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1. OPPOSITIONAL DEFIANT DISORDER
&
CONDUCT DISORDER
Moderator: Dr. P. Krishna Mohan Sir
Professor & HOD
presenter: Dr. P. Roshini

2. CONTENTS
• DEFINITION
• DIAGNOSIS
• EPIDEMIOLOGY
• ETIOLOGY
• COURSE AND PROGNSIS
• DIFFERENTIAL DIAGNOSIS
• MANAGEMENT

3. Oppositional defiant disorder (ODD)
Definition:
A frequent and persisting pattern of angry/irritable mood,
argumentative/defiant behavior, or vindictiveness that is clearly more frequent,
more intense, and more persistent across the child’s development than is typically
observed in individuals of similar age and developmental level.

4. Epidemiology
• Prevalence 1% to 11%, with an average of 3.3%.
• May vary depending on the age and gender of the child M:F ratio(1.4:1) prior to
adolescence.
• Prevalence of disruptive behavior disorders varies according to age, gender,
socioeconomic status, neighborhood, and degree of urbanicity.
• More prevalent among children and adolescents from families of LSES

5. Etiology
• BIOLOGICAL:
• Neurobiological markers:- lower heart rate and skin conductance reactivity to
environmental stimuli, reduced basal cortisol reactivity, and abnormalities in
prefrontal cortex and amygdala are also correlated with ODD.
• ‘Difficult' temperament:- impulsivity, short attention span and restlessness
together with the trait of negative emotionality.
• Social anxiety on the other hand is protective.

6. • PSYCHOLOGICAL FACTORS:
• ODD has been linked to the presence of anxious-avoidant attachment.
• Aggressive children have shown deficient information processing with regard to
social stimuli as described by Kenneth Dodge.
• They underutilize social clues, misattribute hostile intent, generate fewer
solutions to problems, and expect to be rewarded for aggressive responses.

7. Family characteristics
• Parent–child interaction patterns:
• These children- ignored when they are behaving reasonably, but criticized and
shouted at when they are misbehaving.
• Therefore children will behave in whatever way necessary to gain attention as
stated by the attention rule', even though the attention given is negative.
• This leads to a vicious cycle further worsening the behavior.
• Parenting practices:
strongly associated with harsh, erratic, inconsistent discipline, hostility
directed at the child, lack of warmth, and poor supervision.

8. Parental factors that influence parenting include the following:
• Marital Discord
• Mental Illness in parent
• Social Isolation
• Poor socioeconomic status
• Poor parenting experiences as children
• Beliefs about one particular child

9. Risk factors in Family environment
1. Childrearing practices – problems in “goodness of fit” between temperament and
parenting
2. Inconsistent, inadequate, ineffective disciplining patterns
3. Inappropriate reinforcing patterns
4. Lack of adequate supervision
5. Punitive parenting
6. Parental discord – child as the presenting symptom of parental or family discord
7. Inconsistencies due to multiple parenting figures - grandparents vs parents
8. Special position of the child
9. Parental beliefs about the child
10. Sibling rivalry

10. Diagnostic criteria – DSM5
• 4/8 symptoms lasting at least 6 months in either of 3 categories
1) Angry/Irritable Mood- 1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
2) Argumentative/Defiant Behavior
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with
rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
3) Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.

11. B. The disturbance in behavior is associated with distress in the individual or others
in his or her immediate social context, or it impacts negatively on social,
educational, occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic,
substance use, depressive, or bipolar disorder.
• Also, the criteria are not met for disruptive mood dysregulation disorder.

12. PROGNOSIS

14. Differential diagnosis
1. ADHD: No pattern of violation of rights of others seen.
2. Mood Disorder: Depression can + with irritability & oppositional symptoms but unlike
typical ODD/CD, mood is usually clearly low and there are often vegetative features
3. Adjustment Reaction: symptoms shouldn’t persist for >6 mon after cessation of stress
4. ASD: unlike children with ODD/CD who have callous-unemotional traits, children with
ASD fail to understand social situations and judge accurately the emotions of others
5. ASPD: cannot be diagnosed under 18, although it requires evidence of conduct
disorder before the age of 15 years.
6. Subcultural Deviance: Some youths are antisocial and commit crimes but are not
particularly aggressive or defiant

