This piece was originally published by in 2004 by the journal Psychline
Eliminate Conduct Disorders And ODD ... This Is The Right Time!
By Manuel Mota-Castillo, M.D.
The openness demonstrated by the DSM-V Task Force around changes in the diagnostic nomenclature has created momentum for an idea that has been gathering supporters for several years. This refers to the elimination of two diagnoses frequently applied to children and adolescents with aggressive/ disruptive behavior: Conduct Disorder (CD) and Oppositional-Defiant Disorder (ODD).
Conduct Disorder and Oppositional Defiant Disorder have been part of the Diagnostic and Statistical Manual of the American Psychiatric Association since its Third Edition 1. They were developed as part of a descriptive approach to nosology which steered clear of causality so as to avoid inter-ideological conflicts in the field. However, their creation has contributed to much confusion in the field since. They have often been misused as part of the superficial evaluation of children and adolescents, with a focus on the superficial symptoms or problems they present (with disruptive behavioral symptoms being highly frequent in this population). Their frequency and non-specificity has led to their lack of support in everything from insurance coverage by many their party carriers to educational law (with their exclusion from provisions for accommodations by schools under Section 504 of the Americans for Disabilities Act 2. The prevalence of these disorders, particularly that of ODD, has called its specificity as a psychiatric disorder into question and raised other questions of whether it describes developmental, social, and behavioral phenomena 3.
WHAT IS THE EVIDENCE ON THE VALIDITY OF CD AS A DIAGNOSIS?
Dr. Charles Huffine initiated one the first public expressions of concern about the adverse consequences of keeping Conduct Disorder as a diagnostic category. In March of 1999 the American Society for Adolescent Psychiatry approved Dr. Huffine's proposal to formally request to the American Psychiatric Association (APA) the removal of the Conduct Disorder diagnosis from the DSM classification. As could have been predicted, a year passed and very few clinicians and academics were echoing this innovative idea. Fortunately, Dr. Huffine did not abandon his quest, and in April of 2000 he sent the following statement to the Clinical Psychiatry News's "Pros & Cons" column 4:
"Conduct Disorder is a dangerous diagnosis. The diagnosis of conduct disorder, as delineated in the DSM-IV, does not take into account the intrinsic properties or pathology of the condition. It simply categorizes extrinsic behavior. As such, it is not really a diagnosis at all, and it could be leading us astray in our attempts to figure out what is really going on with the kids we label with this diagnosis."
That opinion was the open door to express not only my solidarity with Dr. Huffine's position but also to expand the idea to also remove ODD, a diagnosis which is even more problematic than Conduct Disorder. These concerns were expressed through a Letter to the Editor of Clinical Psychiatry News 5:
"Please allow me to give you a standing ovation for having the courage to bring up the abusive diagnosis of conduct disorder. I cannot agree more with Dr. Charles W Huffine's explanation that Conduct Disorder is just a manifestation of another pathology. I have data coming from the analysis of 5 months of inpatient work that I plan to publish. It shows that the triad of conduct disorder, attentiondeficit hyperactivity disorder (ADHD ), and oppositional defiant disorder was a misdiagnosis for bipolar disorder, anxiety,or psychosis in 100% of the cases. Not surprisingly, another set of data from the Arizona Department of Juvenile Corrections shows almost the same results. The big difference is that the latter study has 3 years of follow-up data. I hope that one of your next "Pro & Con" articles could address the issue of whether oppositional defiant disorder is just another "trash can" diagnosis to justify a reluctance to diagnose bipolar disorders in little children. In the past 3 years I have not found one child, previously diagnosed as such, who did not meet criteria for bipolar disorder and did not become "non-oppositional" with medication. I am sorry for all the scholars who defined both diagnoses and for those who still believe they do exist, but if we go back in history we find that even the greatest minds were wrong at some point."
Other prominent colleagues have raised other concerns about the misuse of the diagnosis of Conduct Disorder. Fabrega, Ulrich, and Mezzich 6, in their study of children referred to outpatient psychiatric clinics, found evidence of racial bias in the assignment of the diagnosis of CD, with it being disproportionately assigned to African-American children. Pumariega 7 has written on how the conduct disorder diagnosis can be problematic, given its excessive use in minority children as well as its rare identification as a solitary condition in children. For example, he cites one study where AfricanAmerican youth at a state psychiatric hospital were diagnosed with solitary conduct disorder, while white youth were diagnosed with conduct disorder and mood or anxiety disorders 8. In another study of a state community mental health system, depressive and conduct disorder diagnoses were found to be assigned to youth depending not on their race and their majority/ minority status 9. Additionally, in studies of youth in juvenile justice he has found that, out of the 45 % of incarcerated youth diagnosed with conduct disorder, 6 % had solitary conduct disorder and the rest were co-morbid with other disorders 10 . This raises doubt as to whether conduct disorder stands alone as a diagnostic entity and not as a complication from other pre-existing disorders .
