FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's answer:
• Diagnosis: Oppositional Defiant Disorder (ODD).
• DSM-5 criteria (must have ≥4 symptoms for ≥6 months):
Angry/Irritable Mood:
1. Often loses temper.
2. Often touchy or easily annoyed.
3. Often angry and resentful.
Argumentative/Defiant Behavior:
4. Often argues with authority figures (or adults, for children).
5. Often actively defies or refuses to comply with rules/requests.
6. Often deliberately annoys others.
7. Often blames others for his/her mistakes or misbehavior.
Vindictiveness:
8. Has been spiteful or vindictive at least twice in the past 6 months.
• This patient has at least 5-6 symptoms (argues, refuses rules, deliberately annoys sister, blames others, loses temper) – meets criteria.
• Severity: Mild (symptoms confined to 1 setting – home only), Moderate (2 settings), Severe (3+ settings). This patient has symptoms at home and school – moderate severity.

✅ Candidate's answer:
• Normal developmental defiance:
- Common in toddlers (terrible twos) and again in early adolescence.
- Occurs infrequently (not daily).
- Mild in intensity (e.g., saying "no" to a request, occasional tantrum).
- Does NOT cause significant functional impairment (school, friendships, family relationships are fine).
- Child can usually be redirected and responds to consistent discipline.
- Usually short-lived (weeks to months).
• ODD (pathologic):
- Symptoms occur frequently (almost daily).
- Persistent for ≥6 months.
- Causes significant impairment (conflicts with parents, teachers, peers; school problems).
- Does NOT respond to typical parenting strategies.
- Often occurs in multiple settings (home and school).
- This patient's symptoms have been present for 1 year, occur daily, and cause impairment – ODD, not normal defiance.

✅ Candidate's answer:
• ODD (less severe):
- No violation of others' rights – no physical aggression, no destruction of property, no stealing, no serious rule violations.
- Symptoms are verbal and behavioral defiance (arguing, refusing, annoying, blaming).
- This patient has never hurt anyone or destroyed property – fits ODD.
• Conduct disorder (CD) – more severe:
- Involves violation of the rights of others or major age-appropriate societal norms.
- Symptoms include: physical aggression (fights, weapon use, cruelty to people/animals), destruction of property (fire setting, vandalism), theft (breaking and entering, stealing with confrontation), serious rule violations (truancy, running away).
- CD is NOT diagnosed if only ODD symptoms are present.
• Why absence of aggression/property destruction matters:
- CD has a worse prognosis (higher risk of antisocial personality disorder).
- CD requires more intensive treatment (multisystemic therapy, possibly medication).
- ODD may be a precursor to CD in some children (30-50% go on to develop CD), especially if comorbid ADHD.
- This patient currently has ODD; monitor for escalation to CD.

✅ Candidate's answer:
• ODD:
- Has three symptom clusters: angry/irritable mood, argumentative/defiant behavior, vindictiveness.
- Does NOT require severe temper outbursts (although may have temper tantrums).
- Symptoms occur at least once per week for ≥6 months (for children ≥5 years).
- Can be diagnosed in children as young as 4-5 years.
• DMDD:
- Requires severe, recurrent temper outbursts (verbal or physical aggression) that are grossly out of proportion to the situation, occurring ≥3 times per week.
- Requires persistent irritability or anger most of the day, nearly every day, between outbursts.
- Onset before age 10 years; cannot be diagnosed for the first time after age 18 or before age 6.
- DMDD cannot be diagnosed with ODD (hierarchical rule: if DMDD criteria are met, ODD is not diagnosed).
• This patient: frequent arguments, defiance, annoyance, but no mention of severe temper outbursts (verbal/physical aggression) occurring 3x/week. Therefore, ODD is appropriate, not DMDD.
• Distinction matters because DMDD may predict later depression/anxiety, whereas ODD predicts later CD.

✅ Candidate's answer:
• Prevalence: Approximately 3-5% of children. More common in males before adolescence (1.4:1), equalizes in adolescence.
• Risk factors:
- Temperamental: High emotional reactivity, poor frustration tolerance, difficult temperament, negative affectivity, impulsivity.
- Environmental: Harsh/inconsistent parenting, parental rejection, neglect, family conflict, domestic violence, maternal depression, low socioeconomic status, parental substance abuse.
- Genetic: Heritability estimated at 30-50%. Family history of ODD, CD, ADHD, mood disorders, substance use disorders.
- Biological: Lower resting heart rate, reduced skin conductance reactivity, prefrontal cortex abnormalities, serotonergic dysfunction.
• This patient likely has a combination of temperamental (emotional reactivity) and environmental factors.

