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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:

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Oppositional Defiant Disorder

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  1. Oppositional Defiant Disorder

  2. 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

  3. 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

  4. 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.

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

  6. 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

  7. 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

  8. 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

  9. 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%

  10. Prevalence Rates

  11. 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

  12. 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

  13. 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

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

  15. 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

  16. Genetics Twin studies evidence for moderate genetic influence, but environment very important Likely inherit risk factors Sensitivity to alcohol Temperament Irritability Impulsivity Sensation seeking Antisocial bias Genetics/Neurobiological TraitsEtiology-Biological

  17. 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.

  18. Etiology-Biological(ref) Neurophysiological Behavioral Inhibition System (BIS) underactive Behavioral Activation System (BAS) overactive OR both systems underactive as child tries to seek sensation Reduced threshold for fight or flight Neuropsychological Frontal lobes Problems with verbal and executive functions

  19. 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

  20. 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)

  21. 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 Data Issues to consider: • Can measure differentiate among subtypes? • Validity of measure

  22. 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)

  23. 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 behaviors Limitations: • Time consuming • Require specialized training in some cases

  24. 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)

  25. Assessment:Other Techniques • Sociometric Data • Vignettes and Hypothetical Situations

  26. Well-Established Therapy • CRITERIA FOR WELL-ESTABLISHED THERAPY • 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) • Statistically significantly superior to pill or psychological placebo or to another treatment. • Equivalent ( or not significantly different) to an already established treatment in experiments with statistical power being sufficient to detect moderate differences • Treatment manuals or logical equivalent were used for the treatment • Conducted with a population, treated for specific problems, for whom inclusion criteria have been delineated in a reliable, valid manner • Reliable and valid outcome assessment measures, at minimum tapping the programs targeted for change were used • Appropriate data analyses

  27. Probably Efficacious Therapy CRITERIA FOR PROBABLY EFFICACIOUS (requires 1 of 2) There must be at least two good experiments showing the treatment is superior (statistically significantly so) to a wait-list control group. 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.

  28. Possibly Efficacious CRITERIA FOR POSSIBLY EFFICACIOUS At least one “good” study showing the treatment to be efficacious in the absence of conflicting evidence.

  29. Coercion Theory Crying/arguing with parent is aversive—parent terminates the aversive behavior by giving in to demands Child irritable, active, has difficult temperament, low frustration tolerance Child is reinforced for their negativistic behavior – learns ‘timing’ Mother Inconsistent parenting (laughs at and punishes same types of behavior on different occasions) Depressed Antisocial tendencies (in some) Lack of follow through Divorced Mother is negatively reinforced via the removal of an aversive Stimuli/event

  30. 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

  31. Interactional-Developmental-Etiological Approach (ref)

  32. 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

  33. 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

  34. 3-Dimensional Theory of OppositionalityStringaris & Goodman, 2009

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