How do you determine whether ODD or CD is the appropriate diagnosis in this case?

Question

DSM Diagnosis
313. 81 Oppositional Defiant Disorder, Severe
315.0 Reading Disorder
315.1 Mathematics Disorder
315.2 Disorder of Written Expression
V62.89 Borderline Intellectual Functioning (Provisional)

Sam was diagnosed with ODD because he fits seven of the eight criteria: he often loses his temper; he is often angry; he argues with adults (both his teachers and parents); he blames others for why he misbehaves; he often defies requests; he is annoyed easily by others (simple requests to do his work or to stop talking); and he is vindictive (threatens to kill staff after they have angered him). His behaviors have been well documented for much longer than the required six-month period as evidenced by the psychological reports dating back more than one year.
Sam’s behaviors are causing significant problems both at school and at home (his multiple trips to support and mother’s admission of being overwhelmed to the point of filing a petition with the juvenile court). These problematic behaviors have also been noted and observed by behavior staff, the social work intern, his teacher, and previous public school staff persons. Since Sam’s escalating and dangerous behaviors are occurring multiple times a week, the frequency and severity of such occurrences far exceed what is assumed to be the “testing” behavior customary for his age set.
Sam was also given the Reading, Math, and Written Expression learning disorders based on his scores on the Woodcock Johnson tests, which indicated that his reading, writing, and math skills were significantly delayed for his age, IQ, and educational level. In addition, no sensory deficits appear to be present, and Sam’s academic achievement is poor, in part, due to these delays.
Additionally, the V-code for Borderline Intellectual Functioning (V62.89) was given but only provisionally because Sam’s oppositional behavior interfered with the testing situation. For the qualifier “provisional” to be removed, Sam would have to be re-evaluated

Additional Information Required
More information from Sam’s mother would be helpful, including the following:
? Sam’s perinatal and postnatal development
? The presence of birth complications
? If Sam’s mother smoked cigarettes during pregnancy
? Whether Sam was physically or sexually abused
? The relationship Sam had with his father before he was deceased
? The relationships between family members where Sam now lives
? Sam’s mother’s history of depression or other mental health problems
? Sam’s biological father’s history of mental problems
? The circumstances around his two older half-siblings leaving the home and his relationship and extent of contact with them
? Sam’s mother’s financial situation; whether she is currently receiving child support from the fathers of her children, and the extent of her welfare benefits to see if the family receives all benefits for which it is eligible.

Other information that is necessary to make a valid diagnosis includes a reliable IQ test to assess Sam’s cognitive functioning. Also, more information regarding the events surrounding the complaint filed by Sam’s previous school to the court may help determine whether a diagnosis of conduct disorder is warranted. Although it is known Sam is shunned by classmates primarily due to fear of his out-of-control behaviors, we don’t know whether he is actively aggressive with them. For instance, does he initiate fights with peers? Finally, because of the recent losses Sam has experienced, along with the potential for comorbid depression with ODD, it would be helpful to see how Sam would score on a childhood depression scale such as the Children’s Depression Inventory.

