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Oppositional Defiant Disorder

Clinical Assessment Portfolio December 4, 2013

Overview of Recommendations for Evidence-Based Assessment and Demographic Information

Overview of Multistage Strategy for Evidence-Based Assessment of Conduct Problems (adapted from McMahon and Frick, 2005; 2007)

Stage 1:

• Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR)
  • Used to broadly identify behaviors relevant to Oppositional Defiant Disorder
• Eyberg Child Behavior Inventory (ECBI)
  • Helps screen for overt and covert conduct problems

Stage 2:

• Structured Diagnostic Interview
  • (Available online: KSADS: http://www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/ksads-pl.pdf)
  • Helps to assess potential comorbidity.
• Standardized intelligence test and academic achievement screener
• Developmental and medical history obtained through clinical interview
• Observational analogues, including parent-child interactions – examples:
  • Child’s Game
  • Parent’s Game
  • Clean Up
• Parent observation measures
  • E.g., Parent Daily Report
• Level of functional impairment or adaptive disability determined through interviews or ratings
  • E.g., Child and Adolescent Functional Assessment Scale
• Age of onset of conduct problems established through clinical or structured interviews with parent or youth
  • Helps determine developmental pathway (see Moffitt’s (1993) seminal article “Adolescent-limited and life-course persistent antisocial behavior: A developmental taxonomy”), which has implications for the “three P’s”
  • Helps determine temporal ordering of potential comorbid disorders (e.g., did anxiety problems precede conduct problems, or vice-versa?), which also has implications for “three P’s”

Stage 3:

• Broader social and environmental context should be assessed.
  • E.g., Neighborhood Questionnaire, Community Interaction Checklist, Things I Have Seen and Heard
• Assessment of social informational processing could yield important information relevant to the “three P’s”
  • E.g., Intention-Cue Detection Task
• Parental/personal adjustment assessment to assess for familial risk factors
  • E.g., Antisocial Behavior Checklist
• Further assessments specific to the symptomatology of the child or adolescent should be conducted
  • E.g., assessments specific to fire-setting behaviors

Additional notes:

• Covert conduct problem behaviors are difficult to assess, and the clinical utility of some innovative observational paradigms needs to be demonstrated.
• McMahon & Frick (2005) point to the “recent proliferation of research concerning girls and CP (p. 496) and suggest that this emerging research “should facilitate the development of evidence-based guidelines that are applicable to girls in the near future.” For the time being, they recommend following the same guidelines for girls as for boys, with the addition of a measure of relational aggression in girls.

Sources:

McMahon, R. J. & Frick, P. J. (2005). Evidence-based assessment of conduct problems in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34, 477-505.

McMahon, R. J. & Frick, P. J. (2007). Conduct and oppositional disorders. In E.J. Mash & R.A. Barkley (Eds.), Assessment of childhood disorders (4th ed., p. 132-183). New York: The Guilford Press.

Overview of Recommendations for Assessment and Treatment

See http://publications.nice.org.uk/antisocial-behaviour-and-conduct-disorders-in-children-and-young-people-recognition-intervention-cg158 the National Institute for Health and Care Excellence (NICE) Practice Guidelines for Childhood Conduct Disorders, for an overview of recommendations for both assessment and treatment of Oppositional Defiant Disorder.

Demographic Information

Table 1 Base rates of Oppositional Defiant Disorder in different clinical settings

Setting (Reference)	Base Rate	Demography	Diagnostic Method
Nationally representative large-scale study (N = 3,119) – adult retrospective report (Nock, Kazdin, Hiripi, Kessler, 2007)	10.2% overall 11.2% males 9.2% females	All of the U.S.	CIDIr
Preschool-aged children (2-5 y.o.)-Recruited from pediatric practices (N = 306) – (Egger & Angold, 2006)	6.6% overall	Semi-Rural North Carolina (Durham and surrounding areas)	PAPAp
The Great Smoky Mountains Study - longitudinal, population-based study of community sample (Costello, Mustillo, Erkanli, Keeler, Angold, 2003)	2.33% overall: 3.16% males, 2.75% females	Western North Carolina	CAPA p,y
Preschool-aged children (4 y.o.) - Recruited from inner city schools and pediatric practices (N = 796) (Lavigne, LeBailley, Hopkins, Gouze, & Binz, 2009)	8.3% overall	Urban- Chicago	DISC-YC p
Meta-analysis of 38 studies- cited in the DSM-5 (Canino et al., 2010)	3.3% overall	Various locations across USA	Varied

^p Parent interviewed as part of diagnostic assessment; ^y youth interviewed as part of diagnostic assessment, ^r adult interviewed for retrospective report as part of diagnostic assessment

Notes: CIDI = World Health Organization (WHO) Composite International Diagnostic Interview; PAPA = Preschool Age Psychiatric Assessment; CAPA = Child and Adolescent Psychiatric Assessment; DISC-YC = Diagnostic Interview Schedule for Children–Parent Scale–Young Child Version.

