Description :
- type of disruptive behavior disorder of childhood
Also called :
ICD-9 Codes :
- 313.81 oppositional disorder of childhood or adolescence
ICD-10 Codes :
- F91.3 oppositional defiant disorder
Who is most affected :
Incidence/Prevalence :
- community prevalence estimates range from 1% to 16%, varying with definitions used and aggressiveness of informant interviews ( 1 )
- lifetime prevalence 8.5%
Causes :
- no convincing evidence of causual linkages for any risk factor ( 2 )
Possible risk factors :
- maternal depression may be associated with oppositional defiant disorder
- based on study of 568 adopted adolescents and 416 nonadopted adolescents
- rates of oppositional defiant disorder
- 23% nonadopted adolescents with depression in either parent
- 12.7% nonadopted adolescents with no parental depression
- 33.6% adopted adolescents with depression in either parent
- 23% adopted adolescents with no parental depression
- maternal depression (but not paternal depression) associated with significantly increased risk for oppositional defiant disorder in adopted and nonadopted adolescents
- Reference - Am J Psychiatry 2008 Jun 16 early online
Associated conditions :
Chief Concern (CC) :
- pattern of negativistic, hostile, or defiant behavior ( 1 )
- angry and vindictive behavior ( 1 )
- problems with control of temper ( 1 )
History of Present Illness (HPI) :
- behavior pattern lasting at least 6 months ( 1 )
- ask about antecedents and consequences of child's behavior ( 1 )
- ask about other's behaviors which may reinforce child's behavior ( 1 )
General Physical :
- exam may be normal
- manifest behaviors may not appear during exam, except in severe cases ( 1 )
Making the diagnosis :
- DSM-IV-TR criteria
- behavior pattern of negativity, hostility and defiance
- occuring for at least 6 months
- at least 4 of 8 criteria occuring often or frequently
- losing temper
- arguing with adults
- actively defying and refusing adult requests and/or rules
- annoying other people in deliberate manner
- blaming others for mistakes and misbehaviors
- easily annoyed by others or "touchy"
- angry or resentful
- spiteful or vindictive
- criteria met only if more frequent than normal for mental age
- functioning is significantly impaired
- does not meet other criteria for
- does not occur during other psychotic or mood disorder
Rule out :
Testing to consider :
Prognosis :
Counseling :
- parent training appears effective (level 2 [mid-level] evidence)
- based on 8 systematic reviews of trials without attention control
- parent training programs evaluated were standardized short-term interventions teaching parents specialized strategies
- positive attending
- ignoring
- effective use of rewards and punishments
- token economies
- time outs
- most rigorous review evaluated 16 randomized trials for parents of children aged 3-10 years with "externalizing problems" (such as temper tantrums, aggression, noncompliance)
- all trials compared group-based parent training program with no treatment or wait list control
- Reference - J Fam Pract 2005 Feb;54(2):162
- collaborative problem solving may provide improvements in functioning at 4 months compared with parent training (level 2 [mid-level] evidence)
- other psychosocial treatments with evidence of benefit in randomized trials include
- Anger Coping Therapy
- Problem Solving Skills Training
- Dina Dinosaur Social Emotional and Problem Solving Child Training
- Incredible Years Teacher Training
- Reference - J Fam Pract 2005 Feb;54(2):162
Medications :
- risperidone
- risperidone may be helpful for children with disruptive behavior disorders and subaverage IQ
- based on randomized trial
- 110 children aged 5-12 years with sub-average IQ (35-84) and conduct disorder, oppositional defiant disorder or disruptive behavior not otherwise specified were randomized to risperidone 0.02-0.06 mg/kg/day vs. placebo for 6 weeks
- mean dose 0.98 mg/day (0.033 mg/kg/day)
- statistically significant differences in disruptive behaviors were seen at 1 week and throughout the trial
- risperidone also improved irritability, lethargy/social withdrawal, stereotyped behavior and hyperactivity
