to occur together.

It is very common to see children with CD plus another one or two neuropsychiatric diagnoses. By far the most common combination is CD plus ADHD. Between 30-50% of children with CD will also have ADHD (1). Another common combination is CD plus depression or anxiety. One quarter to one half of children with CD have either an anxiety disorder or depression (3). CD disorder plus substance abuse is also very common. Also common are associations with Learning Disorders, bipolar disorder and Tourettes Syndrome. It is exceptionally rare for a child to present for evaluation by a pediatric psychiatrist to have pure CD. Here are some examples of the comorbid presentations.

Looking for comorbid disorders in every child with conduct disorder is absolutely essential. Many of the treatments of these children depend on what comorbid disorder is also present.

CD plus substance abuse

Sadly, this is very common. In my clinic, every child with CD is assumed to be abusing substances until proven otherwise. Compared with children who do not have CD, children who have CD are three times more likely to smoke cigarettes, 2.5 times more likely to drink, and five times more likely to smoke pot. As far as having a problem from drug use, children with CD a 5.5 times more likely to be addicted to cigarettes, six times more likely to be a