Oppositional Defiant Disorder

OPPOSITIONAL DEFIANT DISORDER

PRESENTATION OUTLINE

DSM-IV ODD Criteria

Secondary Symptoms

Prevalence Rates

Course / Onset

Genetics / Neurobiological Substrates

Assessment

Treatment

Models of ODD

DSM-IV ODD Criteria Revisited

The Road to DSM-IV ODD Criteria

DSM-III: Oppositional Disorder

- 2 of the following symptoms were needed:

- Violation of minor rules- Temper tantrums- Argumentativeness- Defiance- Provocativeness- Stubbornness

- Onset after age 3

-Symptoms must persist for at least 6 months

DSM-III-R: Oppositional Defiant Disorder

-“Stubbornness” was deleted

-“often” was added to each criterion

-5 symptoms were needed

-Onset after age three was eliminated

-No age minimum was set

DSM-IV ODD Criteria

Often loses temper

Often argues with adults

Often actively defies or refuses to comply with adults’ requests or rules

Often deliberately annoys people

Often blames others for his or her mistakes

Is often touchy or easily annoyed

Is often angry and resentful

Is often spiteful or vindictive

-The DSM-IV leaves open to interpretation how frequently a child has to demonstrate a behavior for it to be counted “often.”

-Behavior that is noncompliant, oppositional, or rule-violating is often seen during the preschool years.

DSM-IV ODD Criteria

A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which 4 (or more) of the following are present:

Often loses temper

Often argues with adults

Often actively defies or refuses to comply with adults’ requests or rules

Often deliberately annoys people

Often blames others for his or her mistakes

Is often touchy or easily annoyed

Is often angry and resentful

Is often spiteful or vindictive

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

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.

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

Secondary Features- Low self-esteem (or overly inflated

self-esteem)

- Mood lability

- Low frustration tolerance

- Swearing

- Precocious use of alcohol, tobacco, or illicit drugs

- Conflict with parents, teachers, and peers

Notes about Prevalence Rates

• Prevalence rates for ODD are affected by different types of assessment and are considered “method specific”

• Specific parameters affecting prevalence rates include: definitions and parameters of pervasiveness, severity, persistence, and impairment

Prevalence & CourseDiagnostic and Statistical Manual-Fourth Edition (APA, 2000)

Prevalence:• 2-16%

Course:• Onset usually before age 8 and not later than early

adolescence• Onset is gradual, occurring over course of months or

years• Developmental antecedent to CD; however, many

children with ODD do not go on to develop CD

Prevalence RatesNational Comorbidity Survey Replication (Nock, Kazdin, Hiripi, & Kessler, 2007)

• Estimated lifetime prevalence: 10.2%• Gender comparison for lifetime

prevalence: – Males: 11.2% *[3.2 to 1.4 males/females]– Females: 9.2%– Difference is not statistically significant

• Age comparison for lifetime prevalence: – 10-24 age range: 13.4%– >24: 7.5-10.1%

Prevalence RatesLifetime prevalence and median duration of ODD by age and sex

  Male     Female     Total  Lifetime Prevalence % se n % se n % se nAge 18-24 14.9 2.1 356 12 1.6 442 13.4 1.5 798 25-29 11.2 . 232 7.2 1.6 341 9.1 1.3 573 30-34 8 2 236 7.1 1.2 332 7.5 1.1 568 35-39 9.3 1.7 322 7.9 1.3 438 8.6 1.1 760 40-44 9.8 1.7 226 10.4 4.2 272 10.1 2.3 498 Total 11.2 1.1 1372 9.2 0.9 1825 10.2 0.8 3197Median Duration Mdn IQR n Mdn IQR n Mdn IQR nAge 18-24 5 4.8-8.0 70 5 3.0-9.0 69 5 4.0-9.0 139 25-29 5 2.0-8.0 33 4 3.0-6.0 30 4 2.0-7.0 63 30-34 8 3.0-17.0 31 7 5.0-14.0 38 7 5.0-14.0 69 35-39 8 4.0-16.0 43 7 4.0-10.0 50 7 4.0-13.0 93 40-44 11 5.0-24.0 30 4 3.0-11.0 27 7 3.0-21.0 57 Total 6 4.0-12.0 207 5 3.0-9.0 215 6 3.0-11.0 421Table: Knock, et al., (2007)

Onset and CourseNational Comorbidity Survey Replication (Knock, et al., 2007)

