Dr. Mota-Castillo is a staff psychiatrist for the ACT Corporation in Daytona Beach and Deland, Fl. His Practice consists of outpatient treatment of children and adolescents.
For the past six years, l have been distressed by the observation that not even one case-out· of several hundreds of a child carrying a diagnosis of oppositional-defiant disorder (ODD) actually had such diagnosis.
Interestingly enough, the findings of one year in Tennessee and two years in Florida were a repetition of. what I saw during my four years in Arizona. Encouraged by that, last year I began to apply the Bipolar Spectrum Disorder Scale (BSDS) (Miller et al 2002) an instrument validated only for adults at this time to children and adolescents who came for psychiatric evaluation with an ODD diagnosis, alone or comorbid.
During the course of a one-hour evaluation, these patients underwent a regular psychiatric interview and completed the BSDS. My goal was to collect 100 cases and to present the analysis of that sample to the psychiatric community, but I had to change my plan when l reviewed the answers given by the first 50. Almost 50 patients previously diagnosed as ODD scored above the BSDS threshold (13 points) for the diagnosis of a mood disorder.
Considering that the DSM-V is currently being developed I felt compelled to disclose what seems to be a very alarming trend.
Two of the five patients who were not afflicted by a mood disorder bad social anxiety disorder. One had generalized anxiety disorder and the other two had obsessive-compulsive disorder. The youths with anxiety disorders had sub-threshold scores on the BSDS, as should be expected, and were diagnosed using the clinical interview. The diagnostic impressions were further corroborated by positive results to treatment with selective serotonin re-uptake inhibitors and cognitive-behavioral therapy.
A second expected outcome from this study should be the validation of the BSDS as an instrument to diagnose children and adolescents with mood problems. So far, it is looking very reliable.
When I stopped counting and reviewed the progress of these 50 patients, what I found was that their parents were reporting the absence of "oppositional-defiant" behavior or attitudes. One of my patients, "Tom," was a 9-year-old white boy being raised by a single parent His mother divorced his father after a year of marriage due to his abusive behavior "during the periods of his elevated mood." That piece of the boy's family history, along with the fact that his maternal aunt was diagnosed as manic-depressive, apparently was irrelevant to the previous three psychiatrists who had diagnosed him with attention deficitl/hyperactivity disorder plus ODD since be was in kindergarten.
In August 2001, he entered my office with an overtly elevated mood. He was funny, talkative and bossy with his mother. When l asked him bow fast his mind was going, be said with a histrionic tone, "Fast, really fast, so fast that I can't even think". He also reported hearing his name being called when he was by himself. His mother stated that he had a hard time falling asleep but that he was not tired during the day. ln school he was as defiant with his teachers as he was at home.
As of April, be is stale on 1 mg of Risperidorie (Risperdal) at bedtime and 100 mg twice per day of Jamotrigine (Lamictal). Now the oppositional-defiant behavior has only been present during transient elevation of his mood, responding positively to adjustments in medication dosages.
The patients I see range in age from 8to 16 (85% are 13 to 16) and are seen in a private outpatient clinic (group practice) or in a Saturday clinic serving Medicaid-insured people in central F1orida. Since the BSDS is intended to assess adults, some of its questions were adapted for children, in areas such as interest in sex and work performance particularly; their parents helped to answer some questions.
Some of the patients came in as referrals from Lakeside Alternatives in Orlando, Fl. This is a center that provides inpatient treatment for people on Medicaid and those involuntarily committed.
Another illustrating case is "Allison" a 14-year-old, biracial female who was admitted to Lakeside Alternatives with a chief complaint of anger outbursts, cursing, fighting with peers and siblings, decreased concentration in school and paranoia about her mother. At age 9, she was diagnosed with ADHD and ODD at a teaching hospital in New Jersey and was prescribed methylphenidate (Ritalin). After a clear worsening of her symptoms, she was giving a combination of amphetamine mixed salts (Adderali) and divalproex (Depakote), which had mixed results at the beginning. After five months, her mother discontinued both medications because the aggressive/defiant behavior was mounting. When she was 12 years old, the family moved to central Florida, and another psychiatrist prescribed methylphenidate HCl (Concerta). This time, according to her mother, she "was really violent."
