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Oppositional Defiant Disorder(ODD)
Chelsea Wiener
Part 1:Introduction to ODD
Disruptive, Impulse-Control, and Conduct Disorders
• Involve problems in regulation of emotions and behaviors
• Behaviors violate rights of others or cause significant conflict with society norms or authority
• Exhibit disinhibition and negative emotionality• E.g. oppositional defiant disorder, intermittent
explosive disorder, conduct disorder, antisocial personality disorder, pyromania, kleptomania
DSM V
What is ODD?
• Characterized by angry/irritable mood, argumentative/defiant behavior, and/or vindictiveness
• Symptoms last 6+ months (not just around siblings)• Behaviors cause stress in individual or those
surrounding them• Symptoms do not solely occur with comorbid
conditions• Prevalence rate: average 3.3% – Male:female ratio of 1.4:1 (prior to adolescence)
DSM V
What is ODD?
• Usually first symptoms in preschool, rarely later than early adolescence (Steiner & Remsing, 2007)
• Provides later risks for antisocial behavior, impulse control, substance use, anxiety and depression in adulthood (DSM V; Steiner & Remsing, 2007)
• Often precedes Conduct Disorder (CD), often earlier onset (DSM V; Steiner & Remsing, 2007)
• May co-occur with ADHD, leading to more problems with peers (Steiner & Remsing, 2007)
ODD and CD
• ODD and CD are the “Disruptive Behavior Disorders” (DBD)– ODD: negative, defiant, and disobedient vs. CD:
violating rights of others– Predictive of later Antisocial Personality Disorder
Loeber et al. (2000)
DBD Continued
– Mixed results for ODD predicting CD• While ODD often predicts CD, often does not
– ODD without CD, CD without prior ODD
– Evidence also for CD ODD link– ODD increases risk for APD, and anxiety. Evidence
that CD lowers risk for anxiety– Headstrong “dimension” of ODD may predict CD,
substance use, and depression more than irritability “dimension”
– Irritability “dimension” may predict anxiety diagnosis
Rowe et al. (2010)
Genetics and ODD
• Genetic heritability estimates:– Wide range of results
• 21-65%, 39%– Eaves et al. (1997), Burt et al. (2001)
• Genetics/Comorbidity: ODD, CD, ADHD– Shared genetic influences
• Dick et al. (2005), Tuvblad et al. (2009), Eaves et al. (2000)
– Unique genetic influences, unique environmental influences• Dick et al. (2005), Tuvblad et al. (2009)
– Shared environmental influences also shown to be important• Burt et al. (2001)
– Evidence that ODD and CD shared more genetic influences than with ADHD• Eaves et al. (2000)
ODD Across Cultures
• Evidence that ODD prevalence rates are similar among cultures and countries
(Canino et al., 2010)
• Pooled estimates 3.3%• Of 25 studies examined, 21 from Europe or Americas
– 3 from Asia, 1 from Middle East
Part 2:ODD and the DSM V
Diagnosing ODD: DSM V SymptomsCriterion A: At least 4 symptoms throughout past 6 months (not only with siblings)
• Angry/Irritable Mood– Often loses temper– Often touchy/easily annoyed– Often angry/resentful
• Argumentative/Defiant Behavior– Often argues with authority or adults– Often actively defies rules and requests– Often deliberately annoys others– Often blames others for own mistakes
• Vindictiveness– Spiteful or vindictive 2+ times in past 6 mos.
Diagnosing ODD: DSM V• Criterion B: Associated with distress for individual or others, or
impacts negatively on education, social occupation, or other areas
• Criterion C: Symptoms do not occur only during course of a psychotic, substance use, depressive, or bipolar disorder. Individual does not meet criteria for disruptive mood dysregulation disorders.
• Severity– Mild: 1 setting– Moderate: 2 settings– Severe: 3+ settings
Diagnosing ODD: DSM V Features and Considerations
• Age and Development– Timing:
• Age X<5: symptoms on most days• Age 5+: symptoms at least 1x/week• Consider normal development for that age, gender, culture
• ODD often presents only at home– Symptoms cannot present with siblings only
• Individuals with ODD often don’t view themselves as angry, oppositional, or defiant– Justify behaviors because of circumstances
• E.g. parenting style
*Regardless of causality, diagnosis is made*
Diagnosing ODD: DSM V Differential Diagnosis
For a diagnosis of ODD to be made, other disorders that might better explain an individual's symptoms should be considered.