✅ Candidate's answer:
• Most common comorbidity: Attention-deficit/hyperactivity disorder (ADHD). Up to 40-60% of children with ODD have comorbid ADHD.
• Screening for ADHD:
- Use Vanderbilt ADHD Diagnostic Rating Scale (parent and teacher) – screens for inattention, hyperactivity/impulsivity, and ODD.
- Ask about: difficulty sustaining attention, careless mistakes, forgetfulness, fidgeting, excessive talking, interrupting, difficulty waiting turn.
- Symptoms must occur in ≥2 settings (home and school).
- This patient has symptoms at home and school – assess for ADHD.
• Why important to identify:
- Children with ODD + ADHD have worse outcomes (higher risk of CD, academic failure, social rejection).
- Treatment of ADHD (stimulants, behavioral therapy) may improve ODD symptoms as well (by reducing impulsivity).
- Comorbid ADHD may require different management (medication + parent training).
- This patient needs a full ADHD assessment.

✅ Candidate's answer:
• Other common comorbidities:
1️⃣ Anxiety disorders (especially when ODD symptoms are driven by worry, avoidance).
2️⃣ Depressive disorders – ODD can precede depression, especially the angry/irritable mood cluster.
3️⃣ Learning disorders (academic frustration can trigger defiance).
4️⃣ Communication disorders (difficulty expressing needs → frustration → defiance).
5️⃣ Conduct disorder (CD) – 30-50% of children with ODD progress to CD, especially those with childhood-onset ADHD.
• Why assess for mood/anxiety:
- Treatment differs: anxiety may require CBT and SSRIs; ODD alone requires parent training.
- Children with ODD + anxiety may have better prognosis (less progression to CD) than ODD alone.
- Depressed mood may require antidepressant medication.
- Screen with PHQ-9 (depression) and SCARED (anxiety) in older children.

✅ Candidate's answer:
• First-line treatment: Behavioral parent training (BPT) – evidence-based, reduces disruptive behavior significantly.
• Key components of BPT (taught to parents):
1️⃣ Positive reinforcement for prosocial behavior: Praise, attention, tangible rewards (stickers, privileges) for following rules, complying with requests, being kind.
2️⃣ Clear, simple, consistent rules and expectations – posted where child can see.
3️⃣ Effective commands: Direct, specific, one at a time (e.g., "Please put your shoes in the closet" not "Clean up your room").
4️⃣ Ignoring minor annoying behaviors (if not dangerous) – planned ignoring to reduce attention-seeking defiance.
5️⃣ Logical consequences for non-compliance – time-out (1 minute per year of age), loss of privileges.
6️⃣ Consistency – all caregivers must use same rules and consequences.
7️⃣ Special time (child-directed play) – 10-15 minutes daily of positive interaction.
8️⃣ Parent self-care – manage parental stress, depression.
• Evidence-based BPT programs:
- Parent-Child Interaction Therapy (PCIT) – for children 2-7 years, live coaching.
- Incredible Years (IY) – group-based.
- Triple P (Positive Parenting Program) – flexible delivery.
- Refer to a trained therapist.

✅ Candidate's answer:
• Daily Report Card (DRC): Teacher rates target behaviors (e.g., followed directions, completed work, no arguing). Child brings card home; parents provide rewards for good performance. Bridges home and school.
• Classroom behavior management:
- Clear rules posted.
- Token economy (earn points/rewards for compliance).
- Planned ignoring of minor defiant behaviors.
- Proximity control (teacher stands near child).
- Break cards (child can request a break).
- Consistent consequences for defiance (loss of privilege, time-out).
• Academic support: If learning disability is present, provide IEP or 504 plan accommodations (extra time, reduced workload).
• Social skills training: Group-based to improve peer interactions.
• Collaboration: Pediatrician should communicate with school psychologist and teacher to coordinate interventions.
- Recommend a 504 plan or IEP if ODD significantly impacts learning.

