Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD)

OT Dude Academy’s Free NBCOT® Exam Prep Course Pediatric Psychosocial Disorders Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD)
Contents Hide
1 Video
2 Introduction to Conduct Disorders
3 Changes from DSM IV-TR to DSM-5
3.1 New ODD Criteria
4 Epidemiology
5 ODD Etiology and Risk Factors
6 ODD Symptoms and Diagnosis
7 ODD Differential Diagnosis
8 Outcome Measures (Multidisciplinary)
9 Team and Occupational Therapy Treatment

Video

Introduction to Conduct Disorders

Conduct disorder (CD) is one of the most common mental and behavioral problems in children and young people. CD is characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. Associated behaviors fall outside of socially accepted norms and result in persistent violations of age-appropriate social expectations. CD is classified along with oppositional defiant disorder (ODD) in the spectrum of disruptive behavior disorders. CD can be problematic as the occurrence in early life has been found to be strongly associated with a significant decline in educational performance with an increased risk of social isolation and substance abuse.1  For many children, ODD does improve over-time.2 3 

Changes from DSM IV-TR to DSM-5

  • ODD has a new classification under “Disruptive, Impulsive Control, and Conduct Disorders”.

New ODD Criteria

  • 1. Symptoms are now grouped into three types: angry/irritable mood,
    argumentative/defiant behavior, and vindictiveness. This change highlights that
    ODD reflects both emotional and behavioral symptomatology.
  • 2. The exclusion criterion for conduct disorder has been removed.
  • 3. Frequency of symptoms of ODD must be established. Many behaviors associated
    with ODD occur commonly in normally developing children and adolescents.
    The DSM-5 notes the frequency typically needed for a behavior to be considered
    symptomatic of ODD.
  • 4. Severity of symptoms of ODD must be clarified. A severity rating has been added.
    This reflects research showing that the degree of the pervasiveness of symptoms
    across settings is an important indicator of severity.

Epidemiology

  • ODD ranges from 1-16% depending on criteria and assessments used.4 

ODD Etiology and Risk Factors

  • Data is often combined with CD research.
  • Likely not due to a single cause.5 
  • Likely arises from a mix of risk and protective biopsychosocial factors.6 
  • Studies of the genetics of ODD has produced mixed results.7 

ODD Symptoms and Diagnosis

  • Recurring patterns of negativistic, hostile, or defiant behaviors lasting at least 6 months. The presentation also refers to angry and vindictive behavior and problems with control of temper.
  • Behaviors include stealing, lying, physical and verbal aggression, rule-breaking, and violence.1 
  • More specifically: frequent temper tantrums, excessive arguments with adults, actively refusing to comply with requests and rules, frequent questioning of rules, deliberately annoying and upsetting others, often being touchy or annoyed by others, blaming others for their mistakes, frequent outbursts of anger and resentment, and spiteful attitude and revenge-seeking.
  • Girls may show symptoms of ODD differently than boys.
    • Girls may show their aggressiveness through their words rather than actions or indirectly.8 
  • Behaviors occur more frequently than typically observed in individuals of
    comparable age and developmental level and cause significant impairment in
    functioning.
  • Symptoms appear before the age of 8 years.9 
  • ODD may precede the development of conduct disorder; at risk for developing CD.
  • ODD is conceptualized as a milder form of CD where rights are not violated.1 
  • Persistence of these behaviors into adulthood leads to antisocial personality disorder (ASPD).

ODD Differential Diagnosis

  • ADHD
  • Conduct disorder
  • Mood disorders
  • Learning and developmental disabilities
  • Adjustment disorders
  • Relational disorders
  • Depression
  • Anxiety — ODD has been shown to predict depression and anxiety.10 11 
  • Substance abuse

Outcome Measures (Multidisciplinary)

  • Short Sensory Profile (Parent report)
  • Eyberg Child Behavior Inventory
  • Strengths and Difficulties Questionnaire12 
  • Aggression Scale Questionnaire13 
  • Connors Rating Scale
  • Barratt Aggressive Acts Questionnaire
  • Child Behavior Checklist
  • Youth Self-Report
  • Overt Aggression Scale
  • Life History of Aggression
  • Children’s Aggression Scale
  • Parent Daily Report
  • Interview for Antisocial Behavior14 