• Conduct Disorder– ODD less “severe”
• ODD doesn’t include: aggression, destruction, theft, deceit• ODD does include: emotional dysregulation
• ADHD– ODD includes refusal of requests in situations that aren’t solely when effort
is needed to sustain attention
• Depressive and bipolar disorders– ODD includes emotional symptoms that don’t occur solely during course of
mood disorder
• Disruptive mood dysregulation disorder– ODD less severe in negative mood and temper
• Intermittent explosive disorder– ODD doesn’t include serious aggression
• Intellectual disability
• Language disorder
• Social anxiety disorder
ODD DSM V Risk and Prognostic Features
• Temperamental– Emotional regulation problems
• High levels emotional reactivity, low frustration tolerance
• Environmental– Harsh, inconsistent, or neglectful child care
• Genetic/Physiological– Low heart rate, low skin conductance, reduced basal
cortisol reactivity, abnormalities in prefrontal cortex and amygdala
*many studies do not separate CD and ODD children*
DSM V Visual Schematic for ODD
Oppositional Defiant
Disorder
Environmental Factors
Genetic/Physiological
Factors
Temperamental Factors
Inconsistent parenting
Harsh/neglectful parenting
Reduced basal cortisol
reactivity
Abnormal prefrontal
cortex
Abnormal amygdala
High levels emotional reactivity
Low levels frustration tolerance
Core Features-angry/irritable mood
-argumentative/defiant behavior
-vindictiveness
Secondary FeaturesProblematic
interactions with others
Risk for:CD
AnxietyDepression
Part 3
ODD: The Research
1. Neurobiological Underpinnings2. Parenting3. Prevention, Intervention, and Treatment
Terms and Abbreviations• ANS: autonomic nervous system
– Part of the peripheral nervous system• Resting functions, and “fight or flight” functions
• HPA axis: hypothalamic-pituitary-adrenal axis– Stress reactions, among others– responsible for the release of cortisol
• SCL: skin conductance level– Related to ANS, measure of arousal
• DBD: disruptive behavior disorders• CBCL: Child Behavior Checklist• TRF: Teacher’s Report Form• HR: heart rate• NC: normal control
Part 3
ODD: The Research
1. Neurobiological Underpinnings2. Parenting3. Prevention, Intervention, and Treatment
Neurobiological Underpinnings
• ANS and HPA Activity• Executive Functioning• Neurotransmitters• Frontal brain activation differences• Brain anatomical differences
ANS and HPA Activity• Evidence for children with ODD to experience less ANS and HPA arousal
during stress and baseline
Snoek et al. (2004)
– Comparing children with ODD, ADHD, ADHD/ODD vs. NC on ANS and HPA axis activity• Measured cortisol, heart rate, and skin conductance level during baseline and stress
– 95 children• 7-12 years old• From Department of Child & Adolescent Psychiatry at Medical Center in
Netherlands• DSM IV diagnostic criteria• Group breakdown:
– 15 ODD , 31 ODD/ADHD, 23 ADHD, 26 NC• **ODD groups consisted DSM IV ODD or CD (34 ODD, 12 CD- didn’t perform
differently on measures)
– Stress phase• Stress task: response perseveration task- money could be won or
lost• Completed difficult computer task under time pressure against
videotaped “opponent”– received criticism from opponent to perform better.
Opponent then made participant complete task again.• Participant then controlled whether reward signals or white noise
signals would be played as opponent completed task (measure of aggression)
– Results: • Baseline
– Cortisol: no differences– Heart rate: no differences– SCL: NC group lower
• Stress– Cortisol: ODD and ODD/ADHD weaker response to stress vs. ADHD and NC
(declined throughout test as opposed to increasing or staying the same)» More extreme differences with increased severity of symptoms
– Heart rate: ODD lower throughout test– SCL: NC lower– ODD and ODD/ADHD showed highest levels of aggression
*many ADHD patients were taking methylphenidate, affecting heart rate
*differences in ANS (heart rate and skin conductance) and HPA (cortisol) found for clinical vs. control participants. ODD participants generally less aroused, and more aggressive.
ANS and HPA ActivityVan Goozen et al. (2000)
– Comparing children with DBD vs. NC on ANS and HPA axis activity• Measured cortisol, heart rate, skin conductance, feelings of control, and
negative feelings during stressful and non-stressful activities
– 64 children• 8-12 years old• Caucasian• Recruited from University Department• DSM IV diagnostic criteria• Group breakdown:
– 26 DBD, 38 (NC) (12 non-stress control)
• ODD group consisted of ODD or CD (19 ODD, 7 CD); 12 comorbid with ADHD
– Stress phase• Stress task: response perseveration task- money could be won or
lost• Completed difficult computer task under time pressure against
videotaped “opponent”– received criticism from opponent to perform better.
