¶ Oppositional Defiant and Conduct Disorders
Hello , dear therapist , and welcome to our licensure exam podcast . I'm Dr Linton Hutchinson and I'm with my co-host , stacey Froth . Today , in this episode of Demystifying Disorders , we'll be talking about two commonly confused disorders Oppositional Defiant Disorder and Conduct Disorder .
That's right . Both of these disorders involve problems with emotional and behavioral regulation , which tend to affect kids and teenagers . It's actually very rare for these disorders to spontaneously emerge in adulthood .
Some key differences between Oppositional Defiant Disorder and Conduct Disorder are important for you as therapists to understand , especially as you're studying for your licensuring exam .
Let's start by reviewing each disorder's diagnostic criteria as laid out in the DSM-5-TR . Stacey want to walk us through Oppositional Defiant Disorder first .
Sure . So according to the DSM-5-TR , the standard criteria for Oppositional Defiant Disorder , also called ODD , state that symptoms must be present for at least six months , and the symptoms of ODD are grouped into three categories . Number one is anger and irritability . This includes losing temper , easily annoyed and being angry and resentful .
The second category is argumentative or defiant behavior . For example , the client argues with authority figures , refuses to follow the rules , deliberately annoys others and blames others for their own mistakes and bad behavior .
And the third category is vindictiveness , and this is the tendency to want to harm , get revenge on or see someone suffer who you think is wrong to . An underlying driving force is usually feelings of resentment and bitterness . So , linton , this got me to thinking .
When you gave Wes , our IT guru , a piece of bread with wasabi on it and told him it was avocado toast , would that be considered vindictiveness ?
Stacey , I can even think that . No , it wasn't . That was just payback for when he told me he had erased all the site's contents and didn't have a backup . Talk about giving me a heart attack .
Well , I'm not sure the punishment completely fits the crime there , linton , but that seems a little close to the edge . Now , anger and irritability are normal human emotions , but vindictiveness is on another level . So how can you differentiate the kind of anger and irritability you'd see with ODD from normal anger and irritability ?
Well , the key here is to look at three dimensions the frequency , the intensity and duration of anger and irritability . With ODD , the child or teenagers will show frequent and persistent irritability or anger that is noticeably more severe than peers of their own age .
This includes losing their temper regularly , being easily annoyed or angered by minor things , and having frequent angry outbursts or tantrums . The irritability and outbursts also tend to last for extended periods of time rather than being just the occasional or episodic .
Okay , well , that makes sense . What about argumentative behavior ? This seems like another , you know , one of those normal behaviors that we humans engage in from time to time , therapists excluded , of course .
Of course , argumentative and defiant behavior in ODD includes often arguing or refusing to comply with rules or instructions from authority figures like parents or teachers . The client may deliberately do things that will annoy others or you and actively defy requests . The key is that these behaviors occur persistently over time and exceed what's developmentally normal .
Okay , now , that last category we mentioned , vindictiveness , leads me to a question . I hate to admit it , linton , but there are times when my justice side gets the better half of me and comes out to play . You know , it's those times when things aren't fair and you want to see some kind of retribution against the person who wronged you .
In fact there's even a German word for it , if you believe it or not .
It's a justice-based Schadenfreude . Because they're in time . It's understandable to feel some satisfaction as Stacy or Schadenfreude . Is that right ? Yeah , I think you got it pretty close Okay when someone behaving badly receives punishment or consequences , feeling that justice has been served can elicit a sense of pleasure or relief .
But with ODD , the desire for revenge goes beyond just wanting to see fair justice or penalties given out . Instead , it becomes an obsessive , disproportionate spitefulness that leads the child or teenager to actively seek revenge in excessive ways that cause more harm than good .
They become really preoccupied with getting back at or hurting the person they believe wronged them , even if the retaliation is an overreaction to the situation . Okay , makes sense . So if I'm at Publix and they won't give me my Bogo sushi on Wednesday ? and I accidentally drop a carton of eggs on the floor ? Would that be considered vindictive ?
Oh , Linton , what did you do that they wouldn't give you Bogo sushi ?