Team and Occupational Therapy Treatment

  • Tiers: intervention can be universal, targeted, or intensive.
  • Building a therapeutic relationship may aid treatment and engagement.15 
    • Validate the client’s feelings and behaviors.
    • Set goals through collaboration.
    • Orient the client to their role in the treatment process.
    • Establish credibility by providing a rationale for treatment.
    • Adapt treatment in response to individual differences.
    • Facilitate the completion of homework assignments.16 
    • Provide consistency through structure and routines, e.g., family17 , school.
  • Child-based therapies focus on problem-solving skills.
  • Parent training programs focus on how to respond to the child’s behavior.
  • Medication (medication alone has not proven to be effective).
    • Often the same medications for coexisting conditions, e.g., ADHD.
  • Parent training programs and family therapy. Examples: Incredible Years, Triple P-Positive Parenting Program, Center for Collaborative Problem Solving, The Adolescent Transitions Program (ATP).
  • Cognitive problem-solving skills training may be effective.
  • Social skills programs and school-based programs may be effective.
  • Meditation (meditation alone is not a treatment for ODD).
  • Ineffective therapies: one-time or short duration therapies, e.g., boot camps, tough-love camps, scare tactics.9 
  • Behavioral and Cognitive Behavioral Therapy (CBT) has been shown to be effective in improving child conduct problems, parental mental health, and parenting skills in the short term.18 
  • Group CBT has been found to decrease peer-related aggressive behaviors in boys aged 6-12 years.19 
  • Prevention interventions in schools, clinics, or community locations.
    • Cognitive interventions and skills training, vocational training, academic preparation.20 21 
  • Should be interdisciplinary and include physicians, teachers, and other professionals.
  • Target social skills, conflict resolution, and anger management.
  • Address bullying22 , antisocial behavior, and peer group influences.
  • Consider cultural issues.
  • Conduct a thorough assessment and evaluation (including the degree of functional impairment).
  • Use specific questionnaires and rating scales to evaluate and track progress.
  • Develop an individualized treatment plan with a family-centered approach.14 
  • Consider assessing and providing management for potential sensory processing difficulties — client, environment, activity12 
  • Provide simple and clear instructions.
  • Using time-out may help.23 
  • Avoid: threats, emotional responses, confrontation, responding too quickly, bribes; diminishing power struggles.
  • Decide which rules are negotiable in accordance with the team.
  • Provide praises for reinforcement, but keep them brief and do not bring attention to the client. Consider leaving a note instead of verbal praises.24 
  • Avoid conflict: yelling, sarcasm, and frustration.
  • Have a progression of sequences or back-up plan.
  • In general, praise is negatively associated with problem behaviors, and high amounts of reinforcement are needed to learn positive behaviors.
    • Give praise when client exhibits even simple behaviors.
    • Positive reinforcement alone is not effective for clients with ODD.25 
  • Videotape vignettes and modeling parent skills may be effective in improving parent-child interactions and reducing child conduct problems.
    • Communication skills
    • Problem-solving skills
    • Self-care
    • Socialization26 
  • Address parent self-care and client relapse prevention.27 
  • Use strategies to deescalate and encourage compliance.
  • Give precise and specific warnings for poor behaviors.
  • Ensure consistency across settings to reinforce positive behavior. A behavior chart may help.28 
  • “Music programs are in a unique position to provide protective factors to students who are at-risk for behavior disorders or who are already diagnosed with ODD.”29 
  • Group drumming may be an effective intervention for reducing aggression among adolescent girls diagnosed with CD.13 
  • Art therapy has shown to reduce symptoms of ODD in elementary school boys.30 
  • Media-based parent training, e.g., videos, have shown to be effective.31 
  1. Sagar, R., Patra, B. N., & Patil, V. (2019). Clinical Practice Guidelines for the management of conduct disorder. Indian journal of psychiatry, 61(Suppl 2), 270–276. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_539_18[↩][↩][↩]
  2. Connor DF (2002), Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York: The Guilford Press.[↩]
  3. Rutter M, Giller H, Hagell A (1999), Antisocial behavior by young people. J Am Acad Child Adolesc Psychiatry 38:1320-1321[↩]
  4. Loeber R Burke JD Lahey BB Winters A Zera M Oppositional defiant and conduct disorder: a review of the past 10 years, part I. J Am Acad Child Adolesc Psychiatry. 2000; 39: 1468-1484[↩]
  5. Burke JD Loeber R Birmaher B Oppositional defiant and conduct disorder: a review of the past 10 years, part II.
    J Am Acad Child Adolesc Psychiatry. 2002; 41: 1275-1293[↩]
  6. American Academy of Child and Adolescent Psychiatry Practice parameters for the assessment and treatment of children and adolescents with conduct disorder.