Opponent then made participant complete task again. – participant then controlled whether reward signals or white
noise signals would be played as opponent completed task (measure of aggression)
– Results:• Baseline
– Cortisol: no differences– Heart rate: lower In DBD (DBD Mean=87.3; NC Mean=95.5)– SCL: lower in DBD, especially comorbid ADHD– Negative mood and feelings of control: no difference
• Test:– Cortisol: more rapid decline in DBD children (no difference regarding
comorbid ADHD)– Heart rate: lower in DBD (no difference regarding comorbid ADHD)
» increased for both groups during stress– SCL: lower skin conductance levels for DBD throughout task– Negative moods: DBD more intense – Aggression: DBD administered more punishment
*differences in ANS (heart rate and skin conductance) and HPA (cortisol) found for clinical vs. control participants. ODD participants generally less aroused during baseline and stress, and also report more negative feelings and display more aggression during stress.
Autonomic Underarousal Continued• Evidence found for autonomic underarousal for preschoolers with
ODD/ADHD
Crowell et al. (2006)
– Compared preschool children with ODD/ADHD vs. NC on electrodermal responding (skin conductance), cardiac preejection period (PEP), and respiratory sinus arrhythmia (RSA) during baseline and during reward task• PEP: measure of sympathetic cardiac activity• RSA: measure of parasympathetic cardiac activity
– 38 children• 4-6 years old• Predominately Caucasian• Recruited from ads and fliers in pre-schools• DSM IV diagnostic criteria for ADHD and ODD• Group breakdown:
– 18 ODD/ADHD (no stimulant medication), 20 control
– Played “Perfection”• Reward sensitivity: could choose $10 toy if won
– Results:• Baseline
– SCR: lower for ODD/ADHD (effect size .23)– PEP: longer for ODD/ADHD (effect size .14)– RSA: no differences
• Perfection– PEP: longer for ODD/ADHD (effect size .30)– RSA: no differences– Heart rate change: both PEP and RSA contributed to increased heart rate
for control, only PEP contributed for heart rate increases for ODD/ADHD
ANS and HPA Underarousal- A Review
• Baseline: – mixed results regarding baseline resting heart rate and skin
conductance levels differences between ODD and NC– cortisol levels comparable between ODD and NC children
• Stress: – weaker cortisol response (indicative of HPA underarousal) for ODD
children during stress tasks– lower heart rate (indicative of ANS underarousal) for ODD children vs.
NC during stress tasks found even when baseline levels comparable– Report more negative moods and increased aggression compared to NC
**Indications that ODD children may experience less stress during pressured situations, despite negative feelings
Executive Functioning Deficits?• Mixed evidence for executive functioning deficits
Van Goozen et al. (2004)– Compared ODD, ODD/ADHD, and NC on measures of executive functioning– 77 participants
• 7-12 years old• Recruited from clinic for treatment of ODD, DSM IV diagnostic criteria• Group breakdown
– 15 ODD (or CD), 26 ODD (or CD)/ADHD, 36 NC
– Measured:• Set shifting: Trail-Making Test Forms A and B• Planning: Tower of Hanoi• Working memory: Self-ordered pointing• Inhibition/attention: Stroop, Continuous Performance Test• Perseveration of responses: Door opening task• Impulsivity/Delay aversion: Delay of gratification task
– Results:• ODD/ADHD performed worse on set shifting (Trail B)• ODD/ADHD performed worse on response perseveration
task– ODD opened more doors than NC
• No differences from NC on other tasks (including Delay of Gratification task)
*authors conclude results point not to deficit in executive functioning, but to inhibition, especially with regard to monetary reward (“more motivational than executive in nature”)
Response Perseveration Continued• Evidence for reduced punishment sensitivity in boys with ODDMatthys et al. (2004)
– Comparing boys with ODD and normal control (NC) on response perseveration task• Response perseveration: “the tendency to continue a response set for reward
despite punishment”• Measured reward sensitivity, punishment sensitivity, heart rate (HR), skin
conductance level (SCL)
– Participants:• All boys• 7-12 years old• Recruited from university department• DSM IV diagnostic criteria• Inpatient or outpatient treatment• Group breakdown:
– 20 “ODD” (12 ODD, 8 CD, 12/20 comorbid ADHD), 20 NC
– Door opening task• Participant opens doors sequentially. When door opens,
participant sees either a happy face on the screen and receives a dime, or sees a sad face on the screen and has to give back money.
