Oppositional Defiant Disorder Assessment

[First published on Nathen’s Miraculous Escape]

Oppositional Defiant Disorder is a commonly diagnosed mental disorder in school-aged children, occurring in between 2% to 16% of the population, according to the DSM-IV-TR(American Psychiatric Association [DSM-IV-TR], 2000), though actual prevalence rates may be much lower, as will be discussed below. It is characterized by defiant behavior which causes social or academic impairment. It is treated largely with cognitive-behavioral therapy and/or family therapy and sometimes medication, though there is no evidence to support the use of medication for Oppositional Defiant Disorder (WebMD, 2011; Mayo Clinic, 2011).

Diagnostic Criteria and Indicators

DSM-IV-TR Diagnostic Criteria. Oppositional Defiant Disorder is currently diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders IVTR (DSM-IV-TR, 2000, p. 102):

A. A pattern of negativistic, 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.

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

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

Other indicators. According to the DSM-IV-TR (2000), Oppositional Defiant Disorder is correlated with emotional reactivity, hyperactivity, and difficulty in soothing before starting school, and with very high or low self-esteem, emotionality, conflict with others, ADHD, and learning disorders during school years. There are also correlations with disrupted attachment, authoritarian parenting, child-neglect, maternal depression and parental discord. (As an aside, I would love to see a factor analysis of these correlations. My guess is that the indicators that are child–specific would end up not predicting much or anything once family-specific indicators were factored in.)

Differential diagnosis. The DSM-IV-TR (2000) suggests differentiating Oppositional Defiant Disorder from nine other behavior classifications: Conduct Disorder can be ruled out by the lack of violence, cruelty, stealing, or lying. Antisocial Personality Disorder is primarily ruled out by not meeting the age criterion of 18 years. Mood Disorders and Psychotic Disorders need to be ruled out using the DSM-IV-TR criteria for the various Mood and Psychotic Disorders; the general inference can be made, however, that a condition is not Oppositional Defiant Disorder if it only occurs during periods of abnormally high or low mood, or during periods in which the child’s reality-testing capacity is abnormally low. Attention-Deficit Disorders can occur “comorbidly” with Oppositional Defiant Disorder; if a child’s problematic behavior qualifies him or her for both illnesses, “both diagnoses should be made” (p. 102). Mental Retardation can also be diagnosed comorbidly, but only if a child’s defiance is more intense than average for their degree of mental impairment. “Average” and “appropriate” in this case, and all cases in these diagnostic criteria, are apparently left to the diagnostician to determine. For another example, the DSM-IV-TR suggests ruling out developmentally appropriate defiance, but leaves the definition of such up to the diagnostician. It is also inferred that “developmentally appropriate” is to be in consideration of the child’s age-cohort, not to that child and their circumstances in particular, or to that child’s experiential cohort, e.g. children experiencing severe marital discord, neglect, abuse, and so on. Finally, problems with language comprehension, such as hearing loss, should be ruled out, as they can produce defiant-seeming behavior.

Assessment Tools

Diagnostic Interview Schedule for Children. According to Galanter and Jensen (2009), parts of this interview can be helpful assessing for the ways and extent to which oppositional behaviors are a problem. This assessment tool is intended to produce information strictly in line with the DSM-IV-TR diagnostic criteria. For example, it checks on the 6-month duration requirement for each behavior, not just for the duration of oppositional behavior in general (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000), which may produce a more conservative diagnosis than other assessment tools. Also, it is designed to be easy to administer, without extensive training (Shaffer et al., 2000). The test-retest reliability of this tool is adequate for information from parents, but very low for information from children (Shaffer et al., 2000), meaning for children, the same set of questions administered at different times will yield different diagnoses about 80% of the time, where for parents it is only about 30% of the time.

Child Behavior Checklist (CBCL)The Child Behavior Checklist is a 4-page pencil-and-paper form, with two pages of general information about the child and two pages of 3-point behavior ratings. It is a broad behavioral rating scale that includes questions about oppositional behavior (O’Laughlin et al., 2010). It is described as easy to complete and as reliably discriminating ADHD children with and without Oppositional Defiant Disorder (Biederman, Ball, Monuteaux, Kaiser, & Faraone, 2008). The CBCL has also been criticized as not asking questions consistent with DSM-IV-TR diagnostic criteria for Oppositional Defiant Disorder (O’Laughlin, Hackenburg, & Riccardi, 2010).