✅ Candidate's answer:
• No FDA-approved medications for ODD itself. Medication is used to treat comorbid conditions that contribute to oppositional behavior.
• For comorbid ADHD: Stimulants (methylphenidate, amphetamines) or alpha-agonists (guanfacine, clonidine) – reduce impulsivity and may reduce oppositionality.
• For comorbid anxiety or depression: SSRIs (fluoxetine, sertraline) – if mood symptoms are driving defiance.
• For severe aggression or irritability (off-label, reserved for severe cases): Atypical antipsychotics (risperidone, aripiprazole) – but these have significant metabolic side effects. Not first-line.
• Do NOT use medication as first-line treatment for ODD. Behavioral parent training is the standard of care.
- This patient has no identified comorbid ADHD, anxiety, or depression – no medication indicated at this time.

✅ Candidate's answer:
• IED:
- Characterized by recurrent behavioral outbursts (verbal or physical aggression) that are grossly disproportionate to the provocation.
- Outbursts are impulsive, anger-based, not premeditated.
- Must cause marked distress or impairment.
- Can cause physical injury to others or damage to property.
- Age ≥6 years.
• ODD:
- Does NOT require severe outbursts (though may have temper tantrums).
- Includes argumentative, defiant, and vindictive behaviors that occur more frequently (≥1 time/week) but not necessarily explosive.
- No requirement for grossly disproportionate aggression.
- This patient has no history of aggressive outbursts causing injury → ODD, not IED.
• Importance of distinction: IED may require different pharmacologic approaches (SSRIs, mood stabilizers) and has different prognosis.

✅ Candidate's structured answer:
• “This is NOT your fault. You are not a bad parent. Oppositional defiant disorder is a medical condition, not a reflection of your parenting skills.”
• “Many parents of children with ODD feel guilty and blamed, but the disorder has biological and genetic components. However, the way you respond to his behavior can make a big difference in improving it.”
• “We will teach you specific techniques called behavioral parent training. These are not about being stricter or punishing more – they are about being strategic: praising good behavior, ignoring minor annoying behavior, and using consistent consequences.”
• “The most common mistake parents make is arguing back or yelling – that actually reinforces the defiance. We will teach you to stay calm and disengage from power struggles.”
• “You are doing the right thing by seeking help. With consistent use of these techniques, most children with ODD improve significantly.”
• “I also want to check in on you. Parenting a child with ODD is exhausting. Do you have support? Are you feeling depressed? We can help you too.”

✅ Candidate's answer:
• Prognosis with treatment: Good. With behavioral parent training, 60-80% of children show significant improvement within 3-6 months.
• Without treatment: 30-50% of children with ODD go on to develop conduct disorder, especially those with early-onset (<10 years) and comorbid ADHD.
• Risk factors for progression to CD:
- Early age of onset (preschool years).
- Comorbid ADHD (highest risk).
- Callous-unemotional traits (lack of guilt/empathy) – this patient does not show these.
- Harsh, inconsistent parenting.
- Family adversity (poverty, parental substance abuse, criminality).
- Peer rejection and deviant peer group.
• Protective factors: Early intervention (BPT), warm authoritative parenting, positive peer relationships, academic success.
- This patient (age 7, no aggression, no CD symptoms) has a good prognosis if treated.

✅ Candidate's answer:
• Can be managed in primary care initially (mild to moderate ODD) if:
- Pediatrician is comfortable providing behavioral parent training guidance.
- No comorbid conditions requiring specialist management (severe ADHD, depression, suicidality).
- Family is engaged and able to implement strategies.
- No safety concerns (aggression, self-harm).
• Refer to mental health specialist (child psychologist, psychiatrist, or behavioral therapist) if:
1️⃣ Severe ODD – causing significant impairment (school suspension, family crisis).
2️⃣ Failure of primary care behavioral management after 3-6 months.
3️⃣ Comorbid conditions – moderate-severe ADHD, depression, anxiety, learning disorder requiring specialized testing.
4️⃣ Progression to conduct disorder (aggression, stealing, running away).
5️⃣ Parental mental health issues (depression, substance use) that interfere with parenting.
6️⃣ Need for specialized therapy (PCIT, Incredible Years) not available in primary care.
• This patient (moderate ODD, no aggression, no comorbidities) can initially be managed in primary care with BPT guidance, but refer if no improvement in 3-6 months or if comorbid ADHD is diagnosed.