Online Course
NDNP 870 - Diagnosis and Management 1: Differential Diagnosis of Mental Disorders Across the Lifespan
Module 9: Personality Disorders, Oppositional and Conduct Disorders
Pediatric Considerations
DSM 5 lists oppositional defiant disorder and conduct disorder under the classification of Disruptive, Impulse-Control, and Conduct Disorders.
Oppositional Defiant Disorder (ODD) —
- Symptoms appear during pre-school years and rarely later than early adolescence
- ODD does not necessarily mean it will become conduct disorder (CD)
- Risk of developing mood disorders, higher risk of antisocial behaviors, impulse control problems, substance abuse, anxiety
- Differential diagnoses include CD, ADHD, depression, bipolar disorder, and disruptive mood dysregulation disorder
Psychotherapy is the central focus, usually behavioral with parent training. Family therapy may also be effective. Medications are not recommended.
- Develops as early as preschool, but usually between middle childhood through middle adolescence
- ODD is a common precursor to childhood onset CD
- Rare emergence after age 16 and commonly remits by adulthood
- Early onset predict worse prognosis (risk of criminal behavior, substance abuse)
Childhood onset (1 symptom before age 10)
Tim is a six-year-old boy brought to the family medicine clinic for an initial visit. On entering the examination room, the physician observed Tim spinning in circles on the stool while his mother pled, “If I have to tell you one more time to sit down…” Tim was not permitted to begin first grade until his immunizations were updated. His mother explained that Tim had visited several physicians for immunization but was so disruptive that the physicians and nurses always gave up. She hoped that with a new physician, Tim might comply. The mother described a several-year history of aggressive and destructive behavior, as well as four school suspensions during kindergarten. He often becomes “uncontrollable” at home and has broken dishes and furniture. Last year, Tim was playing with the gas stove and started a small fire. Tim frequently pulls the family dog around by its tail. Tim's older sisters watched him in the past but have refused to do so since he threw a can of soup at one of them. Tim's father is a long-haul truck driver who sees Tim every three to four weeks.
Adolescent onset (no symptoms before age 10)
Sharon, a 15-year-old girl, was brought to the office by her mother. Her mother explained that Sharon was suspended from school for assaulting a teacher and needed a “doctor's evaluation” before she could return to class. The history reveals that this is Sharon's 10th school suspension during the past three years. She has previously been suspended for fighting, carrying a knife to school, smoking marijuana and stealing money from other students' lockers. When asked about her behavior at home, Sharon reports that her mother frequently “gets on my nerves” and, at those times, Sharon leaves the house for several days. The family history indicates that Sharon's father was incarcerated for auto theft and assault. Sharon's mother frequently leaves Sharon and her eight-year-old brother unsupervised overnight.
Differential Diagnoses
ADHD - Its features of disinhibition, inattention, and distractibility should be distinguished from lying, serious aggression, and illegal behaviors.
Major Depressive Disorder - children may act out with impulsive violations of rules and aggression, but they would also have sleep disturbances, appetite problems, and affective symptoms
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