Behavior Assessment System for Children: Second Edition (BASC-2). The BASC-2 is another broad behavior assessment which contains items related to oppositional behavior in children and has been found to have both high internal consistency and test-retest reliability, though it also does not contain questions that are specific to DSM-IV-TR diagnostic criteria for Oppositional Defiant Disorder (O’Laughlin et al., 2010). It has a form for teachers (139 questions) and for parents (160 questions), each with a 4-point Likert scale answer from “never” to “almost always” (O’Laughlin, 2010).

Disruptive Behavior Disorders Structured Parent Interview (DBDSPI). The DBDSPI is a semi-structured interview for clinicians to administer to parents using questions with 4-point Likert scale answers, from “not a problem” to “severe problem” (Pelham, Gnagy, Greensledge, & Milich, (1992). This interview has a section specifically for Oppositional Defiant Disorder, produces data that can reliably distinguish children with and without Oppositional Defiant Disorder diagnoses, and does so across different settings, such as school and home (O’Laughlin et al., 2010).

Burke’s Behavioral Rating Scale (BBRS).This scale is listed by some sources as commonly used to assess for Oppositional Defiant Disorder, but there is apparently no research on its psychometrics for that disorder.

IOWA Conners Teacher Rating Scale (Loney & Milich, 1982) tested in Volpe, Briesch, & Gadow, 2011 is a behavior-rating scale commonly used to distinguish ADHD from ODD and includes two 5-item scales. The more time raters are required to use in rating systems, the less reliable the resulting data is. Also, it should be kept in mind that the IOWA is a better tool for using parent and teacher observations to rule out ODD than to diagnose it (Waschbusch & Willoughby, 2008). Widely used to measure oppositional-defiant behaviors.

Disruptive Behavior Rating Scale (DBRS): There is evidence that the DBRS is “adequate” for use with preschoolers (Pelletier, Collett, Gimpel, & Crowley, 2006). For the teacher version, not the parents, yet—no data yet. This may be a problem, because in a study of 1,785 school-age children, () found that there was more source variance than trait variance for oppositional behaviors in the DBRS for mothers and teachers (but not fathers) (Servera, Lorenzo-Seva, Cardo, Rodriquez-Fornells, & Burns, 2010), indicating that in many cases, these behaviors or the perception of these behaviors are relationship specific.

Oppositional Defiant Disorder Rating Scale (ODDRS): The ODDRS is an eight-item, four-point Likert rating scale designed gather data for possible Oppositional Defiant Disorder by parents and teachers. Initial research on this tool was promising, but more thorough research found that while teachers’ data was reliable, and parents’ data was reliable, the data from teachers and parents barely correlated at all. Additionally, teacher ratings did not correlate with actual diagnoses of Oppositional Defiant Disorder in the study population (O’Laughlin, Hackenburg, and Riccardi, 2010).

SNAP-IV Teacher and Parent Rating Scale. The SNAP-IV is a Likert-scale, checklist-based assessment tool that has an eight item subsection for identifying Oppositional Defiant Disorder based on the DSM-IV-TR diagnostic criteria for that disorder (Munkvold, Lundervold, Lie, & Manger, 2009). Research using this rating scale also shows a source-variance problem, to the point that some researchers have suggested that perhaps there should either be two kinds of Oppositional Defiant Disorder, one for parents and one for teachers, or that Oppositional Defiant Disorder is not a true mental disorder (Munkvold et al., 2009). In one study of 7,007 children using the SNAP-IV, parents identified 1.4% as having Oppositional Defiant Disorder and teachers identified 1.3% as having Oppositional Defiant Disorder (Munkvold et al., 2009). This is below the low end of the scale the DSM-IV-TR suggests of prevalence in the general population of 2-16% (2000), but the sets of students identified by parents and teachers onlyoverlapped in .2% of cases (Munkvold et al., 2009). That is, if we only considered a child as having Oppositional Defiant Disorder if their oppositional behavior was not context specific, this disorder would hardly exist.

