Oppositional Defiant Disorder

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Oppositional DefiantDisorder

• Dr Claude Jolicoeur

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Oppositional Defiant Disorder

• Statistical Manual of Mental Disorders (DSM IV),
  4th edition, 1994, American Psychiatric
  Association
• (update DSM IV-TR, and soon to be published
  2006-2007, DSM V)

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Criterion A

• Diagnostic FeaturesThe essential feature of
  Oppositional Defiant Disorder  is a recurrent
  pattern of negativistic, defiant, disobedient,
  and hostile behavior toward authority figures
  that persists for at least 6 months

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• - and is characterized by the frequent occurrence
  of at least four of the following behaviors

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Criteria

• A1- losing temper
• A2- arguing with adults
• A3- actively defying or refusing to comply with
  the requests or rules of adults
• A4- deliberately doing things that will annoy
  other people

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• A5- blaming others for his or her own mistakes or
  misbehavior
• A6- being touchy or easily annoyed by others
• A7- being angry and resentful
• A8- being spiteful or vindictive

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Criterion B

• To qualify for Oppositional Defiant Disorder, the
  behaviors must occur more frequently than is
  typically observed in individuals of comparable
  age and developmental level and must lead to
  significant impairment in social, academic, or
  occupational functioning

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Criterion C

• - The diagnosis is not made if the disturbance in
  behavior occurs exclusively during the course of
  a Psychotic or Mood Disorder

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Negativistic and defiant behaviors are expressed
by

• . persistent stubbornness, . resistance to
  directions, . unwillingness to compromise, give
  in, . or negotiate with adults or peers.

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• Defiance may also include
• . deliberate or persistent testing of limits,
  usually by ignoring orders, arguing, and failing
  to accept blame for misdeeds.

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• Hostility can be directed at adults or peers and
  is shown by deliberately - annoying others or by
  verbal aggression (usually without the more
  serious physical aggression seen in Conduct
  Disorder).

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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 adultsrequests or rules(4) often
  deliberately annoys people

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• (5) often blames other for his or her mistakes or
  behavior(6) is often touchy or easily annoyed by
  others(7) is often angry and resentful(8) is
  often spiteful or vindicative

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Associated Features and Disorders

• to be more prevalent among those who, in the
  preschool years, have problematic temperaments
  (e.g., high reactivity, difficulty being soothed)
  or
• high motor activity. During the school years,
  there may be low self-esteem, mood lability, low
  frustration tolerance, swearing, and the
  precocious use of alcohol, tobacco, or illicit
  drugs.

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• There are often conflicts with parents, teachers,
  and peers. There may be a vicious cycle in which
  the parent and child bring out the worst in each
  other.
• Oppositional Defiant Disorder is more prevalent
  in families in which child care is disrupted by a
  succession of different caregivers or in families
  in which harsh, inconsistent, or neglectful
  childrearing practices are common.

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Specific Age and Gender Features

• Because transient oppositional behavior is very
  common in preschool children and in adolescents,
  caution should be exercised in making the
  diagnosis of Oppositional Defiant Disorder
  especially during these developmental periods.
  The number of oppositional symptoms tends to
  increase with age.

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• The disorder is more prevalent in males than in
  females before puberty, but the rates are
  probably equal after puberty. Symptoms are
  generally similar in each gender, except that
  males may have more confrontational behavior and
  more persistent symptoms.

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Prevalence

• Rates of Oppositional Defiant Disorder from 2 to
  16 have been reported, depending on the nature
  of the population sample and methods of
  ascertainment.

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Course

• Oppositional Defiant Disorder usually becomes
  evident before age 7 years and usually not later
  than early adolescence.
• The oppositional symptoms often emerge in the
  home setting but over time may appear in other
  settings as well.

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• Onset is typically gradual, usually occurring
  over the course of months or years.

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• In a significant proportion of cases,
  Oppositional Defiant Disorder is a developmental
  antecedent to Conduct Disorder

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Familial Pattern

•     Oppositional Defiant Disorder appears to be
  more common in families in which at least one
  parent has a history of a Mood Disorder,
  Oppositional Defiant Disorder, Conduct Disorder,
  Attention-Deficit/Hyperactivity Disorder,
  Antisocial Personality Disorder, or a
  Substance-Related Disorder.

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• In addition, some studies suggest that mothers
  with a Depressive Disorder are more likely to
  have children with oppositional behavior, but it
  is unclear to what extent maternal depression
  results from or causes oppositional behavior in
  children.

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• Oppositional Defiant Disorder is more common in
  families in which there is serious marital
  discord.

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Differential Diagnosis

•     The disruptive behaviors of individuals with
  Oppositional Defiant Disorder are of a less
  severe nature than those of individuals with
  Conduct Disorder and typically do net include
  aggression toward people or animals, destruction
  of property, or a pattern of theft or deceit

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• Because ail of the features of Oppositional
  Defiant Disorder are usually present in Conduct
  Disorder, Oppositional Defiant Disorder is not
  diagnosed if the criteria are met for Conduct
  Disorder.

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• Oppositional behavior is a common associated
  feature of Mood Disorders and Psychotic Disorders
  presenting in children and adolescents and should
  not be diagnosed separately if the symptoms occur
  exclusively during the course of a Mood or
  Psychotic Disorder

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• Oppositional behaviors must also be distinguished
  from the disruptive behavior resulting from
  inattention and impulsivity in Attention-Deficit/H
  yperactivity Disorder.
• When the two disorders co-occur, both diagnoses
  should be made.