15. General principles of treatment of ODD
1. AIM: To increase compliance, make the child more cooperative and better accepted.
2. Structured psychosocial intervention is the only effective treatment available.
3. Treatment- both parents; improving parenting skills and parent-child interactions
4. Comorbid conditions (ADHD, depression) are to be identified and treated.
5. Parental depression, psychosis, substance abuse, marital discord needs to be explored
6. Imp to build on children's and families' strength in addition to focusing their problems.
7. De-stressing the family should be a necessary initial step.
8. Impairment in other aspects of functioning- learning difficulties- effectively intervened.
If necessary school system needs to be involved to the extent that is required for the given
child‟s problem

16. Parent management training (PMT)
• Parents are trained to alter their child's behavior at home.
• Based on parent–child interaction, social learning theories and behavioral principles.
• Approach to PMT:
1: Promoting a child-centered approach
2: Increasing acceptable child behavior - Positive reinforcement of desired behavior
- Reward charting
3: Setting clear expectations- Making demands more authoritative, less nagging
- Focus on what child should be doing, not what the parent doesn’t want the child to do
- When-then Commands are better than threat

17. 4: Reducing unacceptable behavior
Consequences for disobedience, Ignore negative behavior, Time out from
positive reinforcement
5: Strategies for avoiding trouble
Planning ahead to avoid potential situations
Negotiating to incorporate child’s wishes if reasonable
6: identifying and rectifying long-standing maladaptive patterns

18. Child therapies
• Cognitive-behavioral therapies and social skills therapies for ODD/CD typically aim to
1. Reduce children’s aggressive behavior such as shouting, pushing and arguing
2. Increase prosocial interactions such as entering a group, starting a conversation,
participating in group activities, sharing, cooperating, asking questions politely,
listening, and negotiating;
3. Correct the cognitive deficiencies, distortions and inaccurate self-evaluation
4. Ameliorate emotional regulation and self-control problems so as to reduce
emotional lability, impulsivity, and explosiveness, enabling the child to be more
reflective and able to consider how best to respond in provoking situation

19. Conduct disorder
• DEFINITION :
A repetitive and persistent pattern of violating basic rights of others or age-
appropriate societal norms or rules, including:
– aggression to people and animals (e.g., bullying, threatening, fighting, using a
weapon)
– destruction of property (e.g., deliberate fire setting)
– deceitfulness or theft (e.g., “conning” others, shoplifting, breaking into others’
property)
– serious violations of rules (e.g., running away, truancy, staying out at night
without permission)

20. EPIDEMIOLOGY
• One-year population prevalence estimates range from 2% to > 10%, median of 4%.
• Lifetime prevalence of conduct disorder is associated with younger age, male
gender, and low educational attainment, being separated or divorced as an adult,
and residing in urban settings.
• CD is more prevalent among youths from families living in poverty and of LSES.
• Prevalence- higher in urban, inner-city neighbourhoods as compared with rural.
• Early onset conduct disorder- associated with the worst prognosis may be
concentrated in the most disadvantaged, high-risk, inner-city communities.

21. Etiology
 Individual level
 Genotypes- MAO-A promoter polymorphism
 Perinatal complications- Alcoholism in pregnancy
 Temperament- “callous” , “unemotional”
 Neurobiology- Volumetric changes in pre frontal cortex.
 Neuro transmitters- Low CSF serotonin levels is liked with aggression in children.
 Verbal deficits – increased deficits in language-based verbal skills .
 Executive dysfunction- executive deficits linked to disruptive behaviors in preschool
 Information processing & social cognition- children who prone to aggression focus on
threatening aspects of others actions, interpret hostile intent in the neutral actions of
others, and are more likely to favour aggressive solution to social challenges

22. Risks within family
• Genetic liability - family genetic liability +
environmental risks
• Low income- family economic stress was associated
with adolescent conduct problems, but this was
mediated via parental depression, marital conflict
and parental hostility
• Parent child attachment
• Discipline and parenting - hostile, critical, punitive
and coercive parenting
• Exposure to adult marital conflict and domestic
violence
• Maltreatment
Risks outside family
• Bad Neighborhood
• Poor Peer relationships

23. DIAGNOSIS
• Assessment must involve multiple informants including parents and the youngster.
• The use of rating scales to document the severity and pervasiveness of conduct
disorder symptoms.
• Presence of comorbid psychiatric conditions such as ADHD, depression, bipolar
disorder, substance-use disorders, developmental delay, learning disabilities, or
psychotic disorders that frequently accompany a diagnosis of conduct disorder.