Well , Stacey , as it turns out , I got mixed up and it was actually Thursday .
Oh , Linton , that is so wrong on so many levels . But yes , your accidental dropping of eggs is excessive and an overreaction to the situation . Are you sure it was an accident ?
Well , I'm not sure , but I do remember a feeling of satisfaction and justice was served .
Okay . So feeling a sense of justice being served can be normal , but with a client with ODD , for example , the vindictiveness goes too far . They get obsessed with getting revenge in ways that go way overboard .
So here's a good example If a classmate bumps into a kid with ODD at school , the kid with ODD might wait days or weeks to get back at that person , like destroying their homework or stealing their backpack , even though you know they just bumped into them on an accident .
Right .
Or let's say a teacher admonishes a child with oppositional defiant disorder . A few days later that child might take the teacher's car keys and hide them .
Well , I guess I'm out of the woods , Stacey , given those examples . I mean , the whole thing happened just because I mixed up what day it was .
I think you've missed the point here , Linton .
Okay , I'll just have to take your word for it , because next let's change the subject . Let's talk about duration , okay , okay , for a diagnosis of ODD , these behaviors must lead to significant impairment in social or educational functioning , occurring for at least how long Six months and fall outside the normal limits for the child's developmental level .
Gotcha Okay . So this basically rules out that you know run-of-the-mill sibling rivalry .
Right , right yeah .
And there are also severity specifiers for ODD . Mild is if the angry , irritable mood , argumentative , defiant behavior and vindictiveness are isolated to just one setting , like only happening at school or only happening at home . Moderate is it if the symptoms are present in at least two settings . And severe is it the symptoms are present in three or more settings .
That's strange . Usually , severity specifiers are based on how many symptoms the client exhibits , not the setting where the symptoms occur and other diagnoses .
So you have been listening , linton , when I would talk about specifiers . Well , that's a great observation . With ODD , basing the severity specifier on the number of settings with symptoms helps to highlight the scope of functional impairment for the child .
Symptoms that appear across multiple settings , like at home , also at school and with peers , indicates a more serious impairment . And the more areas of a child's life that are impacted by those ODD behaviors , the worse the prognosis . Without effective treatment and catching ODD early on , before it generalizes , can improve outcomes .
Of course you know it's important to consider the child's or the client's age when making this diagnosis , so you can determine whether the frequency and intensity of the behaviors fall within normal limits for the child's developmental levels .
Right you are . Is there an age limit on diagnosing ODD Linton ?
I wish there was .
Make things simple , very , you know , neat and tidy .
It would , but there's no age limit in the diagnostic criteria , although it's very rare for symptoms to first emerge in adulthood . You might see an adult who was not properly diagnosed or treated for ODD in childhood and their symptoms had persisted into adulthood .
Okay , that makes sense . So we've gone over the detailed list of diagnostic features , but the big picture really is that children with ODD struggle to manage their emotions in an age appropriate manner . When they get upset or frustrated , their reactions tend to be disproportionate to the situation and difficult for them to control .
Their coping skills are really underdeveloped . They lack an age appropriate ability to self soothe , distract themselves or problem solve when they're confronted with disappointment . So , Linton , how are we going to remember the features of oppositional defiant disorder ?
Well , I just happened to have a memory device for that Stacy .
Why aren't I surprised ?
Clients with ODD are Bratz .
What the heck .
A Annoying R Resentful . E Easily annoyed . That's R Bratz . B Blames others . R Rulebreaker . A Argue with authorities . T Tempor and S Spiteful or vindictive . So you can see how ODD clients are Bratz . If in a case study you see the client exhibiting those are Bratz behaviors , you should be thinking ODD .
Okay , I see what you did there .
Yeah , well , now let's switch gears and talk about conduct disorder .
According to the DSM-5TR , the diagnostic criteria for conduct disorder include the following A repetitive and persistent pattern of behavior in which the basic rights of others or major age , appropriate societal norms or rules are violated , as manifested by the presence of at least three of 15 criteria in the last how long 12 months with at least one criterion present in
the last six months .