• Ratio of winning to losing doors decreases over time• Can stop game at any point
*Sensitivity to punishment: how long it takes to open a new door after losing
*Sensitivity to reward: how long it takes to open a new door after winning
– Results:• ODD group opened more doors (M=99.4) vs. NC
(M=62.8) • Punishment sensitivity: ODD took less time to open
next door after losing (M=1.1) vs. NC (M=4.1)• Reward sensitivity: no difference• HR during task: no difference• SCL during task: lower for ODD (M=12.4) vs. NC
(M=18.9)• No differences between ODD and ODD/ADHD on any
measure
Neurotransmitters• Possible neurotransmitter-ODD symptom link
Snoek et al. (2002)
– Compared serotonergic function in ODD and control using Growth Hormone (GH) levels following “sumatriptan challenge”• Sumatriptan is 5-HT (1b/1d) agonist; measure of growth hormone
reflection of 5-HT receptor sensitivity
– 35 Caucasian participants• 7-12 years old• Recruited from inpatient clinic at medical school• DSM IV diagnostic criteria• Group breakdown
– 20 ODD (17 ODD, 3 CD, 13 comorbid ADHD), 15 NC
– Sumatriptan Challenge• Overnight fast• Multiple blood draws• GH measured• Cortisol levels measured by saliva sample
*ODD group showed stronger peak GH response (no differences in baseline and peak between ODD and ODD/ADHD)*suggests differing sensitivity of 5-HT receptors between ODD And NC *link between serotonergic functioning and aggression+impulsivity
*unclear by what mechanisms
Frontal Brain Activation• Different patterns of frontal brain activation: children with ODD vs .NC
Baving et al. (2000)
– Compared children with ODD vs. NC on frontal brain activation via EEG
– Participants• Caucasian- German ancestry• Recruited from hospitals• Two groups: 4.5 year olds, 8 year olds• DSM IV diagnostic criteria• Participant breakdown
– 61 4.5 yr. olds» 23 ODD (no co-occurring CD or ADHD), 28 NC
– 58 8 yr. olds» 26 ODD (no co-occurring CD or ADHD), 32 NC
– Results:• 4.5 yr. old girls
– Oppositional: greater right than left frontal activation– NC: no frontal asymmetry
• 4.5 yr. old boys– Oppositional: no frontal asymmetry– NC: greater right than left frontal activation
• 8 yr. old girls– Oppositional: greater right than left frontal activation– NC: greater left than right frontal activation
• 8 yr. old boys– Oppositional: no frontal asymmetry– NC: greater right than left frontal activation
*oppositional and NC boys and girls differ on frontal brain activation patterns*did not discuss specific areas
*gender differences in activation exist as well*authors discuss that frontal brain has been shown to be related to emotionality
activation of left frontal brain found to be associated with positive emotions and less externalizing problems vs. right frontal brain negative emotions, anxiety etc.
Brain Anatomical Differences• Fahim et al. (2012)
– Investigated brain anatomical differences using MRI in children with ODD and NC• Participants
– 38 children, 8 yr. olds» 18 ODD
• Dominic’s ODD scale• DSM IV symptoms in cartoon format
• 10 girls, 8 boys» 20 NC
• 10 girls, 10 boys
– Looked at gray matter density (GM), white matter density (WM)
– Results (Partial):• No whole brain density differences between groups• ODD vs. NC:
– Decreased GMd in orbitofrontal gyrus (r=.33)– Decreased WMD in frontal pole (r=.43)
• Gender specific– ODD boys decreased GMd left inferior frontal and left frontal
poles– ODD boys decreased WMd in left middle frontal pole– Symptoms for ODD girls associated with left orbitofrontal
cortex density, inferior frontal cortex density, and right anterior cingulate cortex density
Relevance:
frontal pole: related to “brain-social behavior relationships”, emotion regulation, and empathy
orbitofrontal pole: related to empathy
Authors explain that differences in gender might explains differences in aggression style and what comorbidities different genders are at risk for developing (anxiety, depression vs. substance use)
Neurobiological Underpinnings-Review
• ANS and HPA Activity– Evidence for underarousal during baseline and stress
• E.g. heart rate, cortisol
• Executive Functioning– Mixed evidence for EF deficits– Evidence for lower punishment sensitivity
• Neurotransmitters– Possible role of serotonin 5-HT receptors explored
• Frontal brain activation differences– Oppositional boys and girls show differing patterns of frontal brain activation
symmetry/asymmetry compared to normal counterparts• Brain anatomical differences
– Oppositional children show different patterns of gray matter and white matter density in various brain regions compared to normal counterparts
Part 3
ODD: The Research1. Neurobiological Underpinnings2. Parenting3. Prevention, Intervention, and Treatment
