Oppositional DefiantOppositional DefiantDisorderDisorder

Dr Claude JolicoeurDr Claude Jolicoeur

Oppositional Defiant DisorderOppositional Defiant Disorder

• Statistical Manual of Mental Statistical Manual of Mental Disorders (DSM IV), 4th edition, Disorders (DSM IV), 4th edition, 1994, American Psychiatric 1994, American Psychiatric AssociationAssociation

• (update (update DSM IV-TR, and soon to , and soon to be publishedbe published 2006-2007, DSM V))

Criterion ACriterion A

• Diagnostic FeaturesDiagnostic Features

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

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

CriteriaCriteria

• A1A1- losing temper- losing temper

• A2- arguing with adults A2- arguing with adults

• A3- actively defying or refusing to A3- actively defying or refusing to comply with the requests or rules of comply with the requests or rules of adults adults

• A4- deliberately doing things that will A4- deliberately doing things that will annoy other people annoy other people

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• A5- blaming others for his or her own A5- blaming others for his or her own mistakes or misbehaviormistakes or misbehavior

• A6- being touchy or easily annoyed A6- being touchy or easily annoyed by othersby others

• A7- being angry and resentful A7- being angry and resentful

• A8- being spiteful or vindictive A8- being spiteful or vindictive

Criterion BCriterion B

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

Criterion CCriterion C

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

Negativistic and defiant Negativistic and defiant behaviors are expressed bybehaviors are expressed by

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

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Defiance may also include Defiance may also include

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

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

Diagnostic criteria Diagnostic criteria

•AA. A pattern of negativistic, hostile, and . A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, defiant behavior lasting at least 6 months, during which four (or more) of the following during which four (or more) of the following are present:are present:(1) often loses temper(1) often loses temper(2) often argues with adults(2) often argues with adults(3) often actively defies or refuses to (3) often actively defies or refuses to comply with adults’requests or rulescomply with adults’requests or rules(4) often deliberately annoys people(4) often deliberately annoys people

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

Associated Features and Associated Features and Disorders Disorders

• to be more prevalent among those who, in to be more prevalent among those who, in the preschool years, have problematic the preschool years, have problematic temperaments (e.g., high reactivity, temperaments (e.g., high reactivity, difficulty being soothed) or difficulty being soothed) or

• high motor activity. high motor activity. During the school years, there may be low During the school years, there may be low self-esteem, mood lability, low frustration self-esteem, mood lability, low frustration tolerance, swearing, and the precocious tolerance, swearing, and the precocious use of alcohol, tobacco, or illicit drugs. use of alcohol, tobacco, or illicit drugs.

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• There are often conflicts with parents, There are often conflicts with parents, teachers, and peers. There may be a vicious teachers, and peers. There may be a vicious cycle in which the parent and child bring out cycle in which the parent and child bring out the worst in each other. the worst in each other.

• Oppositional Defiant Disorder is more Oppositional Defiant Disorder is more prevalent in families in which child care is prevalent in families in which child care is disrupted by a succession of different disrupted by a succession of different caregivers or in families in which harsh, caregivers or in families in which harsh, inconsistent, or neglectful child rearing inconsistent, or neglectful child rearing practices are common. practices are common.

Specific Age and Gender Specific Age and Gender FeaturesFeatures

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

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

PrevalencePrevalence

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

CourseCourse

• Oppositional Defiant Disorder usually Oppositional Defiant Disorder usually becomes evident before age 7 years and becomes evident before age 7 years and usually not later than early adolescence. usually not later than early adolescence.

• The oppositional symptoms often The oppositional symptoms often emerge in the home setting but over emerge in the home setting but over time may appear in other settings as time may appear in other settings as well. well.

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

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

Familial PatternFamilial Pattern

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

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

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

Differential DiagnosisDifferential Diagnosis

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

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

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

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• Oppositional behaviors must also be Oppositional behaviors must also be distinguished from the disruptive distinguished from the disruptive behavior resulting from inattention and behavior resulting from inattention and impulsivity in impulsivity in Attention-Deficit/Hyperactivity Disorder. Attention-Deficit/Hyperactivity Disorder.

• When the two disorders co-occur, both When the two disorders co-occur, both diagnoses should be made. diagnoses should be made.

Disruptive Behavior Disruptive Behavior disorder Not Otherwise disorder Not Otherwise Specified, 312.9Specified, 312.9•

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

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

Melissa, 7 y.o.Melissa, 7 y.o.