• Median age-of-onset: 12 years old– Self-reported onset begins at age four and

steadily increases into late adolescence

• Median duration: 6 years, varies little by sex or age

• Offset: Usually occurs before age 18 (>70% of respondents who report lifetime history of ODD no longer having symptoms)– Early onset of ODD, mood, anxiety,

impulse-control, and substance use disorders longer duration with ODD

Strengths and LimitationsNational Comorbidity Survey Replication (Knock, et al., 2007)

Limitations:• Use of retrospective self-report data• Diagnosis of ODD relied on a single

informant (self)

Strengths:• First to provide an estimate of

lifetime prevalence of ODD• New data on the persistence of ODD

Prevalence RatesBritish Child Mental Health Survey (Maughan, Rowe, Messer, Goodman, & Meltzer, 2004)

Gender Differences (based on diagnostic procedure)• Males: 3.2% met diagnostic criteria• Females: 1.4% met diagnostic criteria• Significantly more common in males

Differential Reporting:• Parents did not report significant gender differences• Teacher reports did report significant gender

differences

Age Trends

• Constant from age 5 to 10, then linear decrease in late childhood and adolescent years (same for both genders)

Strengths and Limitations

Limitations:• Focus on age was broad and future studies

should examine more specific age-ranges.Strengths:• Used clinically confirmed diagnoses• Multiple informants

Genetics/Neurobiological TraitsEtiology-Biological

GeneticsTwin studies evidence for

moderate genetic influence, but environment very important

Likely inherit risk factorsSensitivity to alcoholTemperamentIrritabilityImpulsivitySensation seekingAntisocial bias

Study Age N Pairs

ODD Assessment

Male-Male Twins

Female-Female Twins

Male-Female Twins

Heritability Estimate

(%)rMZ rDZ rMZ rDZ rDZ

VirginiaEaves et al. (1997)

8-16 1,355 Interview DSM-III-R symptom

count

Self-report .20 .13 .26 .00 .08 M: 21 / F: 23

Mother report .48 .30 .50 .21 .22 M: 53 / F:51

Father report .66 .21 .50 .14 .39 M: 65 / F: 49

MinnesotaS.A. Burt, Krueger, McGue, & Iacono

(2001)

10-12 753 Interview DSM-III-R symptom

count

Combined report

.69 .47 .69 .53 na M + F: 39

MissouriCronk et al., (2002)

11-23 1,948 Interview DSM-IV symptom

count

Mother report na na .82 .45 na F:79

Twin Studies of ODD

Note. ODD = oppositional defiant disorder; MZ = monozygotic; DZ = dizygotic; M = males; F = females. Heritability estimate in percentage of variation (or of variation in risk) due to genetic factors. Combined report is self-report and mother report combined. Unweighted M = 51 and weighted M = 60 from independent samples with multiple estimates form the same sample averaged.

Slutske,W. S., Cronk, N. J.,& Nabors-Oberg, R. E. (2003). Familial and genetic factors. In C. Essau (Ed.), Conduct and oppositional defiant disorders: Epidemiology, risk factors, and treatment (pp. 137–162). New Jersey: Lawrence. Erlbaum Associates.

Etiology-Biological(ref)

NeurophysiologicalBehavioral Inhibition System (BIS)

underactiveBehavioral Activation System (BAS)

overactiveOR both systems underactive as child tries to seek sensationReduced threshold for fight or flight

NeuropsychologicalFrontal lobesProblems with verbal and executive

functions

Assessment

• Comprehensive and empirically based• Tailor assessment battery to specific presenting

problem and child being evaluated• Consider context (school versus home)• Use multiple informants and multiple modalities • Gather information at multiple points• Conceptualize behavior within multiple domains

related to child functioning

Assessment: Rating Scales

Commonly Used Rating Scales:• Behavior Assessment System for Children

(BASC; Reynolds & Kamphaus, 1992)• Achenbach Series– Child Behavior Checklist (Parent Report)– Teacher Report Form (Teacher Report)– Youth Self Report (Self Report)

Assessment: Rating Scales

Benefits:• Gather info from multiple informants• Brief, take little time to administer• Easy to administer• Can allow detection of low-frequency behaviors• Normative DataIssues to consider:• Can measure differentiate among subtypes?• Validity of measure

Assessment:Structured/Semi-Structured Interviews

Commonly Used Interviews:

• Diagnostic Interview Schedule for Children (DISC; Shaffer et al, 1997)

• Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS; Ambrosini, 2000) http://www.wpic.pitt.edu/ksads/ksads-pl.pdf

• Child Assessment Schedule (CAS; Hodges, 1987)