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Disruptive Behavior disorder Not Otherwise
Specified, 312.9

• This category is for disorders characterized by
  conduct or oppositional defiant behaviors that do
  not meet the criteria for Conduct Disorder or
  Oppositional Defiant Disorder.

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• For example, include clinical presentations that
  do not meet full criteria either for Oppositional
  Defiant Disorder or Conduct Disorder, but in
  which there is clinically significant impairment.
  

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Melissa, 7 y.o.

• Mélissa se refuse aux routines, dès le matin,
• de shabiller,
• de préparer sa toilette,
• de déjeûner,
• mais veut seulement jouer,
• regarder la télé

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Suite 1

• La jeune mère de 27 ans se dévalorise, au point
  de menacer de quitter la maison et tout laisser
  au père seul,
• Pour lui, cest surtout la mère qui aurait du mal
  à se faire écouter, trop douce, incapable de
  tenir son bout comme lui.

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Suite 2

• Dans la crise,  la chaise revolle,
• elle donne des coups de pieds, de poings , à la
  mère surtout.
• Le soir, ne veut pas aller au lit
• Exige sur le champ, sans délai dattente

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Suite 3

• Elle aime grimper, sauter.
• Elle na  peur de rien ,
• Mélissa bouge pas mal, depuis la tendre enfance
  elle aurait même déboulé les escaliers destrade
  du Parc Jarry à 3 ans, par imprudence

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Conners- parents, (enseigants)

• Évaluation questionnaire Conners parents  père
  (mère) Opposition  85 (126) inattention  72
  (63)  hyperactivité  86 (101) anxiété  47
  (86)
• perfectionnisme  55 (69) manque de
  sociabilité  62 (55 ) psychosomatique  65
  (nil)
• ADHD index  79 (97)
• CGI impulsivité  84 (97) CGI labilité
  émotive  57 (113) CGI total  77 (110)
• DSM-IV  parents (prof).inattention 72 (75)
  hyperactivité- impulsivité 84 (96)
  DSM-IV total  83 (93)

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Suite 4

• En classe, elle dérange, mais serait influencée
  par une autre gamine très active qui lexcite,
  selon le père qui est contre la médication.
• Lui-même était turbulent, opposant,
• Abandonne lécole en sec. 1
• Se fait expulsé de chez lui à 15 ans

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Suite 5

• Mais reprend les études à 23 ans
• Termine secondaire
• Fait cours des matériaux composites
• Travaille dans fibre de verrs
• Mère fait actuellement le sec. 2.

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Jonathan, 11 ans

• Il a beaucoup de misère à se concentrer, selon la
  jeune.
• Il a de la misère à comprendre il ne peut
  accorder ses verbes.
• Et de plus, il refuse de faire des exercices.

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Suite 1 Jonathan

• Pour les devoirs,  cest la guerre .
• Cette année, il se fait expulser de laide aux
  devoirs, après lécole, pour induscipline.
• Dans la classe,  il parle, il rie fort, il lit
  un libre, il fait des blagues , et devient ainsi
  populaire parmi ses pairs.

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Suite 2 Jonathan

• Le prof le place à lavant et lui demande de ne
  pas bouger, de cesser sa danse constante du pied.

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Suite 3 Jonathan

• Excelle dans le sport, comme hockey
• Récemment il refuse dalterner, aux minutes, son
  temps de glace comme les autres.
• Il est très mauvais perdant

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Suite 4 Jonathan

• Jonathan est peu organisé dans ses affaires, et
  manifeste un grand désordre dans sa chambre.
• Le patient fait des oublis à répétition il perd
  des chandails, souliers, des tuques, mitaines,
  crayons, etc. Il égare ses jeux favoris dans la
  maison. Il ne remplit pas son agenda et il ne
  connaît pas les devoirs à faire.
• À la maison, il envahit vite la conversation des
  adultes, et donne son opinion sur tout, sans
  retenue.  Lui

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Suite 5 Jonathan

• En classe, il se distrait, dérange les autres,
  parle fort, fait des blagues, refuse de
  travailler, de suivre les consigne.
• Il fait des erreurs dattention, il ne se donne
  pas la peine de corriger ses fautes. Il perd
  facilement le fil des idées du prof. ne peut
  suivre la dictée et saute des lignes

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Suite 1 Jonathan, fabulation

• Il change facilement sa version des faits, à
  quelques minutes de distance

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Suite 1 Jonathan Insomnie, immaturité

• Il sendort mal le soir et se réveille souvent en
  pleine nuit, puis soccupe jusquau matin ou se
  lève tôt vers 5-6 heures. Alimentation limitée
  sur les légumes.
• Petit, il pleurait souvent et ne fait pas ses
  nuits avant 24 mois.

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Conners parents (enseigants)

• Évaluation questionnaire Conners parents
  (ens) Opposition  80 (88) inattention  85
  (78)  hyperactivité  100 (79) anxiété  74
  (75)
• perfectionnisme  54 (59) manque de
  sociabilité  76 (48) psychosomatique  66 ( nil
  )
• ADHD index  83 (80)
• CGI impulsivité  87 (80) CGI labilité émotive 
  70 (91) CGI total  85 (89)
• DSM-IV  parents (prof).inattention 81 (78)
  hyperactivité- impulsivité 97 (83)
  DSM-IV total  90 (84)