Oppositional Defiant Disorder Assessment Handout

[First published on Nathen’s Miraculous Escape]

The most useful assessment tool is the DSM-IV-TR Diagnostic Criteria:

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.

 

There are also several assessment tools, which have varying degrees of consistency with clinical-interview-derived diagnoses, test-retest reliability, and source-variance problems. They also cost a lot. What you basically need to know about them is that using these rating scales, teacher and parent opinions about ODD barely agree, and if their agreement was necessary, ODD would be about .2% of the population, down from up to 16%, according to the DSM. Parents’ opinions tend to be more closely related to clinicians’ and are probably more accurate. Note that the DSM does not require ODD to be present in more than one context, but consider your stance on this. If teacher says ODD and parents say no ODD, or vice versa, will you make the diagnosis?

Here are a list of common assessment tools, so that you can recognize them: Diagnostic Interview Schedule for Children, Child Behavior Checklist, Behavior Assessment System for Children: Second Edition, Disruptive Behavior Disorders Structured Parent Interview, Burke’s Behavioral Rating Scale, IOWA Conners Teacher Rating Scale, Disruptive Behavior Rating Scale, Oppositional Defiant Disorder Rating Scale, SNAP-IV Teacher and Parent Rating Scale. I did a fair bit of research on the use of these systems for ODD. If you’re interested, see my summary here.

Considerations for making a systemic diagnosis: I have my doubts that this diagnosis can be made in good faith by a system thinker; it pathologizes an individual child for a condition that is very likely contextual in nature. However, it is medicated less than many of its alternatives, such as ADHD, CD, and RAD, and its treatment goals are inherently relational, so a case can be made to use this diagnosis to funnel resources to families in need. In making a systemic diagnosis, remember that ODD is correlated with disrupted attachment, parenting that is authoritative, neglectful, or abusive, parental psychopathology (especially maternal depression), and marital discord.

Some books which might be helpful: Books for Parents: Your Defiant Child, Russell A. Barkley, PhD, Guilford Press, 1998; The Explosive Child, Ross Greene, PhD, Harper Paperbacks, 2001; Raising Your Spirited Child, Mary Sheedy Kurcinka, Harper Paperbacks, 1998; The Angry Child, Timothy Murphy, PhD, Three Rivers Press, 2002; How to Behave So Your Child Will Too, Sal Severe, PhD, Penguin Books, 2003; It’s Nobody’s Fault, Harold Koplewicz, MD, Three Rivers Press, 1997; Books for Children: The Behavior Survival Guide for Kids, Thomas McIntyre, Free Spirit, 2003; How to Take the Grrrr Out of Anger, Elizabeth Verdick and Marjorie Lisovskis, Free Spirit, 2002; Josh’s Smiley Faces: A Story About Anger, Gina Ditta-Donahue, Magination Press, 2003; Learning to Listen, Learning to Care, Lawrence Shapiro, Instant Help Publications, 2004; Books for Professionals: What Works for Whom: A Critical Review of Psychotherapy Research, Anthony Ross and Peter Fonagy, Guilford Press, 2004; Helping Children with Aggression and Conduct Problems: Best Practices for Intervention, Michael Bloomquist and Steven V. Schnell, Guilford Press, 2005

Diagnostic Criteria for Oppositional Defiant Disorder

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there is a mental disorder that is usually diagnosed in childhood or adolescence called Oppositional Defiant Disorder. It afflicts somewhere between 2-16% of people, more boys than girls before puberty, but equal numbers of boys and girls after puberty. Family therapists are not into giving medical-model diagnoses in general, but in many cases, a DSM diagnosis is the only way for a family to get their insurance companies to pay for them to get help. In one of my internship sites, for example, I will need to provide a DSM diagnosis after the first session with a family in order to get the clinic paid for our work. As I understand it, this is a common diagnosis for kids who are giving their parents and teachers a hard time.

Note that the word “often” is used to mean something like “more than usual,” so whichever kids who are most like this will qualify for this Disorder, as long as someone important believes that their behavior is significantly impairing their social or academic functioning. Note also that these symptoms could be occurring in just one setting (say, just at school) and the kid will still qualify for ODD, unlike the symptoms for ADHD, which have to occur in at least two settings to qualify for the diagnosis.

Outside of family therapy, ODD is very commonly treated with Ritalin for “comorbid” ADHD. Kids diagnosed with ODD are also fairly commonly given antidepressant and/or antipsychotic medication, on the guess that they have an underlying Mood Disorder or Bipolar Disorder, though there is little to no research on these medications for children, especially in combination.

The following is word-for-word from the DSM-IV-TR, page 102:

Diagnosis criteria for 313.81 Oppositional Defiant Disorder

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.

[First published on Nathen’s Miraculous Escape, May 14, 2010.]

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.