Oppositional Defiant Oppositional Defiant disorder:disorder:

Comorbid or stand alone Comorbid or stand alone diagnosis? Disruptive Behavior diagnosis? Disruptive Behavior

DisordersDisordersJennifer Hanley NAPS 866 Jennifer Hanley NAPS 866

Teaching ProjectTeaching Project

Spring 2008 UTHSCSpring 2008 UTHSC

OverviewOverview• Objectives Objectives

• Define and differentiate from other Define and differentiate from other disruptive behavior disordersdisruptive behavior disorders

• EpidemiologyEpidemiology• Etiology-Thoughts, theories and Etiology-Thoughts, theories and

researchresearch• Diagnosis and Clinical FeaturesDiagnosis and Clinical Features• Course and Prognosis-Is it all bad?Course and Prognosis-Is it all bad?• Treatment-Modalities. Just the Family?Treatment-Modalities. Just the Family?• Summary Handout and Questions/QuizSummary Handout and Questions/Quiz

Project ODDProject ODD

• DifferentialsDifferentials• Management to include web sites Management to include web sites

evidence based algorithms; evidence based algorithms; therapy and medicationtherapy and medication

• Assessment tools and keys Assessment tools and keys • Key Findings/Results from Key Findings/Results from

LiteratureLiterature

Facts and IssuesFacts and Issues

•ODD and other conduct problems, are the greatest reason for referrals to inpt and outpt mental health settings-more than half! 18% of children will have ODD if the parents are alcoholic and the father has been in trouble with the law (Chandler 2002). •Does run in families.•Rare to see alone. Usually other comorbids such as ADHD, depression and/or anxiety.•Blames for misbehavior/mistakes, is spiteful or vindictive -3 months•2x/wk: loses temper, argues with adults, refuses to comply with authority, is touchy and easily annoyed. •May have major social problems with little academic problems if with ADHD( >30%)

• Forming an identityForming an identity• Psychoanalytic theoryPsychoanalytic theory• BehavioristsBehaviorists• The Brain The Brain • Key assumptionsKey assumptions

• Ours?Ours?

Etiology

Processing disability?Processing disability?

• 55% of children with language processing 55% of children with language processing difficulties also met the diagnostic difficulties also met the diagnostic criteria for ODD, suggesting that, if a criteria for ODD, suggesting that, if a child does not possess the linguistic skills child does not possess the linguistic skills necessary to label and categorize necessary to label and categorize emotions or communicate needs to emotions or communicate needs to others, the stage may be set for others, the stage may be set for concurrent difficulties with frustration concurrent difficulties with frustration tolerance and problem solving (Greene tolerance and problem solving (Greene and Ablon, 2003). and Ablon, 2003).

Numbers and More Numbers and More NumbersNumbers

•DSM-IV-2-16%•Studies of negativistic traits in non clinical kids-22%•Usually noted by 8, starts as early as 3 years. Not later than adolescence.•More in boys until puberty, then equal (may be because boys get more conduct d/o diagnosis). •Parents-No distinct patterns, but usually overly concerned with issues of control power and autonomy. More neg. responses, less pos. reinforcement•Twin studies: genetic precursor. Not just the parents

Neurobiology of AggressionNeurobiology of AggressionLesions of prefrontal cortex, particularly orbital frontal

cortex, early in childhood can result in antisocial disinhibited, aggressive behavior laterin life (160).

Reduced prefrontal gray matter has been associated with• autonomic deficits in patients with antisocial personality• disorders characterized by aggressive behaviorsThe clinical psychopharmacology of aggressive behavior

began in the mid-1970s with the first placebo-controlled, double-blind, study of lithium carbonate in prison inmates where impulsive, aggression was reduced to extremely low levels during a 3-month course of treatment. Levels of aggression remained unchanged in inmates treated with placebo.

Antagonism of 5HT2 may explain the ability of newer antipsychotic agents (which, unlike the older medications, block 5-HT2 receptors) to produce a reduction in aggression and agitation independent of effects on psychotic symptoms (215,216).

www.acnp.org Pathophysiology and Treatment of Aggression Neuropsychopharmacology: The Fifth Generation of Progress. Edited by Kenneth L. Davis, Dennis Charney, Joseph T. Coyle, American College of Neuropsychopharmacology 2002.

Pathophysiology of Pathophysiology of Aggression 2Aggression 2Twin, adoption, and family studies all suggest a

genetic influence underlying aggression (5), Heritability estimates range from 44% to 72% in adults. A meta-analysis of more than 20 twin studies confirmed a role for a genetic influence underlying aggression .

Plasma testosterone levels have also been reported to be higher in psychiatric and criminal populations characterized by high aggression.

Cortisol concentrations are reported to be relatively low in aggressive individuals.