24. ICD-10 DSM-V
At least one symptom in last 6
months.
Presence of at least 3/15 in the past 12 months
from any of the categories , with at least 1
criterion present in the past 6 months
Defiant provocative behaviour Four categories.
1.Agression to people and animals
2. Destruction of property
3.Deceitfullness or theft
4.Serious violation of rules
Persistent severe disobedience

25. Aggression to People and Animals
ICD-10 DSM-V
Excessive levels of fighting or
bullying
Often bullies, threatens, or
intimidates others.
Often initiates physical fights.
Has used a weapon
Cruelty to animals or other people Has been physically cruel to people
Has forced someone into sexual
activity
Has been physically cruel to animals.

26. Destruction of Property
ICD-10 DSM-V
Fire setting Deliberately engaged in fire setting
Severe destructiveness to property Has deliberately destroyed others’ property
(other than by fire setting).
Deceitfulness or Theft
ICD-10 DSM-V
Has broken into someone else house,building/ car.
Often lies to obtain goods or favors or to avoid
obligations
Stealing Has stolen items of nontrivial value

27. Serious Violations of Rules
ICD-10 DSM-V
Often stays out at night despite parental
prohibitions, beginning before age 13 years.
Running away from home Has run away from home overnight at least
twice
Truancy from school Is often truant from school, beginning before
age 13 years

28. Childhood-onset conduct
disorder,
• Onset before 10 years
• Display physical aggression
toward others
• Disturbed peer relationships,
• More likely to have persistent
conduct disorder into
adulthood.
• Males>females
Adolescent-onset conduct
disorder
• Symptoms not seen until 10
years.
• Less likely to display
aggressive behaviors
• More normative peer
relationships
• Less likely to have conduct
disorder that persists into
adulthood.
• The ratio of males to females
with conduct disorder is more
balanced

29. SEVERITY
• Mild: Few if any conduct problems are in excess of those required to make the
diagnosis, and conduct problems cause only minor harm to others;
• Moderate: The number of conduct problems and the effects on others are
intermediate between “mild and severe”;
• Severe: There are many conduct problems in excess of those required to make the
diagnosis, or the conduct problems cause considerable harm to others—e.g., severe
physical injury, vandalism, or theft.

30. Examination
• Those meeting diagnostic criteria for the disorder merit a complete physical
examination to rule out associated physical trauma associated with a high-risk lifestyle.
• Particular attention should be paid to the possibility of drug abuse and risk for sexually
transmitted diseases.
• In females with CD, early onset sexual activity may lead possibility of early pregnancy.
• Because of the association with learning disabilities, the presence of academic
difficulties requires psychoeducational testing in youngsters with conduct disorder.

31. DIFFERENTIAL DIAGNOSIS
Diagnosis Distinguishing features
ADHD No pattern of violation of rights of others.
Adjustment reaction Resolves within six months of elimination of stressors
Oppositional defiant disorder Pattern of opposition to adults but not violation of rights of
others.
Disruptive mood dysregulation
disorder
Aggression maybe a part of temper outbursts. Primary
pattern is irritability rather than violation of rights.
Major depressive disorder or persistent
depressive disorder
Primary symptom is typically depressed mood.

32. Course And Prognosis
• early onset <8 yrs - half persist with serious problems into adulthood.
• Adolescent onset- over 85% there is desist in their antisocial behaviour by their early
twenties.

