How do you assess oppositional defiant disorder (ODD), conduct disorders, substance use, developmental conditions such as attention deficit hyperactivity disorder (ADHD), learning and language disorders, and autism spectrum disorders, as well as physical conditions like tics and sleep apnea in an 18-year-old male?

Assessment of Comorbid Conditions in an 18-Year-Old Male

When evaluating an 18-year-old for oppositional defiant disorder, conduct disorders, substance use, developmental conditions, and physical conditions, you must systematically screen across emotional/behavioral, developmental, and physical domains using targeted questions to multiple informants, as comorbidity is the rule rather than the exception in this population. 1

Core Assessment Framework

Obtain Information from Multiple Sources

• Directly question the adolescent, parents, and when possible, teachers or other observers about symptoms across all domains, recognizing that agreement between informants is typically low but each perspective provides unique clinical value 1
• For adolescents, obtaining teacher reports is challenging due to multiple teachers, and parents may have less opportunity to observe behaviors than with younger children 1
• The adolescent's self-report is particularly important for covert behaviors and predicts stability better than parent or teacher reports 1

Oppositional Defiant Disorder (ODD) Assessment

Ask about the following core symptoms lasting at least 6 months 1:

• Frequency and severity of angry/irritable mood: "How often do you lose your temper? How often are you touchy or easily annoyed? How often are you angry and resentful?" 1
• Argumentative/defiant behavior: "How often do you argue with authority figures? How often do you actively refuse to comply with requests or rules? How often do you deliberately annoy others? How often do you blame others for your mistakes?" 1
• Vindictiveness: "How often have you been spiteful or vindictive in the past 6 months?" 1
• Functional impairment: Document specific problems at home, school, work, or with peers caused by these behaviors 1
• Observe parent-child interactions during the interview, as oppositional behaviors may manifest in these interactions even if not directly with the examiner 1

Conduct Disorder Assessment

• Ask about rule-breaking and aggressive behaviors: "Have you been in physical fights? Have you used weapons? Have you been physically cruel to people or animals? Have you stolen while confronting a victim? Have you forced someone into sexual activity?" 1
• Inquire about property destruction: "Have you deliberately set fires? Have you deliberately destroyed others' property?" 1
• Screen for deceitfulness and theft: "Have you broken into someone's house, building, or car? Do you lie to obtain goods or avoid obligations? Have you stolen items without confronting a victim?" 1
• Ask about serious rule violations: "Have you stayed out at night despite parental prohibitions (before age 13)? Have you run away from home overnight? Are you truant from school?" 1
• Assess access to weapons and level of supervision, as this is critically important for safety 1
• Screen for bullying involvement as either perpetrator or victim, which indicates impaired functioning and risk for aggression 1

Substance Use Assessment

At minimum, all adolescents must be screened for substance use, as this is a common comorbidity and certain substances like marijuana can mimic ADHD symptoms 1:

• Direct questions about use: "Have you used alcohol, marijuana, stimulants, opioids, or other drugs? How often? How much? When did you last use?" 1
• Screen for stimulant-seeking behavior: "Are you trying to obtain stimulant medication to enhance academic or athletic performance?" 1
• Ask about consequences: "Has substance use caused problems at school, work, home, or with relationships? Have you driven under the influence? Have you had legal problems related to substance use?" 1
• Assess for substance dependence symptoms: tolerance, withdrawal, using more than intended, unsuccessful attempts to cut down 2

Developmental Conditions Assessment

Learning and Language Disorders

• Ask about academic performance: "What are your grades? Have you repeated any grades? Do you have an Individualized Education Program (IEP) or 504 plan?" 1
• Screen for specific learning difficulties: "Do you have trouble with reading, writing, or math compared to your peers? Have you ever been tested for learning disabilities?" 1
• Inquire about language problems: "Do you have difficulty understanding what others say? Do you struggle to express your thoughts? Do others have trouble understanding you?" 1

Autism Spectrum Disorders

• Ask about social communication difficulties: "Do you have difficulty understanding social cues? Do you struggle with back-and-forth conversations? Do you have trouble making or keeping friends?" 1
• Screen for restricted/repetitive behaviors: "Do you have very strong interests in specific topics? Do you prefer routines and get upset when they change? Do you have repetitive movements or speech patterns?" 1
• When autism is present, conduct functional analysis to determine if oppositional behavior represents true ODD versus autism-related communication difficulties or sensory issues 3

ADHD (if not already diagnosed)

• Screen for inattention: "Do you have difficulty sustaining attention? Are you easily distracted? Do you have trouble organizing tasks? Do you frequently lose things?" 1
• Screen for hyperactivity/impulsivity: "Do you fidget or squirm? Do you have difficulty remaining seated? Do you feel restless? Do you interrupt others? Do you have difficulty waiting your turn?" 1
• Establish onset before age 12: "When did these symptoms first appear? Can you or your parents recall specific examples from before age 12?" 1
• ADHD is comorbid in more than half of ODD cases and significantly impacts treatment response 4, 5

Physical Conditions Assessment

Tics

• Ask directly: "Do you have any repetitive movements or sounds that you can't control? Do you have eye blinking, facial grimacing, throat clearing, or other repetitive behaviors?" 1
• Inquire about waxing and waning course: "Do these symptoms come and go? Are they worse during stress?" 1

Sleep Apnea

• Screen for sleep-disordered breathing: "Do you snore loudly? Do you stop breathing during sleep? Do you wake up gasping? Are you excessively tired during the day despite adequate sleep time?" 1
• Ask about daytime consequences: "Do you fall asleep during the day? Do you have morning headaches? Do you have difficulty concentrating due to fatigue?" 1

Additional Critical Comorbidities for Adolescents

Depression and anxiety are common comorbidities that must be screened, as they affect treatment approach 1, 6:

• Depression screening: "Over the past 2 weeks, have you felt sad or hopeless? Have you lost interest in activities you used to enjoy? Have you had changes in sleep, appetite, or energy? Have you had thoughts of death or suicide?" 1
• Anxiety screening: "Do you worry excessively? Do you have panic attacks? Do you avoid situations due to fear? Do you have obsessive thoughts or compulsive behaviors?" 1, 6
• Assess for suicidal ideation and self-harm, as risks increase during adolescence 1

Sequencing and Diagnostic Considerations

• First, determine if oppositional behavior represents ODD versus a simple adjustment reaction to a stressor 1
• Second, establish whether this is still ODD or has progressed to conduct disorder, as CD symptoms are the most robust predictor of future antisocial outcomes 1, 7
• If comorbid conditions precede the onset of oppositionality, treating the comorbid condition may reduce or eliminate oppositional behavior 1
• Document duration of at least 6 months for ODD diagnosis, though early intervention using the same modalities is reasonable before 6 months in severe cases 1
• Assess functioning across multiple settings (home, school, work, social) to confirm pervasive impairment 1

Common Pitfalls to Avoid

• Failing to screen for substance use in adolescents, which can mimic or exacerbate psychiatric symptoms 1
• Not establishing symptom onset before age 12 for ADHD, which is required by DSM-5 criteria 1
• Overlooking internalizing comorbidity (anxiety, depression), which is present at all ages with ODD and varies by gender 6
• Ignoring the adolescent's self-report, which is the best predictor of stability for covert behaviors 1
• Failing to assess for trauma, posttraumatic stress disorder, and toxic stress, which are important comorbidities and risk factors 1