the aggressive child: oppositional defiant disorder

The Aggressive Child: Oppositional Defiant Disorder

Robert Hilt, MD, FAAPMay 5th, 2012

May 5, 2012PAL Conference

Disclosure Statement•I have no relevant financial relationships

with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.


Some examples of child aggression


Case “A”•6 year old boy•Angry if video games limited•Talks back to mom and teachers•Bossy with friends•Hits younger sister•During tantrum, poked mom’s face out of

a family portrait


Case “B”•10 year old girl•Hyperactive & inattentive since preschool•Gets frequent timeouts for being “bad”•Is disliked by peers at school•Seems bright, but has poor grades•Now hitting parents/peers when doesn’t

get her way


Case “C”•15 year old boy now in Wyoming Boy’s

School•Assault, burglary, arson, shoplifting•Using and selling drugs•Parents have criminal history•History of school failure•Aggression problems since elementary

school


What is Aggression?•Forceful action or procedure, often with

intent to dominate or master•Usually results from an inability to resolve

a self-perceived vital conflict or need through a non-forceful means

•Is not always pathological: aggression can be socially appropriate or developmentally normal


Developmental Aggression•Infants promote bonding with early

behavior•Anger appears by age 6 months•Toddlers show defiance as they

individuate•Tantrums diminish, social conformity

increase in school age children•Testing new limits, impulses in early teens


Development of Aggression

From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)



Hitting, Biting, Kicking age 2-11 years


Violent Crime in Young Adults



Oppositional Defiant Disorder: What Is It?•Recurrent pattern of negativistic, hostile,

defiant behavior▫More frequent than typical for age▫Causes impaired functioning▫Usually present by age 8 years


DSM-IV ODD checklist:4 + symptoms within past 6 months

1. Often loses temper2. Often argues with adults3. Often actively defies or refuses to comply with

adult requests or rules4. Often deliberately annoys people5. Often blames others for his or her mistakes or

misbehavior6. Often touchy or easily annoyed by others7. Often angry or resentful8. Often spiteful or vindictive


Gender Differences in Aggression•Males: relatively more physical attacks

•Females: relatively more verbal or relational attacks


Prevalence of ODD•About a 5% current prevalence rate

▫Pre-pubertal boys > girls

•Fairly persistent symptoms▫About 3/4 still meet criteria ~2 years after

diagnosis


Causes of ODD•Research consistently points toward a

multifactorial origin▫Psychology▫Biology▫Social/School▫Family


Psychological Contributing Factors•Disordered processing of social

information:▫Underutilize social cues

i.e. don’t respond to a frown▫Misattribute hostile intent

i.e. think accidental contact was an attack▫Generate fewer solutions to problems▫Expect a reward from aggression

Intermittent reinforcement


Psychological Contributing Factors•Insecure attachment

▫Reactive Attachment Disorder a clear example Found in chronic neglect/maltreatment Honeymoon phase, then mistrust of new

caregivers Extreme oppositional limit testing


Social Contributing factors•Community violence

▫Especially antisocial behavior within the family

•Lack of parental supervision•Lack of positive parental involvement•Inconsistent discipline•Marital discord•Child abuse•Bullying•School failure


Biological Contributing Factors•Exogenous biological factors

▫drugs in utero, toxins, malnutrition•Endogenous biological factors

▫Low sympathetic responsiveness ▫Low cortisol▫High testosterone▫Cognitive processing deficits

Communication deficits especially•Temperament


What is Temperament?•Stable personality traits traceable from

infancy through adulthood•Some of these traits are noted as more

difficult to parent:▫High intensity▫More negative moods▫Irregular patterns▫Negative first impressions ▫Less readily adaptable to change

Chess & Thomas, NY Longitudinal Study


Temperament and ODD•Helpful to think that most ODD is

related to mismatch in fit between:▫Child’s temperament ▫Parent’s (& society’s) expectations

Chess & Thomas, NY Longitudinal Study


The Vicious CycleNegativ

e Behavio

r

(child reacts

negatively, has

outburst)

Negative

Attention

(Parent yells at child,loses

control )