Parenting• Parenting practices (e.g. punitive discipline, aggression, warm involvement)
associated with patterns of child externalizing behaviors
Stormshak et al. (2000)– Examined associations among parenting practices and children’s disruptive
behavior problems
– Children from Durham, Nashville, Seattle, and central PA• 51% European American, 49% African American• Multi-step selection process
– Participating schools had teachers fill out questionnaire about behavior problems at school (Teacher Observation of Classroom Adaptation-Revised)
– Top 35% had parents contacted, answered conduct problem questions on CBCL
– Average of those scores used to pick 631 “high risk” (vs. NC from same schools)» T scores on CBCL externalizing scale ~ 85 percentile
– Measured: effect of parenting practices on disruptive behaviors• Parenting practices: “punitive discipline”,
“inconsistency”, “warmth and positive involvement”, “physical aggression”, “spanking”– Measures: The Parent Questionnaire, Parenting Practices
Inventory, and modified Conflict Tactics Scale
• Disruptive behaviors: “oppositional”, “aggressive”, and “hyperactive”– Subscales created from CBCL
– Results:• Parent punitive discipline and spanking associated with all 3 children
externalizing scales– Punitive discipline
» With oppositional behavior: r=.40» With aggression: r=.38» With hyperactivity: r=.31
– Spanking» With oppositional behavior: r=.24» With aggression: r=.30» With hyperactivity: r=.32
• Parent physical aggression associated with child aggression (r=.26)• Low “warm involvement” associated with oppositional behavior (r=.-17)• European American families reported higher oppositional behavior in children
than African American families• Parent punitive discipline and parent physical aggression related to child
oppositional behavior and child internalizing problems – *more associated for EA families than AA families
Parenting Continued• Parent practices (e.g. proactive parenting, hostility, expressed
emotions) can affect children’s externalizing problems over time
Denham et al. (2000)
– Examined the relation between parent emotions/behaviors and children’s externalizing problems over time
– 69 children• Recruited via newspaper and day care • Mean age: ~4.5 yrs. at recruitment (~7 yrs. at T2, ~ 9.7 yrs. at T3)• Group breakdown
– 29% 1-2 SD above norm for behavior problems on CBCL (rated by mom) or on TRF
– 34.8% 2+SD above norm– 26.2% less than 1 SD above norm
– Procedure (abbreviated)• Child and parents played competitive games, read a
book, ate snacks together, solved puzzles, and spoke about emotions• Interactions were observed and coded for supportive
presence, limit setting, allowance of autonomy, negative affect, quality of instructions, and expressions of happiness and anger. • Follow up Questionnaires at T2 and T3
– CBCL completed by mom at all times, TRF completed by teacher at all times, YSR (Youth Self Report) completed by child at T3
– Results (partial)• Results from Observation Data
– Moms’ proactive parenting (“supportive presence, clear instruction, and limit setting”) related inversely to externalizing problems:» CBCL T2: r=-.39, CBCL T3: r=-.46» TRF T2: r=.-.26, TRF T3: r=-.29
– Mom’s anger predicted increased externalizing problem ratings on all measures» CBCL T2: r=.27, CBCL T3: r=.27, YSR T3: r=.24» TRF T2: r=.47, TRF T3: r=.34
– Father’s proactive parenting only predictive of only lower externalizing problems on T3 CBCL (r=.28)
– Father’s anger predictive of greater externalizing problems on T2 TRF (r=.39)
• Results from Reported Data– Father’s self reported hostility correlated with children’s T3
YSR scores (r=.36)– Mom’s self-reported hostility correlated with increased
externalizing problems on CBCL at T2 (r=.31) and T3 (r=.27)– Mom’s self-reported pro-active parenting was negatively
correlated with:» CBCL T2: r=-.54, CBCL T3: r=-.42 YSR T3: r=-.34» TRF T2: r=-.32
Temperament
• “Constitutionally based individual differences in behavioral style that are visible from early childhood”
• Varies in how described and defined• Temperament and behavior hard to separate• Negative emotionality most relevant to development
DBD• Temperament may predict later externalizing and
internalizing behavior problems, but stronger when environmental influences taken into account
• Negative emotionality and resistance related to negative parent interactions, contributing to negative cycle
Sanson & Prior (1999)
Family Reinforcing Processes• Evidence for parent behavior reinforcing child behavior and vice versa. Coercive
interactions predict noncompliance and oppositional behavior over time.