- side effects comparing risperidone vs. placebo
- somnolence in 41.5% vs. 14% (NNH 3)
- headache in 17% vs. 7% (NNH 10)
- increased appetite in 15.1% vs. 3.5% (NNH 8)
- hyperprolactinemia in 11.3% vs. 0 (NNH 8)
- Reference - J Am Acad Child Adolesc Psychiatry 2002 Sep;41(9):1026, commentary can be found in J Am Acad Child Adolesc Psychiatry 2005 Jul;44(7):629
- risperidone maintained efficacy for 48 weeks in open-label extension study of 77 patients following this trial; 76 patients had adverse effects including somnolence (52%), headache (38%), and weight gain (36%) (Pediatrics 2002 Sep;110(3):e34), commentary can be found in Pediatrics 2004 Feb;113(2):421
- risperidone maintenance may reduce recurrence rate in children with disruptive behavior disorders responsive to risperidone (level 2 [mid-level] evidence)
- based on randomized trial with allocation concealment not stated
- 572 children aged 5-17 years with disruptive behavior disorders were treated with open-label risperidone for 12 weeks
- initial dose 0.25 mg/day if < 50 kg, or 0.5 mg/day if > 50 kg
- titrated up to 0.75 mg/day if < 50 kg, or up to 1.5 mg/day if > 50 kg
- mean dose 0.02 mg/kg/day
- 335 children who responded to risperidone were randomized to maintenance risperidone vs. placebo
- 214 of these children had oppositional defiant disorder
- comparing risperidone vs. placebo
- symptom recurrence in 27.3% vs. 42.3% (p = 0.02, NNT 7)
- adverse events in 47.7% vs. 36.2% (NNH 8)
- discontinuation due to adverse events in 1.7% vs. 0.6%
- Reference - Am J Psychiatry 2006 Mar;163(3):402 full-text
- stimulants associated with reduction in oppositional/aggression-related behaviors in children with ADHD and ODD/CD
- clonidine may reduce conduct problems in children with ADHD and ODD/CD (level 2 [mid-level] evidence)
- 67 children aged 6-14 years with ADHD and oppositional defiant disorder or conduct disorder who had received psychostimulant for at least 3 months were randomized to clonidine 0.5 mg twice daily (increaesed to 1 mg twice daily after 1 week, but morning dose decreased to 0.5 mg if excessive sedation) vs. placebo for 6 weeks
- stimulants continued
- 57% clonidine vs. 21% placebo group improved by > 37% on conduct scale (NNT 3)
- Reference - J Am Acad Child Adolesc Psychiatry 2003 Aug;42(8):886 in QuickScan Reviews in Fam Pract 2004 Jan 2;29(5):17
Other management :
Prevention :
- 10-year school-level intervention begun in kindgerarten might decrease antisocial behavior in high-risk children (level 2 [mid-level] evidence)
- based on subgroup analysis of cluster-randomized trial
- 891 children (mean age 6.5 years) at high or moderate risk for antisocial behavior were randomized by matched sets of schools to intervention vs. control
- intervention during grades 1-9 consisted of parent behavior-management training, child social-cognitive skills training, reading tutoring, home visiting, mentoring, and universal classroom curriculum
- 142 (16%) children were high-risk (defined as top 3% of normative population), 84% were moderate-risk
- no significant differences in moderate risk group in rates of any psychiatric diagnosis
- rates of any psychiatric diagnosis at grade 3 comparing intervention vs. control in high-risk children
- any psychiatric diagnosis in 38% vs. 53% (p < 0.05, NNT 7)
- oppositional defiant disorder in 14% vs. 31% (p < 0.01, NNT 6)
- conduct disorder in 11% vs. 20% (p < 0.1)
- attention-deficit disorder in 34% vs. 44% (not significant)
- no significant differences in any psychiatric diagnosis at grade 6 in high-risk children
- rates of any psychiatric diagnosis at grade 9 comparing intervention vs. control in high-risk children
- any psychiatric diagnosis in 26% vs. 46% (p < 0.05, NNT 5)
- conduct disorder in 5% vs. 21% (p < 0.05, NNT 7)
- attention-deficit hyperactivity disorder in 16% vs. 34% (p < 0.05, NNT 6)
- oppositional defiant disorder in 16% vs. 28% (not significant)
- Reference - J Am Acad Child Adolesc Psychiatry 2007 Oct;46(10):1250
General references used :
Reviews :
Guidelines :
Patient information :
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