Evidence-based assessment/Oppositional defiant disorder (disorder portfolio)
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|Steps 1-2: Preparation phase|
|Steps 3-5: Prediction phase|
|Steps 6-9: Prescription phase|
|Steps 10-12: Process/progress/outcome phase|
*** Consider adding background, perhaps paragraph style, like CD section in portfolio (Maybe make similar look and feel, coordinate esp. with CD)
- 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
- Child and Adolescent Disruptive Behavior Inventory (CADBI)
- This measure was used in validation studies in youth 3- 18 years old. It can be used as a screening and diagnostic tool. It has 25 items and 3 subscales: Opposition directed towards adults (items 1-8) and towards peers (items 9-16), and hyperactivity/impulsivity (items 7-25).
- Identifies externalizing behavior of ODD.
- Structured Diagnostic Interview
- Available online: KSADS
- Helps to assess potential comorbidity.
- Standardized intelligence test (e.g., WASI, WISC****) and academic achievement screener (e.g., WRAT, WIAT, WJ cog****)
- Developmental and medical history obtained through clinical interview
- Observational analogues, including parent-child interactions – examples:
- Child’s Game: child directed play
- Parent’s Game: parent directed play
- Clean Up: clean up task in which parent instructs child to clean up specific toys
- 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, 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”
- 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
- 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.
Base rates of ODD in different clinical settings and populations
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of ODD that they are likely to see in their clinical practice.
|Setting (Reference)||Base Rate||Demography||Diagnostic Method||Best Recommended For|
|Nationally representative large-scale study (N = 3,119) – adult
|All of the U.S.||CIDIr|
|Preschool-aged children (2-5 y.o.)-Recruited from pediatric
practices (N = 306)
|6.6% overall||Semi-Rural North
Carolina (Durham and surrounding areas)
|The Great Smoky Mountains Study - longitudinal, population-based study of community sample||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)||8.3% overall||Urban- Chicago||DISC-YC p|
|Meta-analysis of 38 studies- cited in the DSM-5||3.3% overall||Various locations across
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
Note: 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 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.
*** Recommend adding DSM-5 criteria (and ICD specifiers?)
Diagnostic criteria for oppositional defiant disorder
ICD-11 Diagnostic Criteria
- Oppositional Defiant Disorder
- Oppositional defiant disorder is a persistent pattern (e.g., 6 months or more) of markedly defiant, disobedient, provocative or spiteful behaviour that occurs more frequently than is typically observed in individuals of comparable age and developmental level and that is not restricted to interaction with siblings. Oppositional defiant disorder may be manifest in prevailing, persistent angry or irritable mood, often accompanied by severe temper outbursts or in headstrong, argumentative and defiant behaviour. The behavior pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning
- Oppositional Defiant Disorder With Chronic Irritability-Anger
- All definitional requirements for oppositional defiant disorder are met. This form of oppositional defiant disorder is characterized by prevailing, persistent angry or irritable mood that may be present independent of any apparent provocation. The negative mood is often accompanied by regularly occurring severe temper outbursts that are grossly out of proportion in intensity or duration to the provocation. Chronic irritability and anger are characteristic of the individual’s functioning nearly every day, are observable across multiple settings or domains of functioning (e.g., home, school, social relationships), and are not restricted to the individual’s relationship with his/her parents or guardians. The pattern of chronic irritability and anger is not limited to occasional episodes (e.g., developmentally typical irritability) or discrete periods (e.g., irritable mood in the context of manic or depressive episodes).
- Note: The ICD-11 lists 3 additional subcategories of oppositional defiant disorder with chronic irritability-anger. They can be found here.
- Oppositional Defiant Disorder Without Chronic Irritability-Anger
- Meets all definitional requirements for oppositional defiant disorder. This form of oppositional defiant disorder is not characterized by prevailing, persistent, angry or irritable mood, but does feature headstrong, argumentative, and defiant behavior.
- Note: The ICD-11 lists 3 additional subcategories of oppositional defiant disorder without chronic irritability-anger. They can be found here.
Recommended diagnostic interviews
"The Mini International Neuropsychiatric Interview for Children″ (MINI-Kids)-available and ″the Kiddie-SADS-Present and Lifetime Version" KSADS-PL DSM-5 November 2016: Supplemental #4: Neurodevelopmental, Disruptive, and Conduct Disorders Supplement.
The following table 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; see http://www.sdqinfo.com/ to access the questionnaire and scoring information; and the Eyberg Child Behavior Index (ECBI). Appendix 2 includes a copy of the Eyberg Child Behavior Checklist.
Psychometric properties of screening measures for ODD
|Screening Measure (Primary Preference)||AUC||LR+ (Score)||LR- (Score)||Citation|
|Children and Adolescents (6 to 18 years)|
|CBCL Aggression T-score||.803 (N=370)||4.18 (55+)||.35 (<55)|
|CBCL DSM-Oriented Scales||.71 (N=475)||-------||-------|
|-------||2.46 (60+ to 70+)*||.54 (<60 to <70)*|
|Children and Adolescents (4 to 12 years)|
|SDQ- Conduct Problems Scale||-------||8.33 (Not specified)*||.27 (Not specified)*|
|Children and Adolescents (2 to 16 years)|
|ECBI- Intensity Scale||-------||6.92 (131+)||.11 (<131)|
Note: “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.
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.
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.org/concerns-symptoms-disorders/disorders/rule-breaking-defiance-and-acting-out/ 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 assessment and treatment
See 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.
Process and outcome measures
Severity and outcome
Clinically significant change benchmarks with common instruments
|Measure||Subscale||Cut-off scores|| Critical Change |
|Benchmarks Based on Published Norms|
| CBCL T-scores
|CBCL Benchmarks Based on Oppositional Defiant Disorder Samples Were Not Found in Searches*|
| ECBI Scaled Scores
| ECBI Scaled Scores
Note: “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.
See Section 1.1 for overview of evidence-based measures to use depending on etiology and symptomatology of Oppositional Defiant Disorder.
- Society of Clinical Child and Adolescent Psychology
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