Mind the gap: assessing impairment among children affected by proposed revisions to the diagnostic criteria for oppositional defiant disorder.

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) workgroup for disruptive behavior disorders is considering adopting a frequency threshold for symptoms of oppositional defiant disorder (ODD). In the present study, the impact of substituting the term "often" with a specific age-based frequency on impairment and prognosis among preschool children was tested in a longitudinal design. Mutually exclusive groups were created to identify children who met criteria for ODD based on a symptom threshold of "often," as in Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-4), and those that met criteria for ODD based on a threshold of "1-2 times per day," which approximated the proposal for DSM-5. Comparisons of these groups to each other and to nondiagnosed peers determined the impact of changing the symptom threshold on impairment and prognosis. Close to one-third of children who met DSM-4 criteria for ODD did not meet criteria under the alternative diagnosis; African American children were overrepresented in this group. Preschoolers who met DSM-4, but not the alternative criteria, had higher rates of ODD, conduct disorder (CD), and were more impaired than their nondiagnosed peers at baseline and follow-up. Preschoolers meeting DSM-4 criteria were less impaired than children meeting the alternative ODD criteria at baseline according to parent, but not according to teacher report. No differences could be detected between those meeting DSM-4 and those meeting the alternative criteria in rate of ODD, CD, or impairment at follow-up. Among clinically referred preschool children, changing the symptom threshold for ODD could result in a sizable group of children who would no longer meet diagnostic criteria, despite demonstrating significant morbidity concurrently and prospectively.