May 5, 2012 PAL Conference

ODD and the Vicious Cycle•Break the cycle by

▫Parenting education Including behavior management training

▫Show parent that other responses to child can yield better results

▫Special time/positive time for parent and child

▫Parent support, therapy an un-nurtured parent can’t help their

difficult child


Teaching Skillful Parent Responses to a Tantrum


Example of less skilled response•“Put the toy away”•Child yells or tantrums•Parent yells back, aversively demands

compliance

•Child may learn:▫they only mean it when they explode▫this is the only attention I get, which is

better than nothing


Another Example of less skilled response•“Put the toy away”•Child yells or tantrums•Parent removes the demand

▫Child learns that tantrums work


A more skillful response•“Put the toy away”•Child yells or tantrums•One calm repetition of the request

•Follow with firm limit regarding any continued or worsening behavior▫i.e. withdraw attention/praise until task is

completed▫No parent “explosion”


Therapy for ODD•Behavior management training (often called

parent training)▫Evidence based treatment for age <5

•Child training▫EBT for middle/high school age▫Requires active child participation

•Multicomponent treatment▫Delinquent adolescents▫Use both of the above▫Examples are MST, MTFC

SM Eyberg et al 2008


Behavior Management Training•Generally done by a psychologist or other

skilled mental health therapist•Teaches behavioral techniques to reduce

family stress and child oppositionality▫Including proper use of “time out”

•Often uses “token economy” system•Parents learn better communication with

school


Specific Examples of Behavior Management Training Programs•Helping the Noncompliant Child (HNC)•Incredible Years•Parent-Child Interaction Therapy (PCIT)•Parent Management Training Oregon

Model (PMTO)•Positive Parenting Program (Triple P)


Common Elements in ODD Therapy that works

From 2007 Hawaii CAMHD review, n=88 studies


Encourage Regular “Special Time”•Pick a multiple times a week occasion

▫15-30 minutes long•Child selects the activity•Label it “special time”•Happens regardless of good vs. bad

day•1:1 without interruption•End on time•Parent needs their own time too

From www.palforkids.org


Problem with good behavior training•Parents often resist treatments centered

on them▫Child-only treatment is unlikely to succeed

•Manual based, evidence based treatments are hard to find▫If therapist works directly with parents,

greater chance of success▫Parenting skills groups can help▫Supplement with self-help

learning/readings


Value of Self-Directed Treatment•“Bibliotherapy” worked just as well as

therapist lead therapy in a RCT of “Incredible Years” program▫Unless family attended 9 or more therapist

sessions, then the therapist group did better

JV Lavigne et al 2008


Excerpt from Hilt 2010 Primary Care Principles for Child Mental Health, www.wyomingpal.org

Self-Help Behavior Management May 5, 2012PAL Conference

Give Time Out Tips for success• Set limits that are consistent• Focus on changing only one misbehavior at a

time• After announce the time out, do not continue to

engage• Time outs occur immediately after the

misbehavior• If use warnings, make them count• Keep your cool• You (not child) determine when time out is done• Need to have other positive times with your child

• Key is an immediate, temporary withdrawal of positive parent attention

From www.wyomingpal.org


After making a therapy referral:•Encourage good parent/teacher

communication•Suggest self help supplements•Monitor if the intervention helps•Consider co-morbidities

▫Especially if not improving


ODD Comorbities•ADHD

▫ about 10x the frequency as general population•Major Depression

▫ about 7x the frequency as general population•Substance Abuse

about 4x the frequency as general population


ADHD and ODD•About 50% of ADHD cases have co-morbid

ODD

•Still, need to be cautious about over-calling presence of ADHD▫Particularly if very young


Young Children and ADHD• Some degree of inattention, hyperactivity and

defiance is developmentally normal for preschool children▫ So is it normal for the age?