Making a Systemic Diagnosis of Oppositional Defiant Disorder

I have no clinical experience with this disorder, so I am taking my current opinion with a grain of salt, but reading the research on Oppositional Defiant Disorder has been somewhat troubling in terms of making a systemic diagnosis. I understand that this diagnosis can be a way to funnel resources to families and children in need of them, and that this diagnosis is less pejorative than some alternatives, such as Reactive Attachment Disorder or Conduct Disorder, but I have a few concerns. The strongest predictors of the disorder seem to be relational: whether it is a parent or a teacher judging the behavior, disrupted attachment, negative or abusive parenting, maternal depression, and marital discord. It seems ethically shaky to diagnose a child when that child’s behavior is probably an understandable result of their environment. Also, the diagnosis of a mental disorder means ostensibly that the child has an organic brain disorder, which invites the use of drug treatment, even though there is widespread agreement in all the literature that I read that there is no evidence to support the use of drugs to treat Oppositional Defiant Disorder.

So, my opinion about making a systemic diagnosis of Oppositional Defiant Disorder is that I am not sure that one can. For situations in which it seems that it is the least-bad option, it will be important to see the whole family, or at least the parents of the identified patient, to assess family dynamics. Is there serious marital discord? Evidence of disrupted attachment? Any behavioral vicious cycles? Neglect? Abuse? Trauma? Parental psychopathology? Learning disorders? Bad teachers?

I would tend to use a strict interpretation of the DSM-IV-TR diagnostic criteria, based on reports by the parents—as cited above, teacher’s reports have been shown not to correlate with clinical diagnoses of Oppositional Defiant Disorder. By strict, I mean somewhat stricter than theDSM-IV-TR suggests in that I would want to see the oppositional behaviors consistently across contexts. In other words, I do not think a child can have this disorder just at school, or just at home. That would indicate a fully contextual etiology.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author.

Biederman, J., Ball, S. W., Monuteaux, M. C., Kaiser, R., & Faraone, S. V. (2008). CBCL clinical scales discriminate ADHD youth with structured-interview derived diagnosis of Oppositional Defiance Disorder (ODD). Journal of Attention Disorders 12(1) 76-82.

Galanter, C. A. & Jensen, P. S. (2009). DSM-IV-TR-IV-TR casebook and treatment guide for child mental health. Washington, DC: APA.

Mayo Clinic (2011). Retrieved from http://www.mayoclinic.com/health/oppositional-defiant-disorder/DS00630/DSECTION=treatments-and-drugs on March 9, 2011.

Munkvold, L., Lundervold, A., Lie, S. A., & Manger, T. (2009). Should there be separate parent and teacher-based categories of ODD? Evidence from a general population. Journal of Child Psychology and Psychiatry, 50(10), 1264-1272.

O’Laughlin, E. M., Hackenburg, J. L., & Riccardi, M. M. (2010). Clinical usefulness of the Oppositional Defiant Disorder Rating Scale (ODDRS). Journal of Emotional and Behavioral Disorders, 18(4), 247-255.

Pelham, W., Gnagy, E., Greensledge, K., & Milich, R. (1992). Teacher ratings of the DSM-IV-TR-III-R symptoms for the disruptive behavior disorders. Journal of the American Academy of Child and Adolescent Psychiatry31(2), 210-218.

Servera, M., Lorenzo-Seva, U., Cardo, E., Rodriguez-Fornells, A., & Burns, G. L. (2010). Understanding trait and sources effects in Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder Rating Scales: Mothers’, fathers’, and teachers’ ratings of children fro m the Balearic Islands. Journal of Clinical Child & Adolescent Psychology, 39(1), 1-11. DOI: 10.1080/15374410903401187

Shaffer, D., Fisher, P., Lucas, C., Dulcan, M. K., & Schwab-Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children version IV (NIMH DISC-IV): Description, differences from previous versions, and reliability of some common diagnoses. Journal of American Child and Adolescent Psychiatry, 39(1), 28-39.

Volpe, R. J., Briiesch, A. M. & Gadow, K. D. (2011). The efficiency of behavior rating scales to assess inattentive—overactive and oppositional—defiant behaviors: Applying generalizability theory to streamline assessment. Journal of School Psychology, 49, 131-155.

