Oppositional Defiant Disorder (ODD)

Thien-An Le

Oppositional Defiant Disorder Intermittent Explosive Disorder Antisocial Personality Disorder Pyromania Kleptomania Other Specified Disruptive, Impulse-Control,

and Conduct Disorder Unspecified Disruptive, Impulse-Control, and

Conduct Disorder

Disruptive, Impulse-Control, and Conduct Disorders

Four+ symptoms for at least 6 months:

Pattern of angry/irritable mood, includes: ◦ Often loses temper,◦ Often touchy or easily annoyed, ◦ Often angry and resentful.

Argumentative/defiant behavior, includes: ◦ Argues w/authority figures or adults, ◦ Actively defies or refuses to comply w/requests from

authority figures or w/rules, ◦ Deliberately annoys others, ◦ Often blames others for his/her mistakes or misbehavior.

Vindictiveness, includes:◦ Spiteful or vindictive at least twice within the past six

months.

DSM-V Review: Diagnostic Criteria

 For children < 5 years, the behavior should occur on most days for a period of at least 6 months.◦  5 + y/o, the behavior should occur at least once per week for at least 6

months.

Frequency and intensity of the behaviors are outside normative range ◦ Including: developmental level, gender, and culture.

Behavior associated with distress: ◦ individual or others in his or her immediate social context or,◦ impacts negatively on social, educational, occupational, or other

important areas of functioning.

Do not occur exclusively during the course of a psychotic disorder, substance use, depressive, or bipolar disorder and criteria are not met for disruptive mood dysregulation disorder.

Mild, Moderate and Severe Specifications

DSM-V: Diagnostic Criteria Cont’d

ODD- Dr. Phil

Video Clip

Angry/irritable ◦ Temper,◦ Easily annoyed, ◦ Resentful.

Argumentative/defiant behavior◦ Argues w/mom◦ Defying mom◦ Refusing to comply w/requests from mom◦ Refuses to comply with mom◦ Deliberately annoyed mom elbowing her on plane◦ Blames mom for misbehaviors “you jabbed me first”

Vindictiveness◦ Spiteful or vindictive

Symptoms Displayed

ODD is associated with increased risk of other mental disorders during childhood AND adulthood beyond the effects of CD (Burke et al., 2005).◦ Approximately 1/3 children CD (Hamilton & Armando, 2008)◦ Approximately 40% Anti-Personality Disorder (Hamilton & Armando, 2008)

Associated suicide attempts

Increased risk for adjustment as adults◦ Academic failure,◦ Antisocial behavior, ◦ Rejection by peers,◦ Low self-esteem,◦ Impulse-control problems, ◦ Substance abuse,◦ Anxiety, and ◦ Depression. 

Impairments in emotional, social, academic, and occupational adjustment.◦ Parents, teachers, supervisors, peers, and romantic partners.

DSM-V: Associated and Secondary Features

Prevalence: 1-11%, avg. of 3.3%.

More prevalent in families in which child care is disrupted by a succession of different caregivers or families in which harsh, inconsistent, or neglectful child-rearing practices are common.

Rate depends on age and gender of child.

Somewhat more prevalent in males prior to adolescence.

DSM-V: Prevalence

First symptoms usually appear during preschool and behaviors are frequent during preschool and adolescence.◦ Important to evaluate intensity and frequency vs. normative levels.

ODD often precedes development of CD.◦ Childhood-onset type of conduct disorder.◦ Many children and adol. w/ODD do not subsequently develop CD.

Course: 3 years

Manifestations of ODD across development are consistent.

DSM-V: Onset and Course

Temperamental: problems in emotional regulation predictive of ODD.◦ i.e.: High levels of emotional reactivity, poor

frustration tolerance angry/irritable moods.◦ Related to abnormality of the amygdala and

prefrontal cortex (PFC).

DSM-V: Risk and Prognostic Features

Temperamental

Neurobiological markers:◦ Lower heart rate and skin conductance reactivity,

reduced basal cortisol reactivity, abnormalities in the PFC and amygdala. Reduced basal cortisol reactivity associated with higher

rates of aggression and with poor social relationships (Booth, Granger, & Shirtcliff, 2008).

