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OppositionalDefiantDisorderODD.pdf

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2/23/2019

Oppositional Defiant Disorder (ODD)

Case Example: Gordon

He just digs his heels in, “That’s it, I am not wearing these socks! Forget it, I’m not going! And he is right. He’s gone to school in his pajamas, without lunch, in the pouring rain without a coat … He will explain to me, “Mom, we are done with this discussion.” … He doesn’t have an easy‐going bone in his body. He is not ever going to say, “Okay, I’ll put that turtleneck on.” It’s going to be, “I will do something but only on my terms … I will do nothing that you want me to do and furthermore I’ll throw such a tantrum and throw this cereal bowl all over the wall, so you will be up late, and mad at me when you clean it up.” … He enjoys that power.

Adapted from Troubled Families – Problem Children: Working with Parents: A Collaborative Process by C. Webster‐Stratton and M. Herbert (1994)

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DSM‐5 Defining Features

Section on “Disruptive, Impulse‐Control, and Conduct Disorders” ◦ Includes intermittent explosive disorder, pyromania, kleptomania

We will focus on: ◦ Oppositional defiant disorder (ODD)

◦ Conduct disorder (CD)

Both have been found to predict future psychopathology and impairment in life functioning ◦ But ODD is less severe than CD

Oppositional Defiant Disorder (ODD)

Age‐inappropriate recurrent pattern of stubborn, hostile, disobedient, and defiant behaviors

Usually appears by age 8 and often much earlier (ages 2‐3)

Need to have > 4 of 8 symptoms shown with a person who is not a sibling for > 6 months

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DSM‐5 Criteria for ODD

A. Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms:

Angry/Irritable Mood ◦ Often loses temper ◦ Is touchy or easily annoyed ◦ Is often angry or resentful

Argumentative/Defiant Behavior oOften argues with authority figures or, for children and adolescents, with adults oOften actively defies or refuses to comply with requests from authority figures or with rules oOften deliberately annoys others oOften blames others for his or her mistakes or misbehavior

Vindictiveness oHas been spiteful or vindictive at least twice within the past 6 months

DSM‐5 Criteria for ODD (cont’d)

B. Disturbance in behavior is associated with distress in the individual or others in their immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C. Behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood disorders.

Specifiers based on severity: ◦ Mild: symptoms confined to only one setting (e.g., at home, at school, with peers) ◦ Moderate: some symptoms are present in at least two settings ◦ Severe: some symptoms are present in three or more settings

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Prevalence and Comorbidity Prevalence

o12% lifetime prevalence rate (13% for males, 11% for females) o Similar rates for boys and girls (1.4:1) o One of the most stable diagnoses with one of the poorest recovery rates

Comorbidity

o ODD is frequently comorbid with ADHD (may be due to shared temperamental risk factors) o ODD often precedes conduct disorder o Adolescents with ODDs also have higher rates of substance abuse (may be due to overlap with conduct disorder)

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Etiology of ODD: Individual Context

Insecure attachment with mother and/or father o Esp. if in a home characterized by social adversity and maladaptive child‐rearing practices

Difficult temperament

Etiology: Family Context

Exposure to maladaptive parental behavior

o e.g., alcohol or drug use, crime

Family instability

o e.g., divorce, remarriage

Parental commands

o Beta commands (vague and interrupted) rather than alpha commands (clear, explicitly stated objective)

Parental attributions for child’s non‐compliance

o View child’s misbehavior as intentional and malicious ‐> respond more harshly ‐> perpetuates misbehavior

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Integrative Developmental Model (Greene and Doyle, 1999)

o Multiple developmental pathways to ODD

o Incorporates child characteristics & parent‐child transactions as risk factors

Child Characteristics o Poor self‐regulation

o Deficits in execute functioning (inhibition; working memory, cognitive flexibility) o Depression and anxiety disorders (i.e. poor emotion regulation) o Language processing problems (communication) o Cognitive distortions (biased, inaccurate view of social information)

Parent Characteristics

o Parent‐child incompatibility

Interventions

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Eyberg, Nelson, & Boggs (2008) Evidence‐based psychosocial treatments for children and adolescents with disruptive behavior.

16 different EBTs

Some of the “brand name” treatments: ◦ Parent‐Child Interaction Therapy (PCIT) ◦ Triple P (Positive Parenting Program) ◦ The Incredible Years ◦ Helping the Noncompliant Child ◦ Parent Management Training Oregon Model

Common Ingredients of these Interventions

Behavioral strategies focusing on children and adult‐child relationships are most common treatment for ODD and may include:

 Teaching parents more effective command styles

 Teaching parents principles of operant conditioning  e.g., ignore tantrums

 Shift from punishing to rewarding desired behavior  Praise (“catch them being good”)

 Tangible rewards

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Other Common Behavioral Elements Using “time‐out” when punishment is utilized

Natural consequences for behaviors

◦ e.g., if was on the phone past bedtime, take away the phone or restrict from seeing friends

◦ vs. losing all privileges or being grounded “forever”

Why don’t EBTs work for everyone? ◦ Drop‐out

◦ Lack of motivation

◦ Poor therapeutic alliance

◦ Comorbid conditions

◦ Other environmental stressors and events

◦ Treatment fidelity

◦ Skill practice and utilization

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Medications o No medication available to treat disruptive behavior disorders

o Medication often prescribed to treat common comorbid conditions (e.g., ADHD)

o Risperidone (an anti‐psychotic/mood stabilizer) used “off‐label”