    J Am Acad Child Adolesc Psychiatry. 1997; 36: 122S-139S[↩]
  7. Burke JD Loeber R Birmaher B Oppositional defiant and conduct disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry. 2002; 41: 1275-1293[↩]
  8. American Academy of Child and Adolescent Psychiatry. (2009). ODD: A guide for families by the American Academy of Child and Adolescent Psychitary. Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_odd_guide.pdf[↩]
  9. Condensed clinical practice guidelines oppositional defiant disorder (ODD). (n.d.). Retrieved from https://pa.performcare.org/assets/pdf/providers/quality-improvement/cpg/cpg-oppositional-defiant-disorder.pdf[↩][↩]
  10. Dimensions of oppositional defiant disorder as predictors of depression and conduct disorder in preadolescent girls. Burke JD, Hipwell AE, Loeber R J Am Acad Child Adolesc Psychiatry. 2010 May; 49(5):484-92.[↩]
  11. The relationship between DSM-IV oppositional defiant disorder and conduct disorder: findings from the Great Smoky Mountains Study. Rowe R, Maughan B, Pickles A, Costello EJ, Angold A J Child Psychol Psychiatry. 2002 Mar; 43(3):365-73.[↩]
  12. Fox, C., Snow, P. C., & Holland, K. (2014). The relationship between sensory processing difficulties and behaviour in children aged 5–9 who are at risk of developing conduct disorder. Emotional and behavioural difficulties, 19(1), 71-88.[↩][↩]
  13. Janse van Rensburg, E., Hatting, R., van Rooyen, C. M., Chelin, M. B., Van Der Merwe, C., Putter, L., … & Buitendag, T. (2016). The short term effect of a group drumming intervention on aggressive behaviour among adolescent girls diagnosed with conduct disorder. South African Journal of Occupational Therapy, 46(2), 16-22.[↩][↩]
  14. PRACTICE PARAMETERS: AACAP OFFICIAL ACTION| VOLUME 46, ISSUE 1, P126-141, JANUARY 01, 2007 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder
    Hans Steiner, M.D. Lisa Remsing, M.D. The Work Group on Quality Issues DOI:https://doi.org/10.1097/01.chi.0000246060.62706.af[↩][↩]
  15. Constantino, M., & Smith-Hansen, L. (2008, November). Patient interpersonal factors and the therapeutic alliance in two treatments for bulimia nervosa. Psychotherapy Research, 18, 683–698.[↩]
  16. Karver, M. S., & Caporino, N. (2010). The use of empirically supported strategies for building a therapeutic relationship with an adolescent with oppositional-defiant disorder. Cognitive and Behavioral Practice, 17(2), 222-232.[↩]
  17. Lanza, H. I., & Drabick, D. A. (2011). Family routine moderates the relation between child impulsivity and oppositional defiant disorder symptoms. Journal of abnormal child psychology, 39(1), 83-94.[↩]
  18. Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database Syst Rev. 2012;(2):CD008225.[↩]
  19. Goertz-Dorten A, Benesch C, Hautmann C, et al. Efficacy of an individualized social competence training for children with oppositional defiant disorders/conduct disorders. Psychother Res. 2015:1–12.[↩]
  20. Arbuthnot J Sociomoral reasoning in behavior-disordered adolescents: cognitive and behavioral change. in: McCord J Tremblay RE Preventing Antisocial Behavior: Interventions from Birth Through Adolescence. The Guilford Press, New York1992: 283-310[↩]
  21. Connor DF Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. The Guilford Press, New York2002[↩]
  22. Olweus D Bullying at schools: basic facts and effects of a school based intervention program. J Child Psychol Psychiatry. 1994; 35: 1171-1190[↩]
  23. Morawska, A., & Sanders, M. (2011). Parental use of time out revisited: A useful or harmful parenting strategy?. Journal of Child and Family Studies, 20(1), 1-8.[↩]
  24. Woolsey-Terrazas, W., & Chavez, J. A. (2002). Strategies to work with students with oppositional defiant disorder. CEC Today, 8(7), 12.[↩]
  25. Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency,and violence in adolescence through interventions targeted at young children (0-8 years). Prevention Science, 2, 165–192.[↩]
  26. Webster-Stratton, C. H. (1996). Early intervention with videotape modeling: Programs for families of children with oppositional defiant disorder or conduct disorder. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 435–474). American Psychological Association. https://doi.org/10.1037/10196-017[↩]
  27. Winther, J., Carlsson, A., & Vance, A. (2014). A pilot study of a school‐based prevention and early intervention program to reduce oppositional defiant disorder/conduct disorder. Early Intervention in Psychiatry, 8(2), 181-189.[↩]
  28. Danforth, J. S. (2016). A flow chart of behavior management strategies for families of children with co-occurring attention-deficit hyperactivity disorder and conduct problem
    behavior. Behavior Analysis in Practice, 9, 64–76.[↩]
  29. Jones, S. H. (2018). Oppositional defiant disorder: An overview and strategies for educators. General Music Today, 31(2), 12-16.[↩]
  30. Khadar, M. G., Babapour, J., & Sabourimoghaddam, H. (2013). The effect of art therapy based on painting therapy in reducing symptoms of oppositional defiant disorder (ODD) in elementary school boys. Procedia-Social and Behavioral Sciences, 84, 1872-1878.[↩]
  31. Montgomery P, Bjornstad G, Dennis J. Media-based behavioural treatments for behavioural problems in children. Cochrane Database Syst Rev. 2006;(1):CD002206.[↩]
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