PFC regulation of behavior, cognition, and attention (Arsten, 2006).

Amygdala emotion regulation.

May not be specific to oppositional defiant disorder, also similar in conduct disorder.

DSM-V: Risk and Prognostic Features

Genetic and physiological

Disrupted by a succession of different caregivers or families in which harsh, inconsistent, or neglectful child-rearing practices are common.

Associated w/distress in the individual or others in his/her immediate social context.o Could impact negatively on social, educational, occupational, or other

areas of functioning.

Often justify their behaviors as a response to unreasonable demands/circumstances.◦ Do not consider themselves as being angry, oppositional, or

defiant difficult to disentangle relative contribution of the individual with the disorder to problematic interactions

◦ i.e.: Hostile parenting ODD? or ODD Hostile parenting?

DSM-V: Risk and Prognostic Features

Environmental

Higher rate of substance use disorders.◦ Independent?

ODD higher in samples of children, adolescents, and adults with ADHD.◦ Shared temperamental risk factors.

Risk for development of anxiety disorders and major depressive disorder.◦ Defiant, vindictive, & argumentative symptoms carry most risk CD◦ Angry-irritable mood symptoms emotional disorders.

DSM-V: Comorbidity

DSM-V Model

Symptoms are relatively the same.◦ DSM-V categorizes the symptom groups.◦ DSM-V more specific: spiteful or vindictive at least twice within the past 6

months.

DSM-V:◦ Includes consideration of environmental factors in Criteria.◦ Includes caveat for substance use, depressive, or bipolar disorder in Criteria.◦ Distinguishes the age-specific behavioral criteria.

Before and after 5 years of age criteria.

DSM-IV-TR: ◦ Criteria D: Criteria are not met for Conduct Disorder, and, if the individual is

age 18 years or older, criteria are not met for Antisocial Personality Disorder

Classified in different categories.

DSM-IV-TR to DSM-V Changes in Diagnostic Features

Literature Based Theories of ODD

Recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient and hostile behavior toward authority figures. ◦ Including actively defying or refusing to comply with adult

rules and requests, frequent temper outbursts, and excessive arguing

◦ (Anderson et al., 1986; Dumas and LaFrenier, 1993; Dumas et al., 1995; Lytton, 1990; Rey et al., 1988; Schacher and Wachsmuth, 1990; Stormchack et al., 1997)

Arguing with adults, losing one’s temper, and angry or intentionally annoying behavior (Dick et al., 2005).

Diagnostic Description

Early childhood (Dick et al., 2005)

Children with ODD often are diagnosed with CD when they reach adolescence (Dick et al., 2005)

◦ Not all individuals with CD have had a previous diagnosis of ODD.

◦ 3x as likely to develop CD (Lahey, McBurnett, & Loeber, 2000).

◦ Lahey-Loeber Model of comorbity: Only children with ADHD who also exhibit comorbid ODD will

develop CD. Then later develop APD (Loeber et al., 2000).

Diagnostic Onset and Course

Diagnostic Onset and Course

Temperament:◦ Predictive of externalizing behavior problems by

late childhood (Sanson and Prior,1999).◦ Temperamental difficulties due to psychosocial

early life risk factors Low income Maternal depression, social stress, and

support and home environment (Shaw et al., 2001).

Attachment?◦ (Burke et al., 2002)

Risk and Prognostic FeaturesTemperament

Coercive parenting behaviors (Patterson, 1984; Eddy et al., 2001; Stormshak et al., 2000)

Low parental warmth and involvement Oppositional child behavior (Stormashak et al., 2000)

Child abuse (Dodge et al.,1995)

◦ Demonstrated social processing deficit conduct problems Association with deviant peers (Elliott and Menard, 1996; Keenan et al., 1995;

Simons et al., 1996) :◦ Initiation of delinquent behavior in boys◦ For girls, more common with an early onset of pubertal maturation (Stattin

and Magnusson, 1990)

Peer Rejection conduct problems and aggressive responding◦ Peer rejection Conduct problems◦ (Coie and Dodge, 1998; Coie and Lenox, 1994; Dodge et al., 1990; Bolger and Patterson,

2001).