Treatment
Research has demonstrated that parent-training is effective in reducing the symptoms associated with conduct disorder and ODD in approximately two thirds of children under the age of ten (Fonagy & Kurtz, 2002). Parent training may help Sam’s mother use more effective and consistent methods of discipline, such as positive reinforcement, withdrawal of attention, and time out procedures, rather than the corporal punishment to which she occasionally resorts. Risk factors for outcome of parent training displayed by Sam’s family include possible maternal depression, low socioeconomic status, and high levels of parental negativity toward the child. In addition to these factors, Sam’s mother has terminated therapeutic services in the past. However, this termination appears to have coincided with the upheaval in the family’s living situation, and may not be indicative of an unwillingness to receive treatment. Although several risk influences are present in Sam’s case, Sam’s mother also displays a protective influence for positive outcomes in parental training - the perception of the need for treatment.
Building Sam’s mother’s motivation to participate in treatment and working with her in a collaborative fashion is essential. The social work intern will demonstrate empathy for her parenting difficulties and her efforts to manage Sam’s behavior. The social worker should also ensure that mother has her resource and welfare needs met. Helping Sam’s mother stabilize the home environment for her family will be important. Assessment of possible depression in Sam’s mother will be recommended and referrals for medication and psychotherapy will be made, if indicated. If other relatives are to be involved in Sam’s care (great-grandmother, uncle), they should also be involved in the parent training to ensure consistency of discipline practices across caregivers.
Individual treatment has been shown to be less effective than family work for ODD, but problem-solving training coupled with parent training has been shown to improve outcomes. Problem-solving training could help Sam to learn more positive coping strategies to deal with feelings of frustration, anger, or sadness. In addition, social problem-solving skills may help Sam to develop more positive relationships with his peers.
School interventions will include a behavior modification approach (similar to the one devised with Sam’s mother) with reinforcement and rewards for positive behaviors and punishments (taking away tokens, time outs) for negative behaviors.
Unfortunately, if Sam is not able to effectively participate in this setting, he might require a more restrictive setting, such as residential treatment. That is why it is critical that he now receive the services that have proven effective with this disorder.

Critical Perspective
There is a clash between the DSM’s conceptualization of ODD as internal dysfunction compared with the research that has established that the disorder chiefly arises from family and socioeconomic influences. However, the DSM cautions against diagnosing CD if it is a reaction to the social environment. Sam has undergone many stressors in his life – the violent death of his father, the separation of his parents before that, living in a single-parent home, living in poverty, and frequent moves. There may even be other stressors and events that are unknown at this time. Sam’s case is fairly typical in that many youth diagnosed with ODD or CD have experienced a number of environmental stressors; if social workers withheld the diagnosis because of the extent of environmental influence in all these instances, few clients would probably still remain in this category.

Answer 1

The DSM-5 notes that although Oppositional Defiant Disorder includes some of the features observed in Conduct Disorder, it does not include the more serious forms of behavior in which the basic rights of others or age-appropriate societal norms or rules are violated. In order to justify a diagnosis of conduct disorder a minimum of three of the criteria listed in the DSM-5 must be present within the last twelve months and one within the last six months. The criteria for conduct disorder are grouped into four categories: aggression to people and animals; destruction of property; deceitfulness or theft; and serious violation of rules.

Under the category of “aggression to people and animals,” Sam meets the criterion of bullying, threatening, or intimidating others. Sam has to be searched daily secondary to his many threats of bringing a knife or gun to school to kill staff. He has attempted to stab staff with pencils and thumbtacks grabbed from hallway bulletin boards. Sam has spit at staff, lunged at staff, and tried biting them.   His mother reports that he has become both verbally and physically abusive towards her when he gets frustrated and that this behavior dates back to early childhood. Another criterion under aggression to people and animals involves using a weapon. Sam has used pencils and thumbtacks, but these are not considered a weapon that can cause serious physical harm. A final criterion under this category to consider is “initiating physical fights.” Sam’s physical aggression, however, seems like a reaction to frustration about work completion and staff discipline, rather than initiating physical fights.
Under the category of “destruction of property,” Sam can be seen as meeting the criterion of deliberately destroys others’ property, although at this point, the property is relatively minor, such as papers and pencils. In addition, Sam’s destruction appears to be mostly limited to his own property (school papers and pencils), rather than others’ property as the criterion specifies.
The report from Sam’s previous school mentions that the school filed a complaint with the court because of Sam’s “out of control” behavior at school and home. This indicates that Sam may have met additional criteria for conduct disorder, depending on what behaviors precipitated this action. However, at this time, he definitively only meets one criterion (bullying and threatening others) for conduct disorder. It must be noted, however, that some clinicians would use more latitude in the criteria for conduct disorder and might diagnose him with this rather than oppositional defiant disorder, particularly if they believed that reimbursement for services would be more forthcoming for the diagnosis of conduct disorder.