The Aggressive Child: Oppositional Defiant Disorder

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The Aggressive Child: Oppositional Defiant Disorder. Robert Hilt, MD, FAAP May 5th, 2012. 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. - PowerPoint PPT Presentation

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Agitation Care in the Emergency Department

The Aggressive Child: Oppositional Defiant DisorderRobert Hilt, MD, FAAPMay 5th, 2012May 5, 2012PAL ConferenceDisclosure StatementI 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.May 5, 2012PAL ConferenceSome examples of child aggressionMay 5, 2012PAL ConferenceCase A6 year old boyAngry if video games limitedTalks back to mom and teachersBossy with friendsHits younger sisterDuring tantrum, poked moms face out of a family portrait

May 5, 2012PAL ConferenceCase B10 year old girlHyperactive & inattentive since preschoolGets frequent timeouts for being badIs disliked by peers at schoolSeems bright, but has poor gradesNow hitting parents/peers when doesnt get her way

May 5, 2012PAL ConferenceCase C15 year old boy now in Wyoming Boys SchoolAssault, burglary, arson, shopliftingUsing and selling drugsParents have criminal historyHistory of school failureAggression problems since elementary school

May 5, 2012PAL ConferenceWhat is Aggression?Forceful action or procedure, often with intent to dominate or masterUsually results from an inability to resolve a self-perceived vital conflict or need through a non-forceful meansIs not always pathological: aggression can be socially appropriate or developmentally normalMay 5, 2012PAL ConferenceDevelopmental AggressionInfants promote bonding with early behaviorAnger appears by age 6 monthsToddlers show defiance as they individuateTantrums diminish, social conformity increase in school age childrenTesting new limits, impulses in early teensMay 5, 2012PAL ConferenceDevelopment of Aggression

From Developmental Origins of Aggression by Tremblay, Hartup and Archer (2005)May 5, 2012PAL Conference

From Developmental Origins of Aggression by Tremblay, Hartup and Archer (2005)Hitting, Biting, Kicking age 2-11 yearsMay 5, 2012PAL ConferenceViolent Crime in Young Adults

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

May 5, 2012PAL ConferenceOppositional Defiant Disorder: What Is It?Recurrent pattern of negativistic, hostile, defiant behaviorMore frequent than typical for ageCauses impaired functioningUsually present by age 8 yearsMay 5, 2012PAL ConferenceDSM-IV ODD checklist:4 + symptoms within past 6 monthsOften loses temperOften argues with adultsOften actively defies or refuses to comply with adult requests or rulesOften deliberately annoys peopleOften blames others for his or her mistakes or misbehaviorOften touchy or easily annoyed by othersOften angry or resentfulOften spiteful or vindictiveMay 5, 2012PAL ConferenceGender Differences in AggressionMales: relatively more physical attacks

Females: relatively more verbal or relational attacks

May 5, 2012PAL Conference14Prevalence of ODDAbout a 5% current prevalence ratePre-pubertal boys > girls

Fairly persistent symptomsAbout 3/4 still meet criteria ~2 years after diagnosis

May 5, 2012PAL ConferenceCauses of ODDResearch consistently points toward a multifactorial originPsychologyBiologySocial/SchoolFamily

May 5, 2012PAL ConferencePsychological Contributing FactorsDisordered processing of social information:Underutilize social cuesi.e. dont respond to a frownMisattribute hostile intenti.e. think accidental contact was an attackGenerate fewer solutions to problemsExpect a reward from aggressionIntermittent reinforcementMay 5, 2012PAL ConferencePsychological Contributing FactorsInsecure attachmentReactive Attachment Disorder a clear exampleFound in chronic neglect/maltreatmentHoneymoon phase, then mistrust of new caregiversExtreme oppositional limit testingMay 5, 2012PAL ConferenceSocial Contributing factorsCommunity violenceEspecially antisocial behavior within the familyLack of parental supervisionLack of positive parental involvementInconsistent disciplineMarital discordChild abuseBullyingSchool failure

May 5, 2012PAL ConferenceBiological Contributing FactorsExogenous biological factorsdrugs in utero, toxins, malnutritionEndogenous biological factorsLow sympathetic responsiveness Low cortisolHigh testosteroneCognitive processing deficitsCommunication deficits especiallyTemperamentMay 5, 2012PAL ConferenceWhat is Temperament?Stable personality traits traceable from infancy through adulthoodSome of these traits are noted as more difficult to parent:High intensityMore negative moodsIrregular patternsNegative first impressions Less readily adaptable to changeChess & Thomas, NY Longitudinal StudyMay 5, 2012PAL ConferenceTemperament and ODDHelpful to think that most ODD is related to mismatch in fit between:Childs temperament Parents (& societys) expectationsChess & Thomas, NY Longitudinal Study

May 5, 2012PAL ConferenceThe Vicious CycleMay 5, 2012PAL ConferenceODD and the Vicious CycleBreak the cycle byParenting educationIncluding behavior management trainingShow parent that other responses to child can yield better resultsSpecial time/positive time for parent and childParent support, therapyan un-nurtured parent cant help their difficult childMay 5, 2012PAL ConferenceTeaching Skillful Parent Responses to a TantrumMay 5, 2012PAL ConferenceExample of less skilled responsePut the toy awayChild yells or tantrumsParent yells back, aversively demands compliance

Child may learn:they only mean it when they explodethis is the only attention I get, which is better than nothingMay 5, 2012PAL ConferenceAnother Example of less skilled responsePut the toy awayChild yells or tantrumsParent removes the demand

Child learns that tantrums workMay 5, 2012PAL ConferenceA more skillful responsePut the toy awayChild yells or tantrumsOne calm repetition of the request

Follow with firm limit regarding any continued or worsening behaviori.e. withdraw attention/praise until task is completedNo parent explosion

May 5, 2012PAL ConferenceTherapy for ODDBehavior management training (often called parent training)Evidence based treatment for age

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