Smith et al. (2014)• Looked at caregiver-child interactions and child behavior in toddlers and preschoolers
(ages 2-5)
– Coercion theory• Mutual reinforcement
– Participants• 731 mother-child pairs recruited from a nutritional program• Randomly assigned wither to Family Check-Up (FCU) condition, or WIC services as usually
control (e.g. vouchers)– FCU
» 3 session family intervention to help child adjustment» Focus on family management
– Dyadic coercive interactions coded from videotaped home interactions• Someone is negatively engaged or gives directive , other person ignores or
gives directive (negative reinforcement)
– Results (Partial):• In general, coercive interactions predicted oppositional behavior and
vice versa (but coercive interactions were stronger predictors)• Coercive interactions at 2 and 4 predicted noncompliance at ages 3 and 5• Coercive interactions at 5 predicted oppositional behavior at school (7.5
yrs. and 8.5 yrs.)• FCU group showed less oppositional and aggressive behavior (steeper
decline) from ages 2-5 than control
Family Reinforcing Process
• ODD, CD, and ADHD symptoms are predictive of parenting practices over time, and vice versa.
Burke et al. (2008)
– Examined family reciprocal processes from ages 7-17• Parent and child assessments given until 17
– Participants: 177 boys, 7-12 yrs. old at time of recruitment• 70% Caucasian, 30% African American• 83.6% met DSM III-R criteria criteria for ODD, 68.4% for CD,
68.9% for ADHD
– Results• ODD symptom count predictors:
– ADHD symptoms (Incident Rate Ratio/IRR= 1.03)– poor supervision (IRR= 1.01)– poor communication (IRR= 1.02)– positive involvement (IRR= 0.96)– timid discipline (IRR= 1.03) individually predicted ODD (harsh punishment did
not)» When tested together, timid discipline and positive involvement remained
significant– Other predictors: maternal police contact (IRR= 1.05), parental APD (IRR=
1.11), urban residence (IRR= 1.23), pubertal development (IR=1.03)
• CD symptom count predictors:– ODD symptoms (IRR= 1.08)– poor communication (IRR= 1.02)– harsh punishment (marginally; IRR= 1.14)
» when tested together, only poor communication remained significant– Other predictors: maternal smoking (IRR= 1.13), urban residence (IRR= 1.18),
SES (IRR= 0.99)
• ADHD symptom count predictors:– ODD and CD both not predictive– Timid discipline (IRR= 1.02)– poor communication (marginal; IRR= 1.00)
» Together, only timid discipline
• Parent behavior predictors:– ODD symptoms predicted:
» timid discipline (IRR= 1.08)» positive parent involvement (B=-0.06)» poor communication (B=.14)
– CD symptoms predicted:» poor supervision (B=0.22)» harsh punishment (OR=1.10)
– ADHD symptoms predicted poor communication (B=0.06)
**child behaviors found to be more influential of parent behaviors than vice versa
Parenting- Review
• Harsh parenting practices and negative emotions predictive of child oppositional behavior, and vice versa
• Positive parenting practices can be protective of developing externalizing problems
• Parent-child interactions can be mutually reinforcing
Part 3
ODD: The Research
1. Neurobiological Underpinnings2. Parenting3. Prevention, Intervention, and Treatment
Are Prevention Programs Effective?
• Prevention programs have demonstrated small effect sizes in preventing symptoms of ODD and CD– Preventing property violation, oppositional
behavior, and aggression– Effect sizes highest when records (i.e. from
schools, police, or courts) as opposed to teacher, parent, or self reports used to determine effectiveness of programs (more implications for CD than ODD?)
Grove et al. (2008)
Are Intervention Programs Effective?
