Is Oppositional Defiant Disorder a description or a diagnosis?

Our current blog series… Dissecting the DSM-5… What it Means for Kids and Families, continues today with an examination of the recently updated diagnostic criteria for Oppositional Defiant Disorder.

Mental health professionals working with kids and families are often asked to intervene when children chronically exhibit angry or disrespectful behavior. The causes of this behavior are often complex, but typically are grounded in two very different biologic predispositions…referred to in the DSM-5 as disinhibition/constraint and negative emotionality.

My problem with the diagnosis of Oppositional Defiant Disorder (ODD) is that establishing the diagnosis doesn’t tell you anything about what to do to treat it. Consider it a “lite” version of Disruptive Mood Dysregulation Disorder without the severe, protracted tantrums or meltdowns.

In the DSM-5, the eight diagnostic criteria for ODD were regrouped into three categories: Angry/Irritable Mood (loses temper, touchy/easily annoyed, angry/disrespectful), Argumentative/Defiant Behavior (argues with authority figures/adults, defies/refuses to comply with rules/requests from authority figures, deliberately annoys others, blames others) and Vindictiveness. Kids are required to have four or more symptoms for at least six months for an ODD diagnosis, criteria have been included to emphasize that the behavior is beyond the norm for the child’s developmental age and specifiers for severity have been included. In addition, kids with ODD may now be diagnosed with Conduct Disorder as a comorbid condition.

Some kids are disrespectful and defiant because of issues with poor executive functioning. They roughly correspond to the angry/irritable group. One way of understanding their behavior is to view them as impulsively defiant…they argue with parents and authority figures without stopping to think about the issue that upsets them or why they’re upset. It’s not unreasonable to question whether this subtype of kids diagnosed with ODD would be better described as having ADHD, with the defiant behavior representing difficulties with emotional self-regulation caused by the executive functioning deficits central to our understanding of ADHD. In fact, one of the criticisms the folks from Shire Pharmaceuticals faced when they sought FDA approval of Adderall XR for ODD was the question of whether ODD was truly a stand-alone diagnosis-since 79% of the kids in their study were diagnosed with ADHD in addition to ODD.

Other kids are disrespectful and struggle with transitions because of their inability to let go of their mental script of how a given interaction or situation should unfold. They correspond to the argumentative/defiant group in ODD. They perseverate or get “stuck” on a picture in their mind of how things should be and escalate when  adults violate their sense of control. The first subset of kids is defiant because they can’t stop and think. The second subset is defiant because they can’t tolerate the inner frustration when events unfold differently than they’ve pictured in their minds.  We know kids who “ruminate” or perseverate often experience problems with anxiety and/or depression as they get older.

What we do to help is contingent on our conceptualization of the cause of the defiant behavior. If they have difficulties with self-control related to ADHD, we’ll treat the ADHD. If they’re rigid, inflexible and perseverate, we might look at cognitive strategies or behavioral interventions to help. Use of the ODD label adds little to our understanding of how to best help address the behavior that led parents to seek professional help.

Updated January 24, 2016

Disinhibited Social Engagement Disorder… The new term for Reactive Attachment Disorder?

We’ll take a closer look in this post at the new companion diagnosis to Reactive Attachment Disorder related to pathologic care in early childhood… Disinhibited Social Engagement Disorder.

Studies of children who have been maltreated or raised in institutions have demonstrated two characteristic patterns of emotional response and behavior in response to pathologic caregiving environments. The first pattern involves emotional withdrawal…kids who lacked a preferred attachment figure, failed to respond to comfort when distressed, demonstrated decreased social and emotional reciprocity, decreased positive affect and unexplained fearfulness or irritability. Their symptoms could be described as internalized.  This is the group we discussed in a previous post who will continue to be described as meeting criteria for Reactive Attachment Disorder (RAD). In contrast, the second group was observed to demonstrate indiscriminately social behavior-inappropriately approaching unfamiliar adults and a lack of concern for strangers… in some instances, a willingness to wander away with strangers. They may also exhibit a lack of ability to maintain an appropriate sense of body space, and may also demonstrate disinhibition of behavior.

Research has demonstrated that these two patterns differ in terms of clinical correlates, course, and response to treatment. There was also much greater interrater reliability among clinicians using diagnostic criteria based upon the assumption that the two patterns represented separate and distinct conditions compared to the existing DSM-IV criteria for Reactive Attachment Disorder. As a result, the authors of the DSM-5 chose to establish a separate diagnosis of Disinhibited Social Engagement Disorder (DSED) to distinguish the second group from children with Reactive Attachment Disorder. This new designation corresponds to the condition in the ICD-10 referred to as Disinhibited Attachment Disorder of Childhood. Disinhibited Social Engagement Disorder encompasses  the vast majority of children and teens we’ve treated in our practice who in the past were identified with attachment disorders.

Here are the criteria for Disinhibited Social Engagement Disorder in the DSM-5:

A.  A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults.
2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with little or no hesitation.

B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.

C.  The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

E. The child has a developmental age of at least nine months.

Specify if Persistent: The disorder has been present for more than 12 months.

Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

First, we’ll start by looking at the similarities between kids with DSED and RAD. Both conditions are linked to social deprivation, neglect and pathologic care, and are readily identified among children being raised in institutional settings. Both conditions appear to be relatively stable over time in institutionalized children. But some very key differences exist as well…

• Some kids continue to exhibit symptoms associated with DSED after establishing selective or secure attachments with adoptive or foster parents, while RAD has only been observed in research studies among children who lack attachments.
• DSED appears not to be responsive (or only minimally responsive) to enhanced caregiving, whereas RAD is often very responsive. One study done in Romania comparing foster care to institutionalized care found a significant reduction in signs of RAD among children placed in foster care, but no reduction in the signs of DSED.
• Kids with DSED are often interested in, and willing to interact with unfamiliar adults, while kids with RAD typically demonstrate limited interest in interaction with unfamiliar adults.
• Kids with DSED appear to be at greater risk of developing externalizing disorders (ADHD, Oppositional Defiant Disorder, Conduct Disorder) whereas kids with RAD are more vulnerable to internalizing disorders (depressed mood).
• Kids described with DSED are prone to social and verbal intrusiveness and attention-seeking behavior during childhood, and superficial peer relationships along with enhanced peer conflicts during adolescence. The presentation of RAD in childhood and adolescence is less clear.
• Kids with DSED are more likely to be confused with kids with ADHD, while kids with RAD are more likely to be confused with kids with autism. Lack of capacity for self-regulation in social situations is a key feature of DSED, while a lack of comfort-seeking behavior is characteristic of DSED.

We can anticipate lots of confusion because the vast majority of children presenting for clinical care will meet the diagnostic criteria for DSED as opposed to RAD, since DSED is more likely to persist after kids leave pathologic care and causes more difficulties with interpersonal relationships. DSED is easier to observe across settings, especially in schools. I can certainly understand why the name of the condition was changed…not all kids with DSED lack attachments…but I’m not sure this distinction will be recognized by a majority of clinicians for quite some time.

Updated March 1, 2016

Does depression result from a lack of faith?

Consider the stories of the five people described in these passages…

I’ve lost twenty pounds in two months because of your accusation. My bones are brittle as dry sticks because of my sin. I’m swamped by my bad behavior, collapsed under gunnysacks of guilt. The cuts in my flesh stink and grow maggots because I’ve lived so badly. And now I’m flat on my face feeling sorry for myself morning to night. All my insides are on fire, my body is a wreck. I’m on my last legs; I’ve had it—my life is a vomit of groans.

Psalms 38:3-8 (MSG)

He ran for dear life to Beersheba, far in the south of Judah. He left his young servant there and then went on into the desert another day’s journey. He came to a lone broom bush and collapsed in its shade, wanting in the worst way to be done with it all—to just die: “Enough of this, God! Take my life—I’m ready to join my ancestors in the grave!” Exhausted, he fell asleep under the lone broom bush.

1 Kings 19:3-5 (MSG)

Curse the day I was born! The day my mother bore me—a curse on it, I say! And curse the man who delivered the news to my father: you’ve got a new baby—a boy baby!” (How happy it made him.) Let that birth notice is blacked out, deleted from the records, and the man who brought it haunted to his death with the bad news he brought. He should have killed me before I was born, with that womb as my tomb, my mother pregnant for the rest of her life with a baby dead in her womb. Why, oh why, did I ever leave that womb?  Life’s been nothing but trouble and tears, and what’s coming is more of the same.

Jeremiah 20:14-18 (MSG)

We do not want you to be uninformed, brothers and sisters, about the troubles we experienced in the province of Asia. We were under great pressure, far beyond our ability to endure, so that we despaired of life itself.

2 Corinthians 1:8 (NIV)

He was despised and rejected—a man of sorrows, acquainted with deepest grief. We turned our backs on him and looked the other way. He was despised, and we did not care.

Isaiah 53:3 (NLT)

King David, Elijah, Jeremiah, the Apostle Paul, and Jesus (as described in Isaiah’s prophesy). Hardly a collection of guys lacking in faith. Yet, many in the church persist in the view that depression is a consequence of a lack of faith.

While it’s possible that a lack of faith can contribute to symptoms of depression (Elijah in fear for his life from Jezebel) or sin (David), or life stresses (Jeremiah, Paul) it’s difficult to conclude from the number of Biblical illustrations in which giants of the faith struggled with hopelessness and despair that a primary cause of depression is a lack of faith or trust in God. Aren’t we making presumptions about God’s purposes in our suffering? Isn’t it possible, perhaps likely that God might use our suffering to strengthen our faith and to draw us into closer relationship with Him? I’m struck by the number of ministry leaders I’ve met who have struggled personally with depression. Just the other day, our colleague Shannon Dingle shared a wonderful post in which she described how being broken is not bad when God breaks us.

Churches that welcome kids with disabilities and their families will encounter many parents who struggle with depression…in my nearly thirty years in psychiatry I can attest that depression is a frequent complication of having a child with significant disability,especially among mothers. If we’re using family-based ministry models as a strategy to help all kids grow in faith, we need to consider how we’re going to care for parents with depression if they’re responsible for shepherding their kids.

As a psychiatrist, I can’t ever say for sure why any individual kid I’m treating is depressed, other than to say that some combination of biological predisposition, patterns of thinking and perception, environmental influences, situational stressors and sometimes, spiritual factors are involved. From where I sit, churches are most helpful when demonstrating the unconditional love of Christ to all kids and adults struggling with depression, offering biblical counsel if desired, recognizing that depression is a manifestation of our broken world and that God (at times) may use medication and evidence-based psychotherapies as instruments of healing in response to prayer, and acknowledging that like all of us, persons with depression are broken people in need of a Savior.

Updated July 15, 2015