• Mélissa se refuse aux routines, dès le Mélissa se refuse aux routines, dès le matin, matin,

• de s’habiller, de s’habiller,

• de préparer sa toilette, de préparer sa toilette,

• de déjeûner,de déjeûner,

• mais veut seulement jouer, mais veut seulement jouer,

• regarder la téléregarder la télé

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• La jeune mère de 27 ans se La jeune mère de 27 ans se dévalorise, au point de menacer de dévalorise, au point de menacer de quitter la maison et tout laisser au quitter la maison et tout laisser au père seul, père seul,

• Pour lui, c’est surtout la mère qui Pour lui, c’est surtout la mère qui aurait du mal à se faire écouter, trop aurait du mal à se faire écouter, trop douce, incapable de tenir son bout douce, incapable de tenir son bout comme lui.comme lui.

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• Dans la crise, « la chaise revolle, Dans la crise, « la chaise revolle,

• elle donne des coups de pieds, de elle donne des coups de pieds, de poings », à la mère surtout. poings », à la mère surtout.

• Le soir, ne veut pas aller au litLe soir, ne veut pas aller au lit

• Exige sur le champ, sans délai Exige sur le champ, sans délai d’attented’attente

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• Elle aime grimper, sauter.Elle aime grimper, sauter.

• Elle n’a « peur de rien », Elle n’a « peur de rien »,

• Mélissa bouge pas mal, depuis la Mélissa bouge pas mal, depuis la tendre enfance: elle aurait même tendre enfance: elle aurait même déboulé les escaliers d’estrade du déboulé les escaliers d’estrade du Parc Jarry à 3 ans, par imprudence Parc Jarry à 3 ans, par imprudence

Conners- parents, Conners- parents, (enseigants)(enseigants)• Évaluation questionnaire Conners parents : père Évaluation questionnaire Conners parents : père

(mère) :(mère) :Opposition : 85 (126); inattention : 72 (63) ; Opposition : 85 (126); inattention : 72 (63) ; hyperactivité : 86 (101); anxiété : 47 (86);hyperactivité : 86 (101); anxiété : 47 (86);

• perfectionnisme : 55 (69); manque de perfectionnisme : 55 (69); manque de sociabilité : 62 (55 ); psychosomatique : 65 (nil);sociabilité : 62 (55 ); psychosomatique : 65 (nil);

• ADHD index : 79 (97);ADHD index : 79 (97);• CGI impulsivité : 84 (97); CGI labilité émotive : 57 CGI impulsivité : 84 (97); CGI labilité émotive : 57

(113); CGI total : 77 (110)(113); CGI total : 77 (110)• DSM-IV : parents (prof).DSM-IV : parents (prof).

inattention: 72 (75); hyperactivité- impulsivité: 84 inattention: 72 (75); hyperactivité- impulsivité: 84 (96); DSM-IV total : 83 (93)(96); DSM-IV total : 83 (93)

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• En classe, elle dérange, mais serait En classe, elle dérange, mais serait influencée par une autre gamine très influencée par une autre gamine très active qui l’excite, selon le père qui active qui l’excite, selon le père qui est contre la médication.est contre la médication.

• Lui-même était turbulent, opposant,Lui-même était turbulent, opposant,

• Abandonne l’école en sec. 1Abandonne l’école en sec. 1

• Se fait expulsé de chez lui à 15 ansSe fait expulsé de chez lui à 15 ans

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• Mais reprend les études à 23 ansMais reprend les études à 23 ans

• Termine secondaireTermine secondaire

• Fait cours des matériaux compositesFait cours des matériaux composites

• Travaille dans fibre de verrsTravaille dans fibre de verrs

• Mère fait actuellement le sec. 2.Mère fait actuellement le sec. 2.

Jonathan, 11 ansJonathan, 11 ans

• Il a beaucoup de misère à se Il a beaucoup de misère à se concentrer, selon la jeune.concentrer, selon la jeune.

• Il a de la misère à comprendre; il ne Il a de la misère à comprendre; il ne peut accorder ses verbes.peut accorder ses verbes.

• Et de plus, il refuse de faire des Et de plus, il refuse de faire des exercices. exercices.

Suite 1 JonathanSuite 1 Jonathan

• Pour les devoirs, « c’est la guerre ».Pour les devoirs, « c’est la guerre ».