Risk and Prognostic Features Environmental Factors

Community Factors:◦ Community disorganization, drug availability, presence of

neighborhood adults involved in crime (Herrenkohl et al., 2000)

◦ Exposure to violence and exposure to racial prejudice (Hawkins et al., 1998)

Unemployment (Fergusson et al.,1997), Neighborhood violence (Guerra et al.,1995) Family poverty and children’s aggression (among

white children alone) (Guerra et al.,1995) Low income (Shaw et al., 2001) and Duration of poverty (McLoyd,1998)

Risk and Prognostic Features Environmental Factors Cont’d

Prenatal smoking (Landgren et al., 1998; Hill et al., 2000)

Prenatal maternal alcohol use (Hill et al., 2000)

Maternal viral illness (Mellins et al., 2006)

Parental separation (Fergusson et al., 1994; Sullivan et al., 1995)

Early deprivation (Zeanah et al., 2005)

Adoption (Sullivan et al., 1995)

Risk and Prognostic Features Environmental Factors Cont’d

Based on the Coercion theory.

Patterson hypothesized that aggressive behavior develops in families when parents use coercion as the primary mode for controlling their children.

A child who has received abundant negative reinforcement for aversive behaviors and little positive reinforcement for appropriate behaviors ◦ Likely to encounter major difficulties in academic and peer settings

middle childhood.

Parental failure to discipline, which is thought to be a major determinant for increases in antisocial child behavior.

Patterson’s Model

Behavioral event is initiated by the child ◦ Arguing, crying, etc…◦ Highly aversive to the caregiver

Caregiver terminates aversive state by “caving in” to the demands of the child◦ Negative reinforcement conditioning mechanism ◦ Escape behavior

Strengthens the child's behavior of exhibiting ODD

Strengthening the caregiver's inappropriate behavior.

Patterson’s Model

Patterson’s Coercion Theory

Infant irritable cries / Infant is hungry

Mother attends and terminates aversive state

Infant irritable crying is reinforced

Mother attends / All other infant behavior Mother reinforces infant prosocial behavior

Intra-Individual level of analysis: Two conditionals for a contingency model.

Patterson’s Coercion Theory

Child irritable, active, has

difficult temperament

ParentingDisciplineTrackingTeachingInvolved

Relative rate reinforce coercive behavior

Relative rate reinforce prosocial behavior

MotherDepressedAntisocial

Pregnancy and birth Complications

HyporesponsiveDivorce

Genetic influences on behavior (twin studies):◦ Delinquent set of behaviors:

Rule-breaking behaviors: 30-79% (Bartels et al., 2003). Girls: 56%-72% of variance in Rule-breaking accounted by genetic

factors. When assessed by both parents: 80% covariance for rule-breaking due

to genetics. Aggression:

51%-72% (Bartels et al., 2003).

◦ Familial negativity and adolescent antisocial behavior 51%-60% (Pike et al., 1996).

◦ Functioning of PFC Composite genotypes (Nigg et al., 2007).

Risk and Prognostic Features Genetic Factors

Genetic correlation between CD and ODD.◦ Joint Construct (Eaves et al., 2000; Nadder, Rutter,

Silberg, Maes, & Eaves, 2002).

Genetic influences contributes to covariation between ADHD and ODD (Dick et al., 2005)

CD, ADHD, and ODD are largely explained by shared genetic influences (Dick et al., 2005).

Risk and Prognostic Features Genetic Comorbidity

PFC (Nigg et al., 2007). :◦ May be involved in overcoming psychosocial adversity.◦ Dopamine

Developmental pathways (Burke et al., 2002):◦ Pathways to serious conduct and delinquent problem behavior.

Frontal Lobe (Baving et al., 2000):◦ Atypical EEG in frontal lobe activation patterns.◦ Brain asymmetry in oppositionally defiant girls and boys ((F1,33=4.45, p <.05) and (F1,24=4.75, p <.05)

respectively)

Autonomic Nervous System (van Goozen et al., 1998).:◦ Lower levels of baseline heart rate◦ Experimentally induced HIGHER heart rate.

Less gray matter (Fahim et al., 2012):◦ Left orbitofrontal cortex.

Less white matter (Fahim et al., 2012):◦ Left Superior frontal area.