• At least 1/3rd of all preschoolers in one survey noted by their parents to have significant inattention or hyperactivity▫ compare to the ~7% lifetime prevalence of ADHD

Smidts DP and Oosterlaan J 2007;JAACAP practice parameter 2007


Sorting “Normal” from ADHD• Peer context• Persistence across settings• Functional impairment• Increase skepticism with lower age

▫ Age 6 and up, rating scale impairment assessments of home/school are thought to be reliable

▫ 4-5 years I have more skepticism▫ 3-4 years I’m very skeptical▫ <3 years very few in psychiatry would say is possible

to make an ADHD diagnosis


Classroom Interventions for ADHD•You can recommend the following:

▫Smaller Class size▫Sit in front▫Clear rules and consequences▫Slower assignment pace▫Untimed tests▫Daily parent to teacher communication▫Homework tutoring


First Line Medications for ADHDTwo general groups of medicines

StimulantsNon-stimulants

When one fails, stop it and try anotherIf med. treatment unsatisfactory:

Think comorbidityRe-evaluate diagnosisConsider behavior therapy and/or

alternative medications


If determine has ADHD and ODD•Treating ADHD is shown to significantly

improve the ODD▫Stimulants, in particular▫Less evidence for other medications


Review of Comorbid ODD/ADHD trials•Methylphenidate

▫7 RCTs all show decreased aggression Effect size ~0.75

•Atomoxetine▫4 RCTs show mildly decreased aggression

Effect size ~0.15

E Pappadopulos et al, 2006


What About Conduct Disorder?•Often follows ODD•Aggression to people and animals•Destruction of property

▫Fire setting•Deceitfulness or theft

▫Lies to obtain goods•Serious violations of rules

▫Running away, frequently truant


Conduct Disorder•About ½ of conduct disorder children

continue these problems into adulthood

•Often associated with ▫Substance abuse▫Mood disorders▫Anxiety disorders▫Learning/cognitive disorders


Conduct Disorder•Inherent failure of parental authority

▫Are there other parenting arrangements that would work better?

▫Occasionally substitute authority (even a judge) can make a positive difference

•Inherent rejection of available motivations to do “good”▫Other ways to motivate in a positive

direction?


Multi-Systemic Therapy•Steer teens into positive peer group

associations•Support parents•Support school•Behavior management training•Problem solving skills training

•Research supported for chronic, violent juvenile offenders


Medications for ODD and Conduct Disorder?•Yes, if a treatable comorbidity

▫ADHD▫Depression▫Anxiety

•Discourage their use if no treatable comorbidity


Hot versus Cold Aggression•“Cold” aggression is calculating, planned,

instrumental to obtain a goal▫Not reduced by medications

•“Hot” aggression is impulsive, poorly planned, has high CNS fight/flight arousal▫Might be reduced by medications


Medication role with “hot” aggression•Not to be a primary treatment

▫Primary treatment is psychosocial

•If necessary, would consider:▫Alpha agonists▫Beta blockers▫Antipsychotics▫“mood stabilizers” (like lithium/valproic

acid)▫None FDA approved for this indication


Bipolar Disorder NOS: “everyone” has it now

•Label often given to impulsive, aggressive kids▫“rapid cycling”▫No true mania has occurred

•Often the justification for medication treatment

•Future prognosis rarely is to have true bipolar


Bipolar NOS•Why so commonly diagnosed?

▫Sounds better to us than “I don’t know”•Bipolar medicines have many non-specific

effects▫All can decrease impulsivity and aggression ▫We see a response & think the bipolar label

must have been correct


Key Points: Why Do Kids Get Agitated?•Environmental trigger

▫i.e. self-defense, stress•Facilitated by an acute disorder

▫i.e. depression, panic disorder•Inherent to a chronic disorder

▫i.e. ODD, Conduct Disorder•Child feels is the best way to obtain a goal

▫i.e. has poor language ability


Key Points with Aggression•Is multifactorial•Best intervention is with child’s

environment rather than child self-reflection to change

•Self-help parent readings/videos are almost as good as therapist treatments

•Look for treatable comorbidities (i.e. ADHD)

•Resolve any recurring conflicts (i.e. bullying)

•Medications are infrequently the answer for ODD/conduct disorder


Questions?

www.wyomingpal.org877-501-7257


the aggressive child: oppositional defiant disorder

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