Mash and Barkley (2003) note that prevalence rates of ODD must be qualified, because the definition of ODD has changed at a fast rate, the rates adolescents meeting criteria in any cross-sectional evaluation may be misleading because of the developmental progressions with and between ODD and Conduct Disorder, and categorical definitions of aggressive patterns may reflect arbitrary numbers of constituent estimates. These factors may lead to misleading prevalence rates. In addition, few studies have investigated the prevalence of ODD in preschool-aged children, and early onset of these behaviors is associated with more severe and stable impairment.

Sources Consulted:

Canino G, Polanczyk G, Bauermeister JJ, et al. (2010) Does the prevalence of CD and ODD vary across cultures? Social Psychiatry Epidemiology, 45(7):695–704.

Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003) Prevalence and development of psychiatric disorders in adolescence. Arch Gen Psychiatry, 60, 837-844.

Egger, H.L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: Pre-sentation, nosology, and epidemiology. Journal of Child Psychiatry and Psychology, 47, 313–337.

Nock, M. K., Kazdin, A. E., Hiripi, E., & Kessler, R. C. (2007). Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication. Journal of Child Psychology and Psychiatry, 48(7), 703-713.

Lavigne, J. V., LeBailly, S. A., Hopkins, J., Gouze, K. R., & Binns, H. J. (2009). The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. Journal Of Clinical Child And Adolescent Psychology, 38(3), 315-328. doi:10.1080/15374410902851382

Search Terms: [“oppositional defiant disorder”] AND [“clinically referred” OR “community clinic” OR “community sample” OR “outpatient clinic” OR “clinical”] OR [prevalence] in MedLine, PsycINFO, and PubMed

Diagnosis

Recommended Diagnostic Interviews

″The Mini International Neuropsychiatric Interview for Children″ (MINI-Kids)-available at the Finely Clinic and ″the Kiddie-Sads-Present and Lifetime Version″ (K-SADS-PL) – 2009 Working Draft available for free online at: http://www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/ksads-pl.pdf. See page 38. Appendix 1 provides DSM-IV and DSM-5 criteria for diagnosis of Oppositional Defiant Disorder.

Screening Instruments

Table 2 provides diagnostic efficiency information for the Child Behavior Checklist (CBCL; Achenbach, 1991; hardcopy and scoring system available at the Finley Clinic); the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997); see http://www.sdqinfo.com/ to access the questionnaire and scoring information; and the Eyberg Child Behavior Index (ECBI; Eyberg & Robinson, 1983). Appendix 2 includes a copy of the Eyberg Child Behavior Checklist (Eyberg & Robinson, 1983).

Table 2 Areas Under the Curve (AUCs) and Likelihood Ratios For Potential Screening Measures for Oppositional Defiant Disorder

Screening Measure (Primary Preference)	AUC	LR+ (Score)	LR- (Score)	Citation
MINI-Kids	.81	3.00	.65	Sheehan et al., 2010
Children and Adolescents (6 to 18 years)
CBCL Aggression T-score (Achenbach, 1991a)	.803 (N=370)	4.18 (55+)	.35 (<55)	Hudziak, Copeland, Stanger, 2004
	.71 (N=475)	-------	-------	Ebesutani, Bernstein, Nakamura, Chorpita, Higa-McMillan, & Weisz, 2010
CBCL DSM-Oriented Scales (Achenbach, 1991a)	.71 (N=475)	-------	-------	Ebesutani, Bernstein, Nakamura, Chorpita, Higa-McMillan, & Weisz, 2010
	-------	2.46 (60+ to 70+)*	.54 (<60 to <70)*	Warnick, Braken, & Kasl, 2008
Children and Adolescents (4 to 12 years)
SDQ- Conduct Problems Scale (Goodman, 1997)	-------	8.33 (Not specified)*	.27 (Not specified)*	Warnick, Braken, & Kasl, 2008
Children and Adolescents (2 to 16 years)
ECBI- Intensity Scale (Eyberg & Robinson, 1983)	-------	6.92 (131+)	.11 (<131)	Rich & Eyberg, 2001

“LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000).