Jeez . This is a lot of numbers to remember .
Yeah , it is .
I'm gonna throw another one at you
¶ Understanding Conduct Disorder
too .
There are four main categories of symptoms , so those 15 criteria are divided up into four categories of symptoms , and those categories are aggression to people and animals , destruction of property , deceitfulness or theft , and serious violation of rules , and we'll talk about the specific behaviors that go along with these categories , starting with aggression to people and
animals . What does this include , linton ?
Well bullying , threatening , intimidating others , initiating physical fights , using a weapon to cause physical harm , physical cruelty to people or animals , stealing while confronting the victim like a mugging or an armed robbery , and forced sexual activity .
Okay , and second , destruction of property .
Examples of destruction of property would be deliberately starting a fire to cause damage and destroying other people's property . I don't know if I told you this , but I did accidentally set the baseball field on fire when I was a kid , but I finally stomped it out . And there was this time when I accidentally set the back porch on fire .
Okay , I know , but it was only because I was practicing to get my Cub Scout fire Sanji badge .
Okay , well , you barely get a pass on both of those Linton .
Oh good .
Oh , geez , okay . So the third category is theft or deceitfulness .
Okay , this covers lying to obtain goods , conning others and stealing items of non trivial value without confronting the victim , like forgery or shoplifting . Speaking of Stacy , tell me when you were little , did you never lifted , nicked , swiped , boosted ? Take a five finger discount when you were young ?
Well , let me think about that for a minute . I must have Okay . Well , there was this one time my mom sent me to the grocery store at Albert Sins Do you ? Do they still even have those stores ? I don't know .
And after I checked out and got home , I realized they didn't charge me for the pack of big red chewing gum that I put in my jacket pocket to keep it from falling through the holes in the shopping cart .
Sure .
And I yeah , it's true , and I never went back to pay for it . I think I just forgot .
I suppose when you got home you gave your mom the correct change right .
Of course I did . I'm not a criminal . And for the fourth and final category of conduct , disorder symptoms serious rule breaking . What does that entail , Linton ?
Well , this includes staying out past curfew , starting before the teenage years , like you never did , stacy . Running away from home overnight at least two times , or running away from home for a long period of time at least one time . And school truancy also is part of that .
Wow , well , that's pretty specific , especially those details about the running away from home .
But what ?
about if the client is running away from home because they're being physically or sexually abused .
Okay , obviously you know that's an exception . If that's , the reason they're running away from home is to escape any kind of abuse . That doesn't qualify as criteria .
Okay , and just on the hunch , linton , you , I'm guessing , have a way of remembering the behaviors associated with conduct disorder .
Funny . You should mention that Stacy Wait a minute . Is this some kind of trap ?
What do you mean ?
Trap T that's her deceit R Rule breaking A Aggression P , property destruction Trap . So if you see these behaviors in a case study , you should be thinking what Stacy .
Conduct disorder . Sneaky Linton , sneaky , sneaky . All right , how about a duration ? How long does the client need to demonstrate symptoms before you can make a diagnosis of conduct disorder ?
In the past 12 months . The client has to exhibit at least three of the 15 specific behaviors we just covered , and at least one of the behaviors must be present in the past six months .
Okay , so the duration is one of the keys that can help you distinguish conduct disorder from another disorder that could look similar Adjustment disorder with mixed disturbance of emotions and conduct .
I hate to ask you this Stacey , but are there any specifiers for conduct disorder ? I ?
thought you'd never ask Clinton . Yes , there are , and it's actually a really long list of specifiers for conduct disorders . So we suggest that , as you're studying for your exam , you take a few minutes to brush up on those specifiers and you can find them in the DSM-5TR at the end of the diagnostic criteria list for conduct disorder .
The specifiers relate to the age of onset , interpersonal and emotional functioning and , of course , the severity of conduct problems .
You're not copping out here , are you Stacey ?
No , are you ?
Okay , okay , so we've laid the foundation for ODD and conduct disorder . How are these two diagnoses similar ?