Torres 11 reviewed the admitting di ag noses given to adolescents between the ages of 12 and l7 during a 6 month period in a New York City psychiatric hospital. In his analysis of the data Dr. Torres found that all the patients diagnosed as Conduct Disorder belonged to a racial minority (Hispanic or Black) while the White patients with disrupted behavior got a diagnosis of Adjustment Disorder. He was so disturbed by the fact that no even one Caucasian youth had been diagnosed with Conduct Disorder that he went to a senior attending physician to seek advice only to find more reasons to be concerned: The doctor advised him not to touch that is sue and to look in another direction because "this is the way it is." Against his wishes, he did.
WHAT ABOUT OPPOSITIONAL-DEFIANT DISORDER?
Several other academics, among them Dr. Rakesh Jain in Houston, Dr. Lewis Brodsky in Tallahassee and Dr. Ronald Pies in Boston, have also voiced their rejection to the notion that oppositional-behavior by itself (as in ODD) qualifies as a diagnostic category. Jain in particular stated "There is not such thing as ODD in response to a question I posed about the validity of the ODD diagnosis during a presentation he made in Miami Beach, Florida 12. His answer validated my concerns.
CLINICAL EXPERIENCE AND STUDY
Support from several colleagues and the wise counsel of Dr. Pies motivated me to initiate a 6 months study on diagnostic accuracy. Since March 31st of this year, I have been reviewing my patients previous diagnoses and nothing how many had been currently versus previously diagnosed as having Attention-Deficit Hyperactivity Disorder (ADHD), ODD and CD. (This study is a derivative from another study, started last year, to validate the Bipolar Spectrum Diagnostic Scale (BSDS) 13 in children and adolescents.)
In this practice, all new patients are first screened by a case manager and later on by a Masters' degree therapist who then refers them for psychiatric evaluation. At the end of the first three months (March through May, 2004) we reviewed the previous (referral) diagnoses on 258 patients seen during that period of ti me (for initial diagnostic evaluation or follow-up appointments; with children seen for at least two appointments each in our clinic), comparing them to diagnoses established in our clinic and checking for how they currently met diagnostic criteria.
The results of this study provide added reason to be concerned with the manner in which diagnoses in children and adolescents are being made: 125 of the ADHD diagnoses were not corroborated by our assessment, even though some of them have carried such label for as long as 7 years, and many of those cases had as the common denominator the ODD or CD "co-morbidity." It is important to emphasize that 125 patients wrongly diagnosed as ADHD plus ODD or CD mean that almost half of the time ( 48.5%) a trained professional failed to detect clear symptoms of other conditions. The percentage with a correct ADHD diagnosis was 30% representing 78 youths, while 22% (55 patients) had no previous diagnosis at the time of the initial evaluation and actually 7 children (2.8%) were diagnosed by us as having ADHD. This outcome is even more concerning if we examine the percentage of those diagnosed as having Conduct Disorder or Oppositional-Defiant Disorder that were corroborated by our assessment: None (ZERO PERCENT).
Many of these youths have been in our clinic for more than a year, and the transformation from "oppositional" and "conduct disordered" to "well behaved" has been remarkable and beyond any doubt. In other cases, more serious diagnoses have been confirmed. Such is the case of a 15 years old male of mixed ethnicity who was at the verge of being sent to a detention center because of severe aggressive-disrespectful behavior and substance abuse. Despite his two involuntary hospitalizations in a two weeks period he was diagnosed again with ADHD and ODD but CD was added by inpatient doctor. When I convinced the parents to request an "unruly" determination by the County Court and he was mandated to take medications, after a week on a combination of olanzapine (Zyprexa) and lamotrigine (Lamictal) all his inappropriate behavior had disappeared. You don't need to be an experienced psychopharmacologist to realize that his previous treatment (methylphenidate and clonidine) was of no benefit and actually was causing harm, because olanzapine is a substance that does the exact opposite of methylphenidate.
Many other patients had their obsessive-compulsive or Post-Traumatic Stress Disorder symptoms worsened by stimulant medications. Of note, Obsessive Compulsive Disorder (OCD) was the second most commonly missed diagnosis (4% ), after bipolar Disorder (9 % ). Patients with clear OCD symptoms were labeled oppositional-defiant and bipolar patients were, in many occasions, given a diagnosis of ODD or CD. OCD behaviors and attitudes can be misinterpreted as oppositional-defiant because children with OCD can present with strong opposition to change their rigid rules. In the classroom, for example, they can destroy schoolwork they have already finished because it does not look perfect. At home a girl can "go ballistic" because her mother wants her to wear a dress with a wrinkle, or her shoes do not match perfectly.