• Intervention programs for ODD that focus on either parents, children, or both have been shown to be effective in treating symptoms
Bradley & Mandell (2005)
– Metanalysis of 7 studies focused on interventions for ODD (not CD)
– Characteristics of included studies• Children were diagnosed before inclusion in the study, based on any
version of DSM (5 studies) OR had a T score of 55 or higher (2 studies) on CBCL aggression scale of CBCL (1 SD above norm)
• Treatments targeted parents, children, or both
– Results• Symptoms at Home:
– Treating parents (SMD = 1.06) and children (SMD = .93) alone were more effective than treating both together (SMD = .25)
• Symptoms at school:– No significant effects
• Academic Functioning– No significant effects
• Social functioning– Treating children alone (SMD = .55) vs. SMD = .20 for treating parent and
child
• Parental stress/strain– Treating parents (SMD = .88)
• Parenting environment (“the nature of the parenting relationship”)– Treating parents (SMD = 0.85)
Interventions: A Focus on Parents• Intervention programs for parents can be particularly helpful in
treating ODD
Kazdin (1997)
– Reviewed parent management training (PMT) as an intervention for oppositional, aggressive, and antisocial behavior in children
– PMT: “treatment procedures in which parents are trained to alter their child’s behavior at home”• Uses social learning principles
– Operant conditioning
• Aims to increase positive and decrease deviant behaviors• Focuses on “ABC’S”
– Antecedents, Behaviors, Consequences» Positive reinforcement especially crucial (mild punishment sometimes also helpful)
• Most effective when contingent and timely• Most effective when parents truly understand principles
– Does it work?• Yes, effects can sometimes be seen for years
– Improvements on parent and teacher reports– Improvements to non-clinical range– Has performed better than wait-list control and other treatments
• Treatment outcome affected by:– Home life factors
» E.g. high parent stress, harsh punishment, parent history of antisocial behavior
– Challenges: • drop out rates• cultural considerations neglected• differences between children and adolescents• less training opportunities for professionals
Parent Interventions Continued• Some treatments focus on teachers, in addition to parents and children.
Targeting any combination of parents, teachers, and children may result in fewer conduct problems later on.
Reid et al. (2003) “Incredible Years Intervention”– 2 year follow up data on a 6 month intervention for ODD– 159 children
• 4-8 years old with ODD (or CD) as defined by DSM IV• Scored more than 2 SD above mean on Eyberg Child Behavior Inventory
– Conditions• Parent training (PT)• Parent and teacher training (PT+TT)• Child training (CT)• Child and teacher training (CT+TT)• Parent and child and teacher training (PT+CT+TT)• Wait-list control (CON)
– At conclusion of 6 month intervention:• All treatment condition children had fewer conduct
problems with mothers, teachers, and peers vs. controls• More prosocial behavior with peers in CT condition (d=.35)
and PT+CT+TT condition (d=.46) vs. control• Negative behavior with fathers lower in all PT conditions vs.
control (d ranging .51-.63)• Less negative parenting for mothers in all PT conditions,
and CT condition vs. control (d ranging .51-.81)• More positive parenting for mothers in all PT conditions vs.
control (d ranging .46-.51)• Less negative parenting for fathers in all PT conditions vs.
control (d ranging .51-.91)
– Additional treatment and services obtained in-between intervention and 2 year follow up• 49.5% ADHD medication• 39.6% special education• 26.7% child therapy• 12.1% family therapy
– 2 Year follow up results:– Determining clinical significance
» At home: 20% reduction on ECBI scores» At school: moved below clinical threshold on TRF (X>63)
• Conduct problems at home– ~75% were treatment responders at home– PT+TT fared significantly better than PT alone
• Conduct at school – No significant differences between treatment groups– 50-58% of children who had shown problems at school were
treatment responders (only about 50% of original had baseline school problems, so around 25% of total sample were nonresponders at school)
• Predictors of Outcomes– Problems at home
» PT and PT+TT greater rates of treatment success» More positive parenting (mother and father) at baseline
and 1 year follow up (mother only) predictive of success» Higher level of depression in mothers related to having
nonresponder child• Father’s predicted in opposite direction
– Problems at school and home» 26% treatment responders, 29% home only responders,
15% school only responders, 29% nonresponders» PT+TT most likely to respond in both environments» Mother positive parenting at baseline was higher for
overall responders rather than home-only responders» Marital discord predicted nonresponse at home
Parent Interventions Continued