Well , both tend to appear during childhood , both involve problems with emotional and behavioral regulation Right and both bring the client into some sort of conflict with adults and authority figures .
Okay , so if I'm doing a case study , I might be able to find both of those behaviors for conduct disorder and ODD right .
Exactly , there's some overlap there , for sure .
Okay , so I guess how you're going to differentiate , that is , by figuring out what the key differences are .
Yeah , and one of the defining differences between the two is all about control . So children or teens who have oppositional defiant disorder fight against being controlled through the use of angry outbursts , irritability and defying their parents or their teachers' instructions .
So you tend to see a lot of verbal hostility like arguing , losing their temper or blaming other people . So children or teens with conduct disorder , on the other hand , not only do they fight against being controlled , they take it a step further and they try to control others by using aggression or intimidation tactics and manipulating people to do what they want .
The behaviors associated with conduct disorder can really be downright scary physically hurting people or animals , threatening people , destroying property think like arson or keying someone's car and stealing . And the best way that I've heard it described is that parents of children with oppositional defiant disorder feel frustrated , angry , discouraged and sad .
Parents of children with conduct disorder feel fear . So they may actually be afraid to live in their own home with their child because they aren't sure of what they're going to do that child . You know they may be worried they're going to hurt them , hurt another family member , destroy the house . You know it's kind of like a wild card .
That's a really good way to just look at something and determine if it's ODD or CD , isn't it ? So let's take a brief case study right now so everyone can understand the differences between ODD and CD . Okay , All ?
right , sounds good , take it away .
Okay , here we go . Liz's parents describe her frequent temper outburst at home , where she yells , screams , cries and slams doors when she does not get her way . Recently , when her parents refused to let Liz play Minecraft on a school night , liz screamed I hate you . And stormed out of the room , slamming the door forcefully behind her .
At school , liz often refuses to comply with classroom rules . Despite reminders and consequences , she continues to get out of her seat without permission , calls out in class instead of raising her hand and talks to classmates during quiet work time . When she's reprimanded by her teacher , liz argues and talks .
Back Yesterday , when the teacher asked Liz to stop chatting with a peer , liz responded that's so stupid . You never let us talk and she just continued her conversation . Last week , liz purposely threw paper clips at a classmate sitting next to her , even after he asked her to stop .
When the teacher intervened , liz lied and claimed that the other student flicked paper clips at her first . When Liz was not invited to a classmate's birthday party last month , she retaliated by excluding the classmate from games at recess . All right , from that case study , which disorder fits Liz's symptoms ? The best ? Oppositional Defiant Disorder ?
Or Conduct Disorder , music All right , what is oppositional defiant disorder ?
¶ Oppositional Defiant and Conduct Disorders
That is correct , and why is that ?
All right . Well , there seems to be a pattern of angry outbursts . So Liz , for example , losing her cookies when her parents tell her that she can't play Minecraft on a school night . We've got defiant behavior towards authority figures . You know she's not following the rules at school .
She's talking back to her teacher and there's this intent to aggravate or annoy peers . For example , the paper clip episode with her classmate . Right right and to really drive it home .
If I were to put myself in Liz's parents shoes , I don't think I'd be feeling fear so much , but more like maybe exasperation , probably some anger at her inability to follow the rules .
You got it . How about a quick summary before we sign off for today ?
Sure Oppositional Defiant Disorder involves problems regulating emotions , including frequent angry outbursts , irritability and defiant behavior toward authority figures . The behaviors occur persistently for at least six months .
Fundex disorder involves violating rules and the rights of others through aggression , destruction of property , deceitfulness or theft , and serious rule violations . At least three specific behaviors must have occurred in the last 12 months , and one of those behaviors must be present in the last six months .
While both disorders involve emotional and behavioral dysregulation and conflict with authority figures , oppositional defiant disorder is characterized more by verbal hostility and a defiant attitude . Conduct disorder involves actively trying to control or harm others through more severe behaviors .
Oppositional defiant is often frustrating for parents or caregivers , while conduct disorder tends to elicit fear .
All right , that's another pair of disorders , demystified . Until we meet again . Remember , it's in there , it's in there .