Waschbusch, D. A. & Willoughby, M. T. (2008). Parent and teacher ratings on the IOWA Connors Rating Scale. Journal of Psychopathology Behavioral Assessment, 30, 180-192.

WebMD (2011). Retreived from http://www.webmd.com/mental-health/oppositional-defiant-disorder?page=2 on March 9, 2011.

Advertisements

Assessing Sexual or Physical Abuse

Another unfortunately common situation I will have to assess for in the families I see (in addition to drug & alcohol abusedomestic violence and many other things) is sexual or physical abuse. One of my texts (Patterson’s Essential Skills in Family Therapy: From the First Interview to Termination) estimates that 1 in 5 women and 1 in 9 men were sexually abused as kids. My other practicum text, Brock & Barnard’s Procedures in Marriage and Family Therapy, gives this list of indicators of abuse(p. 52):

The presence of an alcoholic parent

The family with poor mother-daughter connections/bonds

A mother who is very dependent either psychologically or physically as the result of illness or accident

A father who appears to be very controlling and possessive of his daughter(s)

An acting-out adolescent girl engaging in sexual promiscuity or suicidal gestures who is a frequent runaway or drug abuser

A child who appears to be very overresponsible and parentified in the family context

[First posted on Nathen’s Miraculous Escape, May 5, 2010.]

Gearing Up For My First Overnight Crisis Line Shift

I’m settling in for my second shift for my university’s crisis line, and my first overnight shift. It was a beautiful day, and it was difficult to drag myself into our underground lair, but here I am until 8 tomorrow morning. It’s a pretty nice little room, painted earth tones and with lots of nice nature photography framed on the walls. I have my own bathroom, TV, computer, fridge, microwave, bed, and, of course, coffee maker. I don’t plan on drinking any coffee. If no one calls, I’d like to be able to get to sleep tonight. I’m anticipating being able to sleep fine. It’s very quiet here, and the room gets very dark with the lights off. That is, unless someone calls–the phone rings very loudly. And it’s also possible that the possibility of getting a call will keep me up–I haven’t had a call yet. We’ll see!

The first thing I do is make sure the phones are working. We have two, one for crisis calls, and one backup. I have a backup colleague and two supervisors that I can call or text if I get in over my head. I can also bring them in on a three-way call, if it seems the right thing to do. I don’t anticipate that, but it’s nice to know I can. They are all very experienced at this job.

The next thing I do is look over the call sheets since my last shift. Every call gets its own sheet. It’s been pretty slow in the last week–only a few calls. It’s tempting to think that that means it’s unlikely I’ll get a call tonight, but I have no idea. I also looked back a couple months to see if there was any easily recognizable pattern for Friday shifts, but there wasn’t. Just in our current call sheet book we have calls going back about a year, and I believe that we have sheets for many years around somewhere. This line has been running for about 40 years. (And, unfortunately, the administration is shutting us down at the end of this term, for beaurocratic reasons.) I would love to enter all this info into a stats program and look for patterns! I don’t believe I would be allowed to do that, though. There would be no way to get consent from our past ”research participants.” The line is totally anonymous.

The next thing I do is look at our “regular caller” book. I didn’t know this about hotlines, but there are people who use them regularly, mostly very isolated individuals, taking advantage of a free, professinal listening service to help them deal with their troubles. Pretty smart thing to do, really. It had never occurred to me. We have extensive files on these folks, sometimes going back decades. They have “contracts,” too–agreements they’ve made with us about how often and what times they can call, because they don’t tend to be in crisis, just needing some listening. The regular caller book has all the regular caller call sheets, a record of their current contracts, and a list of their calls with how much time they have left until a certain date.

Then I wait for someone in crisis to call. We define a crisis as a situation where a person’s stress overcomes their ability to cope. This can happen a lot of different ways. Our call sheets have the following categories, in addition to “other”: academic, alcohol/drugs, anxiety (popular one), bereavement/grief (another popular one), depression (popular), domestic violence, eating disorder, harassment/descrimination, homocide, information/referral, interpersonal/relationship (popular), loneliness, medical/somatic, psychosis, sexual abuse/rape, sexual concerns, sexually exploitive (this is where a caller tries to use us as a masterbation aid), sexual orientation/gender ID, and suicide (also popular).