• Parent interventions for ODD children shown to be effective for preschoolers
Schuhmann et al. (1998)
– Interim results of a parent-child-interaction therapy (PCIT) for ODD preschoolers
– PCIT created to improve relations between parents and children with conduct problems, and manage child’s behavior• Two phases of PCIT
– 1. child-directed interaction (CDI)» Parent-child relationship focus» Parents learn “nondirective play skills”
– 2. parent-directed interaction (PDI)» Child compliance focus» Parents learn appropriate instructions and consequences (consistency)
– 64 families• ODD diagnosis according to DSM III-R standards• 81% boys• Group breakdown
– 21 ODD only– 29 ODD and ADHD– 13 ODD, CD and ADHD– 1 CD and ODD
• Immediate Treatment (IT) vs. wait-list control (WL)
– 4 assessments, 4 months apart (WL group 4 month lag “behind” IT)– PCIT lessons 1 hr./week
• Role playing with therapists• Therapists taught parents CDI and PDI• At beginning of each assessment, parent-child interactions were
videotaped/observed
– Assessment 2 results:– percentage of praise parent talk higher for IT than WL– IT criticized children less than WL– IT described behavior more than WL– Child compliance to demands increased for parents of IT (23%47% for mothers,
27% 45% for fathers) but not WL– Conduct problems decreased for IT
» measured by Eyberg Child Behavior Inventory; scores dropped from clinical range to normal range for IT group, WL remained in clinical range• IT group:
• Intensity scale of ECBI: M=170 117.6• Problem scale of ECBI: M=21.9 10.9
• WL group:• Intensity: M=172.9 169.7• Problem: M= 21.2 22.1
– Parenting stress decreased for IT parents» Measured by Parenting Stress Index; mean for IT parents normal vs. WL mean
in clinical range
Managing ODD- Medication• Adderall XR shown to be helpful in reducing ODD symptoms as rated by
parents and teachers
Spencer et al. (2006)
– looked at Mixed Amphetamine Salts Extended Release (Adderall XR) in ODD and ODD/ADHD children
– Participants: 308 children• 6-17 years old• Met DSM IV criteria for ODD
– Conditions• MAS XR 10 mg, 20 mg, 30, mg, 40 mg, and placebo • Excluded for CD
– Measured symptoms using the ODD subscale of the Swanson, Nolan, and Pelham-IV (SNAP IV) parent and teacher ratings
– Participants completed 1-4 week washout phase, then randomly assigned to one of the five conditions, then 4 weeks of medication
• Intent to Treat (ITT) population: 96.4% ; 79.1% comorbid ADHD, 29.1% “pure ODD”
• Per Protocol (PP) population: 74.4%
– Results:• ODD SNAP IV Parent Rating
– ITT» MAS XR 30 showed greater improvement vs. placebo
– PP» MAS XR 30 and 40 showed greater improvements vs. placebo
• ODD SNAP IV Teacher Rating– ITT
» MAS XR 10, 20, and 30 greater improvements vs. placebo– PP
» MAS XR 10, 20, 30, 40 greater improvements vs. placebo
• ADHD Snap IV Parent Rating– ITT
» MAS XR 10, 30, and 40 greater improvements vs. placebo– PP
» MAS XR 10, 20, 30, 40 greater improvements vs. placebo
• ADHD Snap IV Teacher Rating– ITT
» MAS XR 10, 30, 40 greater improvements vs. placebo
• Clinical global impressions scales for ODD (completed by investigator and caregiver)– Baseline: 88.3% placebo and 89% treatment were “moderately” or “markedly” ill.
» Improvements for 20 mg, 30 mg, and 40 mg vs. placebo to “very much improved” or “much improved• 20 mg: 55.4%• 30 mg: 40.61%• 40 mg: 61%• Placebo: 26.7%
Prevention, Intervention, and Treatment- Review
• Prevention programs have shown small effects in preventing symptoms of ODD
• Intervention programs may involve children, teachers, and parents– Interventions involving parents are particularly
effective• Medication may also be effective in treating
ODD
Schematic
ODD
Neurobiological Factors
ANS underarousal
HPA underarousal
Neurotransmitters
Frontal brain differences
Family Risk Factors/Parentin
g Styles
Discipline Styles
Negative emotions
Poor Communication
Core Features-angry/irritable mood
-argumentative/defiant behavior
-vindictiveness
Secondary FeaturesProblematic
interactions with others
Treatment/Interventions
Medication
Parent, Child, and Teacher
Interventions
Risk for:CD
AnxietyDepression
Substance abuse
Brain anatomical differences
DSM V Visual Schematic for ODD
Oppositional Defiant
Disorder
Environmental Factors
Genetic/Physiological
Factors
Temperamental Factors
Inconsistent parenting
Harsh/neglectful parenting
Reduced basal cortisol
reactivity
Abnormal prefrontal
cortex
Abnormal amygdala
High levels emotional reactivity
Low levels frustration tolerance
Core Features-angry/irritable mood
-argumentative/defiant behavior
-vindictiveness
Secondary FeaturesProblematic
interactions with others
Risk for:CD
AnxietyDepression
ODD Research Challenges
• Comorbid CD and ADHD (lack of individual studies and metanalyses focusing on ODD alone)– Many DBD studies focus mostly on CD, and
features relating primarily to CD (e.g. aggression)• Less data on mood/temperament • Medication confounds• Small sample sizes
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