Oppositional defiant

ADHD is rarely encountered without comorbid conditions and often is underdiagnosed. Between 40% and 75% of patients with ADHD will have one or more comorbidities (e.g., learning disabilities, oppositional defiant conduct, anxiety, or depressive disorders).10 It is important to identify other coexisting conditions in patients with ADHD to assist in initial and ongoing selection of treatment. 

If the client is an adolescent or child and engaging in antisocial behavior, then comorbid Conduct Disorder should be considered, although such behavior also may indicate an Oppositional-Defiant Disorder if there is little deviant behavior but lots of arguing and defying the wishes of authorities such as parents and teachers. Adult antisocial behavior is difficult to treat but usually involves use of behavior modification (see Chapter 5) through the use of incentives. Conduct Disorder and Oppositional-Defiant Disorder can be successfully treated with behavior modification and by modifying the youth s environment (e.g., using multisystemic therapy or the community reinforcement model — see Chapter 5). 

ADHD, Conduct Disorder, and Oppositional-Defiant Disorder in youth... 

False positive. A signal that a problem exists when in fact it really does not. Oppositional-Defiant Disorder. Adolescent disorder featuring defiance toward authority. 

Other Childhood Disruptive Disorders. The child with ADHD typically avoids schoolwork that taxes his/her attention. Difficulty completing work can quickly become a frustrating experience independent of one s age. A child with ADHD who complains about an assignment in many respects resembles the defiant refusal of a child with oppositional defiant disorder or conduct disorder. These disorders must be carefully distinguished from ADHD, but it is entirely possible that a child with ADHD may also have a comorbid disruptive behavior disorder. 

In early-onset OCD, comorbid psychiatric disorders are present in about 80% of the cases. Major depression is seen in approximately 66% attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or multiple anxiety disorders in 50% and enuresis or speech and language disorders in 33%... 

Approximately three-quarters of children with OCD have comorbid diagnoses. These include tic disorders (24%-30%) and mood disorders, especially major depression (26%-29%). Riddle and colleagues (1990) found that 38% of children with OCD have other anxiety disorders, while Swedo (1989) more specifically identified increased rates of simple phobias (17%), overanxious disorder (16%), and separation anxiety disorder (7%). Other reported comorbidities include specific developmental disabilities, adjustment disorder with depressed mood, oppositional defiant disorder, attention-deficit hyperactivity disorder (ADHD), conduct disorder, and enuresis/encopresis (Swedo et ah, 1989b Riddle et ah, 1990). 

Studies at the National Institutes of Health (NIH) have detailed the clinical characteristics of patients in the PANDAS subgroup (Swedo et al., 1998). The rate of neuropsychiatric comorbidity in this population is quite striking. Twenty of the 50 children (40%) met DSM-IV criteria for ADHD and/or oppositional defiant disorder (ODD), 18 (36%) for major depressive disorder, 14 (28%) for overanxious disorder, and 10 (20%) for separation anxiety disorder. Six children (12%) were enuretic, often episodically and closely correlated with periods of OCD and tic exacerbations. Depressive symptoms, ADHD, and separation anxiety disorder also waxed and waned in concert with the OCD/ tic symptoms. In addition, exacerbations of OCD and tics were accompanied frequently by the acute onset of choreiform movements (clinically distinct from chorea), emotional lability and irritability, tactile/sensory defensiveness, motoric hyperactivity, messy handwriting, and symptoms of separation anxiety (Perlmutter et al., 1998 Becker et al., 2000). 

Barkley, R.A., Edwards, G., Laneri, M., Fletcher, K., and Metevia, I. (2001) Executive functioning, temporal discounting, and sense of time in adolescents with attention-deficit/ hyperactivity disorder (ADEID) and Oppositional-Defiant Disorder (ODD), Abnorm Child Psychol 29 541-556. 

Connor, D.F., Barkley, R.A., and Davis, H.T (2000) A pilot study of methylphenidate, clonidine, or the combination in ADHD comorbid with aggressive oppositional defiant or conduct disorder. Clin Pediatr 39 15-25. 

Oppositional-defiant disorder 1. Parent and teacher 2. Sitter, after-school director, coach, scout leader 1. Parent 2. Teacher 3. Employer, coach 4. Adolescent... 

Greene, R.W. and Doyle, A.E. (1999). Toward a transactional conceptualization of oppositional defiant disorder implications for treatment and assessment. Clin Child Pam Psychol Rev 2 129-148. 

Younger children with manic symptoms tend to have severe functional impairment and comorbid psychopathology such as anxiety dysregulation, disruptive behaviors, and developmental delays that further complicate their clinical picture. In addition, these children may have mood symptoms that merge with other disorders, making manic episodes difficult to define. Irritability is part of the clinical picture of depression, anxiety, attention-deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). Poor concen-... 

Preliminary evidence that this issue is an important one for clinicians derives from post hoc analyses of the double-blind, placebo-controlled paroxetine withdrawal study (Geller et ah, 2001b), in which no strict exclusionary criteria were applied. In that study, 193/ 335 (58%) patients had at least one psychiatric disorder in addition to OCD and 102/335 (30%) had multiple ( 2) other disorders. The response rates in patients with comorbid ADHD, tic disorder, or oppositional defiant disorder (56%, 53%, and 39%, respectively) were significantly less than in patients with OCD only (75%, [ITT LOCF] p < 0.05). Psychiatric comorbidity was also associated with a greater... 