• Diagnostic Interview for Children and Adolescents (DICA; Reich, 2000)

Assessment:Structured/Semi-Structured Interviews

Benefits:• Can collect more detailed information• Allows for enough coverage of core symptoms to differentiate

among subtypes• Can gather information on severity, onset, and situational

variables• Help determine attribution and reasoning behind the behaviorsLimitations: • Time consuming• Require specialized training in some cases

Assessment:Direct Observation• Allows clinician to see child behavior without the influence of

others’ opinions

• Can take place in the laboratory setting/clinic, at home, and at school

• Multiple settings and multiple time periods most accurate view

• Observe child in multiple interpersonal relationships as well (peers, parents, teacher)

• Trade off: More information but takes more time

• Example: CBCL Direct Observation Form (Achenbach Series)

Assessment:Other Techniques

• Sociometric Data

• Vignettes and Hypothetical Situations

Well-Established TherapyWell-Established

BEHAVIOR THERAPYParent Management Training

CRITERIA FOR WELL-ESTABLISHED THERAPY

1. There must be at least two good group-design experiments, conducted in at least two independent research settings and by independent investigatory teams, demonstrating efficacy by showing the treatment to be: (requires 1 of 2)

1. Statistically significantly superior to pill or psychological placebo or to another treatment.

2. Equivalent ( or not significantly different) to an already established treatment in experiments with statistical power being sufficient to detect moderate differences

2. Treatment manuals or logical equivalent were used for the treatment

3. Conducted with a population, treated for specific problems, for whom inclusion criteria have been delineated in a reliable, valid manner

4. Reliable and valid outcome assessment measures, at minimum tapping the programs targeted for change were used

5. Appropriate data analyses

Probably Efficacious TherapyProbably EfficaciousCBTAnger Control trainingRational-emotive mental health programBEHAVIOR THERAPYHelping the Noncompliant Child

Triple P (Positive Parenting Program) – Standard Individual treatment; EnhancedIncredible Years - Parent training; Child trainingParent-child Interaction Therapy

Problem-solving skills training (Standard; Plus practice; Plus parent management training)Group assertiveness training (Counselor-led; Peer led)Multidimensional treatment foster careMULTISYSTEM THERAPY

CRITERIA FOR PROBABLY EFFICACIOUS

(requires 1 of 2)

1. There must be at least two good experiments showing the treatment is superior (statistically significantly so) to a wait-list control group.

2. One or more good experiments meeting the Well-Established Treatment Criteria with the one exception of having been conduct3ed in at least two independent research settings and by independent investigatory teams.

Possibly EfficaciousCRITERIA FOR POSSIBLY EFFICACIOUS

1. At least one “good” study showing the treatment to be efficacious in the absence of conflicting evidence.

Possibly EfficaciousCBTGroup Anger Control Training

Reaching Educators, Children, and Parents (RECAP)

BEHAVIOR THERAPYTriple P (Positive Parenting Program) – standardized group treatment

First Step to Success Program

Self-administered Treatment, Plus Signal Seat

Coercion Theory

Child irritable, active, has difficult temperament, low

frustration tolerance

Crying/arguing with parent is aversive—parent terminates

the aversive behavior by giving in

to demands

Child is reinforced for their negativistic

behavior – learns ‘timing’

MotherInconsistent parenting (laughs at and punishes same types of behavior on

different occasions) Depressed Antisocial tendencies (in some) Lack of follow through Divorced

Mother is negativelyreinforced via the removal of an aversiveStimuli/event

Attachment Theory

Limitations:• Findings are inconsistent• Insecure attachment is not a necessary or

sufficient cause of ODD• Does not account for the multitude of

variables associated with ODD

Interactional-Developmental-Etiological Approach

(ref)

Interactional-Developmental-Etiological Approach

IDEA:• integrates broad findings• emphasis on ongoing child development

examines the numerous ways in which risk factors and pathways interact with each other

• accounts for children’s biology and how it is influenced by genetics and environment

Interactional-Developmental-Etiological Approach

• Genetic Factors: influence of genetics on parental psychopathology, parenting behavior, and child child disposition

• Environmental Factors: SES, parenting, marital relationship, and peer influence

• Dispositional Factors: age, gender, temperament, reward-dominance, CU traits, cortisol levels, IQ, and social cognition

3-Dimensional Theory of OppositionalityStringaris & Goodman, 2009

• Associated with emotional disorders.Irritable

• Associated with ADHD.Headstrong

• Associated with aggressive symptoms of CD.Hurtful