• Cette année, il se fait expulser de Cette année, il se fait expulser de l’aide aux devoirs, après l’école, pour l’aide aux devoirs, après l’école, pour induscipline.induscipline.

• Dans la classe, « il parle, il rie fort, il Dans la classe, « il parle, il rie fort, il lit un libre, il fait des blagues », et lit un libre, il fait des blagues », et devient ainsi populaire parmi ses devient ainsi populaire parmi ses pairs. pairs.

Suite 2 JonathanSuite 2 Jonathan

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

Suite 3 JonathanSuite 3 Jonathan

• Excelle dans le sport, comme hockeyExcelle dans le sport, comme hockey

• Récemment il refuse d’alterner, aux Récemment il refuse d’alterner, aux minutes, son temps de glace comme minutes, son temps de glace comme les autres. les autres.

• Il est très mauvais perdant Il est très mauvais perdant

Suite 4 JonathanSuite 4 Jonathan

• Jonathan est peu organisé dans ses affaires, et Jonathan est peu organisé dans ses affaires, et manifeste un grand désordre dans sa manifeste un grand désordre dans sa chambre. chambre.

• Le patient fait des oublis à répétition; il perd Le patient fait des oublis à répétition; il perd des chandails, souliers, des tuques, mitaines, des chandails, souliers, des tuques, mitaines, crayons, etc. Il égare ses jeux favoris dans la crayons, etc. Il égare ses jeux favoris dans la maison. Il ne remplit pas son agenda et il ne maison. Il ne remplit pas son agenda et il ne connaît pas les devoirs à faire. connaît pas les devoirs à faire.

• À la maison, il envahit vite la conversation des À la maison, il envahit vite la conversation des adultes, et donne son opinion sur tout, sans adultes, et donne son opinion sur tout, sans retenue. « Lui retenue. « Lui

Suite 5 JonathanSuite 5 Jonathan

• En classe, il se distrait, dérange les En classe, il se distrait, dérange les autres, parle fort, fait des blagues, autres, parle fort, fait des blagues, refuse de travailler, de suivre les refuse de travailler, de suivre les consigne.consigne.

• Il fait des erreurs d’attention, il ne se Il fait des erreurs d’attention, il ne se donne pas la peine de corriger ses donne pas la peine de corriger ses fautes. Il perd facilement le fil des idées fautes. Il perd facilement le fil des idées du prof. ne peut suivre la dictée et saute du prof. ne peut suivre la dictée et saute des lignes des lignes

Suite 1 Jonathan, fabulationSuite 1 Jonathan, fabulation

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

Suite 1 Jonathan: Insomnie, Suite 1 Jonathan: Insomnie, immaturitéimmaturité

• Il s’endort mal le soir et se réveille Il s’endort mal le soir et se réveille souvent en pleine nuit, puis s’occupe souvent en pleine nuit, puis s’occupe jusqu’au matin ou se lève tôt vers 5-jusqu’au matin ou se lève tôt vers 5-6 heures. Alimentation limitée sur les 6 heures. Alimentation limitée sur les légumes.légumes.

• Petit, il pleurait souvent et ne fait pas Petit, il pleurait souvent et ne fait pas ses nuits avant 24 mois. ses nuits avant 24 mois.

Conners parents Conners parents (enseigants)(enseigants)• Évaluation questionnaire Conners parents (ens) :Évaluation questionnaire Conners parents (ens) :

Opposition : 80 (88); inattention : 85 (78) ; Opposition : 80 (88); inattention : 85 (78) ; hyperactivité : 100 (79); anxiété : 74 (75);hyperactivité : 100 (79); anxiété : 74 (75);

• perfectionnisme : 54 (59); manque de perfectionnisme : 54 (59); manque de sociabilité : 76 (48); psychosomatique : 66 ( nil );sociabilité : 76 (48); psychosomatique : 66 ( nil );

• ADHD index : 83 (80);ADHD index : 83 (80);• CGI impulsivité : 87 (80); CGI labilité émotive : 70 CGI impulsivité : 87 (80); CGI labilité émotive : 70

(91); CGI total : 85 (89)(91); CGI total : 85 (89)• DSM-IV : parents (prof).DSM-IV : parents (prof).

inattention: 81 (78); hyperactivité- impulsivité: 97 inattention: 81 (78); hyperactivité- impulsivité: 97 (83); DSM-IV total : 90 (84)(83); DSM-IV total : 90 (84)