Searches (specified below) did not yield any data about sensitivity, specificity, AUC, or ROC for the Externalizing scale of the CBCL. Searches also did not yield data about TRF or YSR scales for Aggression or Externalizing: Achenbach and Rescorla (2001) provide data about clinically referred vs. non-referred samples but not about samples with oppositional disorder specifically; thus, only AUC and LRs for the Aggression scale are reported. In addition, searches did not yield any information on the AUC for Oppositional Defiant Disorder, however, there are studies looking at the AUC for the SDQ at differentiating clinical from non-clinical samples. Also, there was no information on the Problem Scale of the ECBI, and no information on the AUC for the ECBI.

* This study was a meta-analysis of 29 studies looking at the CBCL and 3 studies looking at the SDQ.

Sources Consulted:

Ebesutani, C., Bernstein, A., Nakamura, B. J., Chorpita, B. F., Higa-McMillan, C. K., & Weisz, J. R. (2010). Concurrent validity of the child behavior checklist DSM-oriented scales: Correspondence with DSM diagnoses and comparison to syndrome scales. Journal of Psychopathology and Behavioral Assessment, 32(3), 373-384.

Hudziak, J. J., Copeland, W., Stanger, C. (2004). Screening for DSM-IV externalizing disorders with the Child Behavior Checklist: a receiver-operator characteristic analysis. Journal of Child Psychology and Psychiatry, 45, 1299-1307.

Rich, B. A., & Eyberg, S. M. (2001). Accuracy of assessment: the discriminative and predictive power of the Eyberg Child Behavior Inventory. Ambulatory Child Health, 7(3‐ 4), 249-257.

Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., ... & Wilkinson, B. (2010). Reliability and validity of the Mini International Neuropsychiatric Interview for children and adolescents (MINI-KID). The Journal of clinical psychiatry, 71(3), 313-326.

Warnick, E. M., Bracken, M. B., & Kasl, S. (2008). Screening efficiency of the Child Behavior Checklist and Strengths and Difficulties Questionnaire: a systematic review. Child and Adolescent Mental Health, 13(3), 140-147.

Search terms: (1) “Oppostional Defiant Disoder” AND specificity OR sensitivity OR ROC OR receiver-operator OR receiver OR “area* under curve” OR “area* under the curve”; (2) CBCL AND specificity OR sensitivity OR ROC OR receiver-operator OR receiver OR “area* under curve” OR “area* under the curve”; (3) YSR AND specificity OR sensitivity OR ROC OR receiver-operator OR receiver OR “area* under curve” OR “area* under the curve”; (4) TRF AND specificity OR sensitivity OR ROC OR receiver-operator OR receiver OR “area* under curve” OR “area* under the curve” (5) “Strengths and Difficulties Questionnaire” in PsychInfo, PubMed, and MedLine.

Treatment

Behavioral Parent Training

Behavioral Parent Training is considered the most effective treatment for childhood disruptive behavior disorders (e.g., Oppositional Defiant Disorder), especially for younger children (i.e., 3-8 year-olds). See http://effectivechildtherapy.com/content/disruptive-behavior-problems-odd-cd, a website sponsored by The Society for Child and Adolescent Psychology (APA, Division 53) and the Association for Behavioral and Cognitive Therapies (ABCT), for current summary of evidence-based treatments.

Overview of Recommendations for Both Assessment and Treatment

See http://publications.nice.org.uk/antisocial-behaviour-and-conduct-disorders-in-children-and-young-people-recognition- intervention-cg158, the National Institute for Health and Care Excellence (NICE) Practice Guidelines for Childhood Conduct Disorders, for an overview of recommendations for both assessment and treatment.

Process and Outcome Measures

Severity and Outcome

Table of Clinically Significant Change Benchmarks

Table 3 Clinically Significant Change Benchmarks with Common Instruments

Measure	Subscale	Cut-off scores			Critical Change (unstandardized scores)
Benchmarks Based on Published Norms
		A	B	C	95%	90%	SEdifference
CBCL T-scores (2001 Norms)	Externalizing	49	70	58	7	6	3.4
CBCL Benchmarks Based on Oppositional Defiant Disorder Samples Were Not Found in Searches*
ECBI Scaled Scores (1983 Norms)	Intensity	80.1	169.5	112.9	9.5	8	4.8
ECBI Scaled Scores (1983 Norms)	Problem	3.9	17.7	11.5	2.1	1.8	1.1

• “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

Search terms: (1) “Strengths and Difficulties Questionnaire,” (2) Strengths and Difficulties Questionnaire AND benchmarks, searches previously mentioned.

Process Measures

See Section 1.1 for overview of evidence-based measures to use depending on etiology and symptomatology of Oppositional Defiant Disorder.