In the sample population that I am reporting two girls with Social Anxiety Disorder were also labeled ODD because they refused to attend school. From these 258 youths, the case of one particular patient can be seen as a wake up call for all of us: A 12 year-old boy with symptoms of disruptive/aggressive behavior, poor performance in class and defiance was diagnosed (by two psychiatrists) as having ADHD, CD and ODD but his mother (a bipolar patient) refused to accept such labels and took him to a neurologist at Miami Children Hospital. That professional diagnosed the boy with another psychiatric diagnosis, Bipolar Disorder, and prescribed a treatment that controlled the child's oppositional-defiant behavior.
Based on the findings reported above and these clinical cases, we have to be aware of the long-term consequences of diagnoses like Conduct Disorder and ODD 14. Just to mention one sad outcome, many of these youths are going to end in residential treatment centers or correctional facilities because many times juvenile courts judges perceive their continued misbehavior as a refusal to change, despite what these youths' clinicians consider reasonable treatment with medications and counseling. The reality is that they never had an appropriate management and the so-called treatments actually were worsening their symptoms, i.e. the aggressive-defiant child with an elevated mood was receiving an amphetamine compound that was making him more aggressive. This is a case of the victim taking the blame (and suffering for it) .
In all fairness to colleagues who still are labeling the grandiosity of a manic child as ODD and CD, I should say that we should look at this problem in a historical perspective. Not too long ago the psychiatric community was against diagnosing children with mood conditions and, consequently, we had to find explanations for behaviors and attitudes that were clearly abnormal and disturbing. These days we understand that an individual with dysphoric mania can show no respect for authorities or rules and reacts aggressively when asked to behave in a proper manner. We now know that their inflated ego and lack of respect is the product of their illness: a feeling of infinite power and superiority along with anger and psychological discomfort.
When blatant disregard for rules or disrespect for authority comes from a child, many professionals have difficulty attributing such behavior to a mental illness. However, we need to become more comfortable with that idea, because thinking of "hyperactivity and decreased concentration" as sole indications of ADHD is too limited a perspective. We forget (at our own peril and that of our young patients), a "racing mind" can explain the "restless body" and lack of concentration. Too easily, we could end considering the defiant behavior as an indication of an ODD or CD diagnosis (in association with ADHD) instead of crucial parts of the mood disorder. That mistake could bring serious consequence for a child due to the indiscriminate use of stimulant medications that pervade the current medical practice. The risk of exacerbating serious conditions that could be developing and manifesting, in its early stages, with symptoms that can be confused with those of ADHD, is always there.
That was the case of an 18 year-old male, whom I will call Shawn. When he was only two years of age and living in Rochester, NY, a psychiatrist gave him Dexedrine because the boy was "slow." In fact, his pediatrician had identified developmental delays (i .e. he was not walking at that time). A year later Shawn's family moved to Florida and a pediatrician thought that he had ADHD and prescribed methylphenidate, medication that was increased several times because "it was not working." Apparently, the doctor didn't take in consideration, at the time of formulating his diagnosis, that the boy's father had schizophrenia.
Many years later, after several residential placements and multiple treatment failures, Shawn (by then a 16 year-old) came to my office on a combination of 4 medications, including Adderall, a popular mixture of amphetamines with psychotropic effects similar to methylphenidate. He was psychotic (hallucinations, paranoia, delusions) had no interest in school or social interactions and his hygiene was poor. In April 2004 his diagnosis was changed from my original one of a psychotic mood disorder to a confirmed Paranoid Schizophrenia. In May of 2004, after more than a year on a combination of two anti-psychotic medications (Geodon or ziprasidone and Abilify or aripriprazole) the now 286 pounds adolescent reported that he just had married an alien ghost and she gave him a child. Shawn's mother stated that when he is in his bedroom she can hear animated conversations between her son and the "ghost." At that time I increased his ziprasidone dose to 400 (along with the 15 mgs of aripriprazole) and during his June visit he was showing a mild improvement in the degree of his delusions (he didn't argue with me when the existence of the "ghost" was challenged) and his affect was brighter. It is my impression that this youth had his schizophrenia made treatment resistant by the long-term use of amphetamines . In other words, we, doctors, added insult to his injury.
It is our duty to remedy this unfortunate situation. There are many avenues that we can use to contribute to this cause and one of them could be to send your opinions to the committee working on the development of the DSM-V. Dr. Michael First 14 is open to suggestions on how to make a more practical and accurate diagnostic manual (contact him through www.dsm5.org).
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Americans with Disabilities Act of 1990 S. 933 (H.R. 2273): Approved July 26, 1990.
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*Quotations from Clinical Psychiatry News reproduced with permission.