34. TREATMENT
• Primary prevention- gold standard in conduct disorder intervention.
• Successful programs typically include
1. Multimodal interventions that simultaneously target the child and family, parent
supports, teacher involvement, and early childhood education
2. Intensive interventions generally delivered on a daily to weekly basis.
3. Sufficient duration of intervention, generally 2 to 5 years or longer
4. Specific interventions- effective in ameliorating known psychosocial mechanisms that
increase risk for conduct problems
e.g., coercive family process, harsh and inconsistent parental discipline

35. 5. Child and parent interventions- skill building, problem solving, and coping skills
6. Interventions that begin early in a child's life (< 6 years old)
7. Individual case management
8. Intensive collaboration among community, juvenile justice, school, family, and
mental health professionals.
• PMT - teaches consistent parenting, positive and less harsh discipline practices,
monitoring of the child, and positive feedback for the child.
• Parent-training programs appear effective in decreasing young children's
oppositional, defiant, noncompliant, and aggressive behaviors.
• Functional family therapy- 4 phases: Engagement, Motivation, Behavioral change,
Generalization

36. • Skills training approaches focus on the individual child.
• Emphasize social skills, problem-solving techniques, and anger management
strategies in reducing child aggression and conduct problems
• Individual therapy approaches based on principles of cognitive-behavioral therapy.
• Multifocused psychosocial programs- combine parent management training,
structural family therapies, and child skill-building treatments.
• Multi-Systemic Treatment (MST) and Multidimensional Treatment Foster Care
(MTFC)- To treat older children & adolescents with established antisocial and
aggressive behavior patterns necessitating juvenile justice involvement.

37. • A variety of psychoeducational, community, and mental health services delivered
simultaneously to the adolescent and their family.
• Pharmacological treatments generally do not focus on conduct disorder per se but
on associated impulsivity, affective lability, on negative emotions that may drive CD
symptom frequency and severity
• Typical and atypical antipsychotics, mood stabilizers, and lithium moderately
effective in treatment of explosive aggression in youngsters with CD.
• When antisocial symptoms arise in the context of ongoing ADHD, studies support
the effectiveness of stimulants.

38. SUMMARY
• ODD is distinct from ADHD and CD
• Significant risk factor for CD, which is more serious disorder.
• ODD by and large develops in relation to child’s response to authority figures such as parents, though there
are other risk factors such as difficult temperament.
• Evaluation of children with suspected ODD should focus not only on establishing the diagnosis, but also on
comorbidities and on mapping all the predisposing, precipitating, and maintaining factors.
• This will serve as good base for planning intervention, which is mostly psycho-social in nature.
• PMT is the most effective approach to management, and there is reason to believe that the effects may last
beyond the period of intervention.
• Child focused therapy such as cognitive behavior therapy is more applicable to older children and adolescents.
• Family therapy and school-based interventions are other forms of therapy that are employed whenever
needed.
• Medications have a role only if there are comorbidities that need pharmacological intervention.

39. OPPOSITIONAL DEFIANT DISORDER CONDUCT DISORDER
Diagnostic Criteria • Angry or irritable mood, argumentative or
defiant, and vindictiveness.
• aggression, destruction, deceitfulness or
theft, and serious violations.
Physical Violence • Less violence- deals with upset moods,
nonconformity, and spitefulness.
• More violence- physical fights, mugging,
rape, and arson
Duration of
Symptoms
• symptoms of ODD must last for atleast 6
months
• last for atleast 12 mon with at least 1
criterion being met * past 6 mon.
Severity • mild - confined to a certain setting,
• Moderate- 2 settings,
• severe - at least 3 settings.
• according to the frequency and extent of
conduct problems
Subtypes • no specified subtypes. • 3 subtypes: childhood, adolescent and
unspecified-onset type
Temperamental Risk
Factors
• high emotional reactivity levels, low
frustration tolerance levels, and other
emotional regulation dimensions.
• pertinent elements are difficult and
uncontrolled infant temperament as well
as a below average IQ
Prosocial Emotions • No specifier • lack of remorse or guilt, being callous or
lack of empathy, unconcerned regarding
performance, and shallow affect.

40. REFERENCES
• Sadock, B.J., Kaplan, H. I., & Sadock, V.A. Kaplan And Sadock’s Comprehensive
Texbook of Psychiatry. 10th ed. Philadelphia:Wolter Kluwer/Lippincott Williams &
Wilkins.
• Thapar A, Pine DS, Leckman JF, Scott S, Snowling MJ, Taylor EA, editors. Rutter's
child and adolescent psychiatry. John Wiley & Sons; 2017 Dec 26.
• Rey JM, Martin A. JM Rey’s IACAPAP e-textbook of child and adolescent mental
health. Lancet. 2006 Jan 28.