Increase in left temporal area (Fahim et al., 2012): ◦ Associated with aggressive, impulsive, and antisocial personality.

Risk and Prognostic Features Neurophysiological Factors

Risk and Prognostic Features Neurophysiological Factors

Risk and Prognostic Features Neurophysiological Factors

Fahim et al., 2012

Risk and Prognostic Features Neurophysiological Factors

Fahim et al., 2012

Low salivary cortisol level (van Goozen et al., 1998).

Dopamine transporter, dopamine D4 receptor, noradrenergic alpha-2 receptor (Nigg et al., 2007).

Testosterone and aggression (Pliszka, 1999).

Serotonin and aggression (Clarke et al., 1999; Kruesi et al., 1992).

◦ Regulation of mood and impulsive behavior (Davidson et al., 2000).

Risk and Prognostic Features Neurochemical Factors

Risk and Prognostic Features Neurochemical Factors

van Goozen et al., 1998

Early physical maturation:◦ Increased problem behaviors in girls (Graber et al., 1997;

Laitinen- Krispijn et al., 1999; Stattin and Magnusson, 1990),

◦ but not in boys (Graber et al., 1997).

“Off-time” in pubertal development:◦ associated with deviant social status and thus

contributes to antisocial behavior (Williams and Dunlop,1999).

◦ Delayed pubertal onset Estrogen and testosterone administration increased aggression (Finkelstein et al., 1997).

Risk and Prognostic Features Developmental Factors

Developmental Pathway (Loeber and Stouthamer-Loeber, 1998):◦ Behavioral development of a group of individuals that is different from the

behavioral development of another group or other groups of individuals.

Pathways to serious conduct and delinquent problem behavior:◦ Overt Pathway:

Minor aggression to physical fighting and then violence◦ Covert Pathway:

Before age 15 Minor covert behaviors to property damage (fire setting or vandalism), and then Moderate to serious forms of delinquency

◦ Authority Conflict Pathway: Before age 12 From stubborn behavior to defiance Authority avoidance

Developmental Pathways of ODD

Developmental PathwaysMore applicable for CD, but strong overlap

Developmental Pathways

Latimer et al., 2012:◦ Prenatal cigarette smoking and alcohol use, ◦ Prenatal viral illness, ◦ Maternal stress and anxiety, ◦ Low birthweight, ◦ Peripartum and early neonatal complications,◦ Parental stress and parenting styles in infancy, ◦ Early deprivation, ◦ Adoption and ◦ Separation.

Shared Risk Factors: ODD, CD, and ADHD

Prevention (Burke et al., 2002; Coie and Jacobs, 1993; Loeber and Farrington, 1998):◦ Parent-directed component◦ Social-cognitive skills training◦ Academic skills training◦ Proactive classroom management◦ Teacher training

Interventions on parenting factors:◦ Focus is on multiple domains and needs (Catalano et al., 1998)

Individual Intervention (Brestan and Eyberg, 1998):◦ Anger control/stress inoculation ◦ Assertiveness training◦ Rational-emotional therapy◦ Problem-solving skills training (Kazdin, 1996; Webster-Stratton and Hammond, 1997)◦ Moral development interventions (Arbuthnot, 1992)

Parent and Family Treatment:◦ Parent management training (Brestan and Eyberg, 1998)◦ Parent child interaction training (Schuhmann et al., 1998)

Integration of universal, targeted, and clinical intervention strategies (Offord et al., 1998)

Multisystemic Therapy (MST)

Behavioral Treatment

In order to best deal with a youth in trouble, treatment must target the many "systems" that impact the youth:• Family, • School environment, • Friendships and,• Peer pressures.

Works closely with the parents and child for 3-5 months in their home and community.◦ Emphasizes recognized risk factors associated with antisocial

behavior.◦ Goal-oriented and focuses on helping the caregivers manage and

nurture their challenging children more effectively. Project LIFT (Reid et al, 1999)

Parent training + classroom social skills + playground behavior + systematic communication

MST Treatment

Psychopharmacological Treatment◦ Mood stabilizers, ◦ Antipsychotics, ◦ Clonidine,◦ Stimulants (Burke, 2002)

Psychopharmacological Treatment

Theoretical Model

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