When someone calls, I am to go through a six-step process with them. 1) Assess for immidiate danger (“Are you in a safe place to talk?”), 2) establish communication and rapport, 3) assess the problem (keep it to one–the biggest problem–and make it specific, as vague problems are almost impossible to solve), 4) assess strengths and resources, 5) formulate a short-term (tonight) and long-term (tomorrow) plan, and 6) mobilize the client, obtaining commitment to the plan and contracting for safety if they have been thinking about suicide. Throughout the process I am to be assessing the potential for suicidality, listening for clues like “feeling overwhelmed,” “worthless”–any indication that they might be thinking about hurting themselves. If that comes up, I have another process to go to. Maybe I’ll write about that in another post.

Well, wish me luck. I’m not sure what being lucky would be. It’s easy to hope for no calls–”no news is good news,” as my dad likes to say. On the other hand, if someone is out there in trouble, I really want them to call. I’d feel lucky to get to help someone out of a jam. That’s something to know. Crisis line workers want you to call if you need help. We’re not particularly doing this for the money. I make something like $85 per shift. Not a lot.

If no one does call, I’m planning to study until I get tired and then go to bed. I’ll let you know what happens. I won’t be able to tell you the details, of course, but I can say if I got a call.

[First published on Nathen’s Miraculous Escape, April 26, 2010.]

Assessing Drug and Alcohol Abuse

One thing I will have to assess in the families I see is possible drug/alcohol abuse, because substance abuse is pervasive, problematic, and interpersonal. One of my texts, Procedures in Marriage and Family Therapy, recommends using “objective” measures such as the Michigan Alcoholism Screening Test (25 items), or the MacAndrew Alcoholism Scale of the Minnesota Multiphasic Personality Inventory (49 items), to give weight to the assessment. However, it also says that there is a correlation of .89 (that’s very high) between answering yes to two or more of the following four questions  and alcohol abuse (p. 47):

1) Have you ever felt you ought to cut down on your drinking?

2)have people annoyed you by criticizing your drinking?

3) Have you ever felt bad or guilty about your drinking?

4) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?

Also, they list Heilman’s eight symptoms of alcoholism:

1) Thinking or talking a lot about drinking or getting high.

2) Increased tolerance. This is not a sign of health!

3) Drinking or taking a drug in a way that speeds up the onset of its effects.

4) Non-social use.

5) Drug/alcohol starts to seem like a medicine. Thoughts of drug/alcohol immediately upon a stressful event.

6) Blackouts. “How did I get home last night?”

7) Taking care to always have a supply of alcohol/drug.

8) Using more than planned.

Finally, Heilman says that anyone who answers yes to the question “Is your drinking ever different from what you would like it to be?” is very likely suffering from alcoholism (p. 48)

[First posted on Nathen’s Miraculous Escape, April 13, 2010.]

Assessing Family Violence

I will start seeing clients this summer, so I’m reading two texts about how to structure my sessions, Procedures in Marriage and Family Therapy, by Brock and Barnard, and Essential Skills in Family Therapy, by Patterson. One of the things I am to assess as a top priority is the possibility of family violence. (I’ll get a whole class on this next year.) It’s almost always perpetrated by a male. According to Patterson, battering is the biggest cause of injury to women. Here is Brock & Barnard’s list of characteristics that can help identify violent men (p. 46):

1) Believes in the traditional home, family, and gender stereotypes

2) Has low self-esteem and may use violence to demonstrate power or adequacy

3) May be sadistic, pathologically jealous, or passive-aggressive

4) Has a Jekyll and Hyde personality, capable of great charm

5) Believes in the moral rightness of his violent behavior even though he may go too far at times

6) Has perpetrated past violent behavior, which includes witnessing, receiving, and committing violent acts, violent acts during childhood; violent acts towards pets or inanimate objects; and has criminal record, long military service, or temper tantrums

7) Indicates alcohol abuse

To this list, Patterson adds preoccupation with weapons or control.

[First published on Nathen’s Miraculous Escape, April 12, 2010.]