Oppositional Defiant Disorder

Overview

Epidemiology

• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency:
  • Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is estimated to be 10%.  
  • Before puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty: more common in boys than girls
  • School-aged children and adolescents: equally common in boys and girls
• Most common comorbidity: 50% of children affected with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder have oppositional defiant disorder (ODD).

Etiology

A combination of risk factors is considered responsible for the development of ODD.

• Biological factors: 
  • Family history Family History Adult Health Maintenance of:
    • Disruptive behavior disorder
    • Mood disorder
    • Alcohol or substance use disorder
  • Impairment in brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification areas responsible for impulse control
• Psychological/social factors:
  • Poverty
  • Abuse
  • Absent or neglectful parenting 
  • Difficulty in forming social relationships
  • Unstable family environment (e.g., divorce or frequent moves)
• Physical factors: 
  • Low birth weight 
  • Neurological injury during childhood

Pathophysiology

• The exact pathophysiology of ODD is not understood. 
• Low resting heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology, as well as decreased cortisol Cortisol Glucocorticoids stress response, are associated with higher levels of aggression in ODD.

Diagnosis

DSM-V diagnostic criteria

• Duration of at least 6 months
• Angry/irritable mood:
  • Easily loses temper
  • Easily annoyed
  • Often angry and resentful
• Argumentative/defiant behavior:
  • Frequently argues with adults
  • Noncompliant with rules
  • Annoys and upsets others
  • Blames others for their misbehavior
• Vindictiveness:
  • Resentful and revenge-seeking behavior
  • Present at least twice within the past 6 months

Further considerations

• The disturbance in behavior is associated with distress in the individual or in other persons in their immediate social context.
• Must exclude:
  • Other psychotic or mood disorders
  • Substance use disorder

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

• 1st-line treatment
• The goal is to include and educate both parent and child.
• May encompass:
  • Interpersonal skills training
  • Anger management
  • Conflict-resolution techniques for the child 
• CBT may be used to develop coping skills and reduce impulsive behavior.

Pharmacotherapy

• Only recommended in combination with psychosocial interventions 
• Indicated if the disorder is associated with other symptoms or conditions

Differential Diagnosis

• Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder: a pediatric mental disorder Pediatric mental disorder Conduct Disorder characterized by recurrent behavior in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over a duration of at least 1 year. An important risk factor is parental rejection and neglect Neglect Child Abuse. Management includes family therapy Family therapy A form of group psychotherapy. It involves treatment of more than one member of the family simultaneously in the same session. Psychotherapy, behavioral modification, and pharmacotherapy.
• ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: a neurodevelopmental disorder characterized by a pattern of inattention Inattention Attention Deficit Hyperactivity Disorder and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Onset is usually before the age of 12.  Attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment deficit hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder disorder is a common comorbidity of ODD; however, those with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder will have difficulty carrying out tasks that require attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment or remaining still. Symptoms associated with ODD will manifest outside of tasks requiring focus. 
• Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder ( DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder): a pediatric mental disorder Pediatric mental disorder Conduct Disorder that involves chronic negative mood, irritability, and severe recurrent temperamental outbursts. Oppositional defiant disorder cannot be diagnosed if DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder is present; if criteria for both conditions are met MET Preoperative Care, only the diagnosis of DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder should be established. The distinguishing clinical feature is the disproportional emotional outbursts relative to the developmental/maturity stage in DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder.