Patient Presentation
A 3-year-old female came to clinic for help with increased aggressiveness. She previously had been a difficult infant with persistent crying and difficulty with sleeping. Her parents do not remember a night where she did not refuse to go to bed, with multiple awakenings and crying all night. They had truly tried multiple behavior management plans under the direction of a child mental health social worker. She eventually would sleep someplace in the house. In the past 2-3 months, she had become more verbally aggressive to the family and child care providers. She would take away items from a child or adult who was using the items, and would throw items at other children trying to provoke reprimands. She had been observed to wait until an adult was watching and then deliberately make messes by tipping over plants, garbage or pulling items off shelving. She would easily become upset when she didn’t get her way and had temper tantrums that were difficult for her to calm down from. The church daycare had told the family that they could not have her participate in their program. The family history was significant for heart disease, depression, and a paternal cousin has been in jail because of “anger problems.” The review of systems was negative. The social history showed no changes in family living, jobs, stress, or depression. Family denies concerns for possible abuse.
The pertinent physical exam showed a well-appearing female with normal growth parameters. She actively pulled books off the shelf in the examination room and initially verbally refused the mother and physician. She looked at the examiner with great anger but refused to talk during the examination which was normal. The diagnosis of a child with escalating oppositional and defiant behaviors was made. A referral was made to a psychiatrist. The physician suggested that the family try to ignore the irritating utterances and behaviors as much as possible, but that behaviors that were a threat to herself or her parents needed to be addressed. They made a safety plan for her and her parents including ways to appropriately restrain her if needed. If the family felt they could not keep her safe or were feeling physically threatened by her, they were to take her to the local emergency room for evaluation.
Discussion
Oppositional defiant disorder (ODD) is a disruptive behavior with elements of defiance, disobedience, negativism and hostility to authority. Depending on the classification system, ODD may be a precursor to, or subtype of conduct disorder as they both share characteristics. The DSM IV criteria can be found here. ODD can be diagnosed alone or is also associated with other disorders such as ADHD, depression, and anxiety. Children are often not diagnosed with ODD until school age, but data supports temperamental antecedents even in early infancy, including exhibiting extreme emotions and activity consistent with ODD but at an earlier developmental level.
Learning Point
Children with ODD may or may not have abatement of symptoms as they get older. One 5-year longitudinal study of children with preschool onset of ODD found that “there was a significant relationship between the presence of a … diagnosis of ODD [at the initial time period] with later continued diagnosis of ODD….younger children were more likely to have ODD subsequently.” A literature review of the developmental origin of disruptive behavior summarized the current literature about ODD by saying “… a) the vast majority of preschool children manifest these [ODD] behaviours; b) the vast majority also learn with age to use other means of solving problems; c) some need more time than others to learn; d) there does not appear to be substantial differences between females and males; e) approximately 7% of children could be considered chronic cases from childhood to adolescence;….”
Questions for Further Discussion
1. What is the DSM IV criteria for conduct disorder or antisocial personality disorder?
2. What social and educational supports are available locally for children with ODD and their families?
Related Cases
- Disease: Oppositional Defiant Disorder | Child Behavior Disorders
- Symptom/Presentation: Behavior Problems
- Specialty: Psychiatry and Psychology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Child Behavior Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Lavigne JV, Cicchetti C, Gibbons RD, Binns HJ, Larsen L, DeVito C. Oppositional defiant disorder with onset in preschool years: longitudinal stability and pathways to other disorders. J Am Acad Child Adolesc Psychiatry. 2001 Dec;40(12):1393-400.
Tremblay RE. Developmental origins of disruptive behaviour problems: the ‘original sin’ hypothesis, epigenetics and their consequences for prevention. J Child Psychol Psychiatry. 2010 Apr;51(4):341-67.
Stringaris A, Maughan B, Goodman R. What’s in a disruptive disorder? Temperamental antecedents of oppositional defiant disorder: findings from the Avon longitudinal study. J Am Acad Child Adolesc Psychiatry. 2010 May;49(5):474-83.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 