As in the first case, it seemed that diagnosticians ignored a family history loaded with mental illness, including a maternal grandmother with schizophrenia, as well as a past history of poor responses to methylphenidate. Her mother stopped the methylphenidate HCL. She had been without medication until her hospitalization. Curiously, her mother joined the local chapter of National Alliance for the Mentally Ill and was prompted by some of its members to learn about bipolar disorder. She even brought a letter with the patient's history and a request to start her on ziprasidone (Geodon), "because my daughter does not want to gain weight."
Cases like the two presented here may cause many clinicians like me to consider an ODD diagnosis more damaging than helpful. This statement should not be construed as an attack on the validity of the DSM as a whole.
The questioning of the validity and reliability of this diagnosis goes back to the DSM-III-R. In a study reviewing literature on the condition of ODD, Rey (1993) stated that ODD has attracted little research and, while defending its validity, acknowledged the research challenges. Actually, the DSM-IV states that oppositional behavior is a common associated feature of mood disorders and psychotic disorders presenting in children and adolescents and should not be diagnosed separately if the symptoms occur exclusively during the course of a mood or psychotic disorder. When the two disorders co-occur, both diagnoses should be made.
The problem, l believe, starts out when clinicians fail to detect an elevated mood in a child who is defiantly acting out. This situation is compounded by the reality of the current managed care environment in which patients are first seen by a therapist who refers to a prescribing doctor who, overwhelmed by too many 15-minute medication checks, chooses to follow the therapist's diagnosis without further questioning.
(The author welcomes discussion from treating psychiatrists who have assessed patients meeting criteria for the ODD diagnosis-Ed.)
In my experience, if we stop the stimulant medication and/or antidepressants followed by the introduction of a mood stabilizer and we re-direct therapy from blaming and "you must change" to understanding and support, the outcome will be a non-oppositional child.
Lately there has been a more receptive atmosphere toward the concept of mood disorders in children contrasting with what was going in the psychiatric arena not long ago. In the early '90s, only very few prominent professionals like Hagop Akiskal, M.D., Janet Wozniak, M.D., Barbara Geller, M.D., Karen Dineen Wagner, M.D., Ph.D., and Joseph Biederman, M.D. dared to postulate that children could have mood disorders.
The DSM-IV is actually updated with respect to this issue, considering that it was published in 1994. But, apparently trying to escape from the tied control kept for too long by psychoanalytic theories, its framers actually neglected some widely accepted theories. For example, if we shared the ideas of Erik Erikson as presented in his eight stages of psychosocial development expanded and discussed in Kaplan and Sadock's Synopsis of Psychiatry (8th edition, Williams & Wilkins) it would be unjustifiable to accept that a 13-year-old child, who up to that age was well behaved, all of a sudden could become oppositional-defiant.
A better explanation for such a behavioral deterioration could be that this youth, after learning that there are limits to their wishes during a fair negotiation of their "Initiative versus Guilt" stage-phallic psychosexual in Freudian conception has lost control of their ego boundaries because of an elevated mood, a psychosis or a significant anxiety. A typical example of the latter could be a child who refuses to attend school because of social phobia, but such behavior is interpreted as ODD.
In essence, we are all child advocates, but we are not organized in a coherent group and hence have no power to influence the implementation of changes. My hope is that this article will ignite controversy around this issue. I have discussed the validity of ODD with distinguished colleagues who are open to questioning this diagnosis. If such outstanding researchers, as they are, agree with the idea of not blaming the oppositional-defiant child for their behavior, it is very possible that a multitude of psychiatrists could be interested in finding the answer to this question defined by the DSM-IV: Why would a child maintain a recurrent pattern of negativistic, defiant, disobedient and hostile behavior toward authority figures that persists. for at least six months?
I am convinced that an early correct diagnosis of these children with ODD that searches the etiology of these behaviors rather than their phenomenology could avoid a painful childhood. It could be the difference between a possible referral or a correctional facility, with damaged self-esteem, versus a productive and fulfilling life supported by focused treatment that addresses the underpinnings of these so called ODD behaviors.
Miller CJ, Ghaemi N, Klugman Jet al. (2002). Utilily of Mood Disorder Questionnaire and Bipolar Spectrum Diagnostic Scale. NR2. Presented at the 155th Annual Meeting of lhe American Psychiatric Association. Philadelphia; May 18·23
Rey JM (1993}, Oppositional defiant disorder. Am J Psychiatry 150(12):1769-1778.