Multiple studies have noted the comorbidity between PTSD and depressive disorders (Goenjian et ah, 1995), as well as between PTSD and externalizing disorders (Cuffe et ah, 1994 Glod and Teicher, 1996). Younger children with PTSD may present with classical features of attention-deficit hyperactivity disorder (ADHD), including hyperactivity, impulsivity, restlessness, irritability, and distractibility (Cuffe et ah, 1994 De Beilis and Putnam, 1994 McLeer et ah, 1994 Loof et al., 1995 De Beilis et ah, 1999). More serious externalizing disorders, such as conduct disorder (CD) and oppositional defiant disorder (ODD), are also commonly comorbid with PTSD (Arroyo and Eth, 1985 Steiner et al., 1997). Similarly, the relationship between PTSD and substance use disorders in children has been noted in several studies (Arroyo and Eth, 1985 Brent et al., 1995 Loof et al., 1995). 

Recently, Janssen Pharmaceutica launched several studies of risperidone in children with borderline IQ or MR and a diagnosis of disruptive behavior disorder (usually oppositional defiant disorder or conduct disorder). To be admissible into the study, subjects needed to be 5 to 12 years old, inclusive, and score above 24 on the Conduct Problem subscale of the Nisonger Child Behavior Rating Form (NCBRF). One 6-week acute trial (n = 118) was conducted in the United States (Aman et al., in press), whereas the other n = 110) was based in Canada (Snyder et al., in press). The findings of the two studies were virtually identical, with... 

Spelz, M.L., Varley, C.K., Peterson, K., and Beilke, R. (1988) Effects of dextroamphetamine and contingency management on a preschooler with ADHD and oppositional defiant disorder. / Am Acad Child Adolesc Psychiatry 27 175—178. 

Children with attention-deficit hyperactivity disorder (ADHD) have high rates of arrests (Satterfield and Schell 1997), comorbid oppositional defiant disorder (ODD), CD, and affective disorders, which increase their risk of aggression (see Fig. 50.1). 

FIGURE 53.1 Cumulative distribution curves of final ADHD scores by treatment group in the MTA Study. The SNAP rating is average score of the 18 items corresponding to the DSMTV defining symptoms for attention-deficit-hyperactivity disorder and oppositional defiant disorder (range 0, not present to 3 very much). Beh, Behavior... 

The criteria for conduct disorder (CD) are less strict in the ICD-10 than in the DSM. In a study of the comorbidity of ADHD and conduct disorder, it was found that only 42% of children diagnosed with ADHD also fulfilled the diagnostic criteria for either oppositional defiant disorder (ODD) or CD, according to the DSM-IV, whereas 71% of the same children fulfilled the ICD-10 criteria for CD (Dalsgaard et ah, 2001). The ICD-10 retains the distinction socialized/ unsocialized, while the DSM-IV has moved to a distinction based on age of onset, childhood/adolescent, for conduct disorders. 

A trial published by Gillberg et al. (1997) comprised 62 children (52 males, 10 females), aged 6 11 years and meeting DSM-HI-R criteria for ADHD. The children suffered from severe attention deficits and 42% had comorbid diagnoses including mild mental retardation, autistic features, oppositional defiant disorder and tic disorder. They were included in a parallel-group, randomized, double-blind, place bo-cont ro 1 led study of amphetamine treatment. 

Clinical outcomes before, during and after treatments were assessed in six multiple domains represented by 19 separate measures. The domains were ADHD symptoms aggression-oppositional defiant disorder internalizing symptoms social skills parent child relations and cognitive performance (measured with three subscales of the Wechsler Individual Achievement test readmg, mathematics, spelling). 

Running on Ritalin, testified in front of the U.S. Department of Justice in Washington, D.C. There is no question in my mind that Tom Sawyer and Huck Finn, in many Contra Costa (California) schools, would be carrying the diagnoses of ADHD and oppositional defiant disorder, and put on at least one medication, if not two. 9... 

Along with conduct disorder and oppositional defiant disorder, ADHD was originally considered one of the disruptive behavior disorders in the DSM-III-R (APA, 1987). In the DSM-IV, an attempt is made to separate ADHD from the other two disruptive disorders, at least when ADHD manifests itself primarily as inattention, rather than hyperactivity. The DSM committee found that while disruptive behavior and attention problems often occur together, some ADHD children are not hyperactive and disruptive (Fasnacht, 1993). 

Certain individuals may even leam to turn childhood deficits such as excessive sensitivity (separation anxiety), unrelenting stubbornness (oppositional defiant disorder), or uncontrolled activity and enthusiasm (attention deficit hyperactivity disorder) into strengths in adulthood, (p. 2)... 

As monotherapy or in combination with methylphenidate for ADHD with conduct disorder or oppositional defiant disorder, may improve aggression, oppositional, and conduct disorder symptoms... 

Highly comorbid—oppositional defiant disorder and conduct disorder most common. 1 Only a small proportion of those with ADHD are identified, diagnosed and treated. 

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