• A low concentration of salivary cortisol was associated with persistent aggression in boys referred because of disruptive behavior

Biomarkers/Indicators AKA The BrainBiomarkers/Indicators AKA The Brain

Increased Adrenal Androgen Functioning in Children Increased Adrenal Androgen Functioning in Children With Oppositional Defiant Disorder: A Comparison With Oppositional Defiant Disorder: A Comparison

With Psychiatric and Normal ControlsWith Psychiatric and Normal ControlsDOI: 10.1097/00004583-200011000-00020DOI: 10.1097/00004583-200011000-00020

ISSN: 0890-85671527-5418ISSN: 0890-85671527-5418Accession: 2000-12258-019Accession: 2000-12258-019

Author(s): VAN GOOZEN, STEPHANIE H.M. PH.D.; VAN DEN BAN, ELS M.S.; MATTHYS, Author(s): VAN GOOZEN, STEPHANIE H.M. PH.D.; VAN DEN BAN, ELS M.S.; MATTHYS, WALTER M.D.; COHEN-KETTENIS, PEGGY T. PH.D.; THIJSSEN, JOS H.H. M.D.; VAN WALTER M.D.; COHEN-KETTENIS, PEGGY T. PH.D.; THIJSSEN, JOS H.H. M.D.; VAN

ENGELAND, HERMAN M.D.ENGELAND, HERMAN M.D.Issue: Volume 39(11), November 2000, pp 1446-1451Issue: Volume 39(11), November 2000, pp 1446-1451

Children with oppositional defiant disorder (ODD) are at high risk for criminality and antisocial personality disorders in adulthood (Rutter, 1997). Finding a biological marker that is specific to persistent antisocial behavior is therefore important. Psychobiological studies on aggression have focused on serotonin and testosterone as major biological variables (Higley et al., 1996).

From around age 6, children exhibit a gradual increase in androgens of adrenal origin, a period called the adrenarche, and it is not until puberty that gonadal androgens, such as testosterone, become more important. Research in prepubertal children should therefore focus on adrenal androgens, such as dehydroepiandrosterone (DHEA), its sulfate (DHEAS), which is also made endogenously in the brain.. (Robel and Baulieu, 1994), increase neuronal excitability, and have neuroprotective properties (Wolf and Kirschbaum, 1999), They appear to have potent antagonistic effects on GABA mechanisms, which are involved in aggressiveness (Majewska, 1992. Whereas other studies have found evidence of lower levels of cortisol in individuals with ODD (McBurnett et al., 1991; Vanyukov et al., 1990), they found in this study and a previous one (van Goozen et al., 1998b) that levels of adrenal androgens were elevated in children with ODD.

Diagnosis and Clinical Diagnosis and Clinical FeaturesFeatures

• Negativistic hostile defiant behaviorsNegativistic hostile defiant behaviors• DSMIV-TR: Pattern lasting >6mo with 4 or DSMIV-TR: Pattern lasting >6mo with 4 or

more:more:• Loses temper oftenLoses temper often• Often argues with adultsOften argues with adults• Often actively defies or refuses to comply with adults’ requests Often actively defies or refuses to comply with adults’ requests

or rulesor rules• Often deliberately annoys peopleOften deliberately annoys people• Often blames others for his mistakes or misbehavior.Often blames others for his mistakes or misbehavior.• Touchy or easily annoyedTouchy or easily annoyed• Often angry and resentfulOften angry and resentful• Often spiteful or vindictive.Often spiteful or vindictive.• Only if more frequent than typical of comparable developmental Only if more frequent than typical of comparable developmental

ageage

DSM-IV-TR Continued DSM-IV-TR Continued ODDODD

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

• C. Do not occur exclusively during C. Do not occur exclusively during psychotic or mood d/opsychotic or mood d/o

• Criteria not met for Conduct d/o, or if Criteria not met for Conduct d/o, or if over 18, antisocial personality d/o.over 18, antisocial personality d/o.

DifferentialsDifferentialsNormal defiant behavior

Adjustment Disorder

Conduct Disorder

Schizophrenia or mood d/o

ADHD, Cognitive or MR

2-3, adolescence

Stress reaction-temporary

A big one! Show negativism

Frequent comorbid dx 30-65% ADHD

Shorter duration, same as others in same age

Recent Hx: deaths, moves, changes, trauma

More Later. Minority of ODD progress to CD. Think of ODD as a potential precursor to CD.

Don’t Dx as comorbid.

Think severity, duration and pervasiveness

Most show signs with those they are closest too. May not display during exam/interview. Observe interactions with parent and without. More distress to those around them. Little insight into their own behavior;make excuses for it. If school problems, must eval for learning disabilities.Chronic ODD despite normal intelligence, often leads to friendlessness, isolation, poor school performance due to resistance of external demands.

Secondary: ETOH, Drug abuse, low self esteem, depression, low frustration tolerance and may lead to conduct disorder or a mood disorder.

Differential Diagnoses

Course Prognosis and Course Prognosis and TreatmentTreatment

Course Comorbid development/pear

ls

Result Comorbid/Progno

sis

Progression

1 ODD purposeful disagreeableness. Like to see you get mad. Like to incite. Child calms after a

blowout.

ADHD 30-65%Algorithm(s) This has impulsiveness

but no aggressiveness.

ODD can sit still.

Conduct Disorder No CD after 3y with Dx, won’t progress.Conduct d/o: may

not feel safe in home. ADHD is

worse with CD. >18 think APS.

2 Persistence/Severity:

Aggression level high predictor of CD

progression as is paternal criminal

history.

Dx of ODD by 8, only5% no comorbid.

½ with preschool dx outgrow by age 815-20% mood >

w/ anxiety –watch for s/s

Antisocial Behavior Disorder/Substance

Abuse: 1/3-1/2 problems in adulthood:

6x ETOH, 7x pot addiction.

3 The caregiver/the pt

Maternal depression

Consider case management for in home training and

observation of interaction.

Best:Parent training

Child interventionPossibly teacher

training

Parenting skills (PMT)

Positive reinforcement

psychotherapy/anger mgmt, preschool

interventionsMany states have effective "wrap

around" services, which include a full-day school program and home-based

therapy services to maintain progress

in the home setting

65% show clinical benefit from well designed parent

management programs.

Stronger when less severe presentation

One study showed parents with 50% refusal to attend

intervention/classes. Empathy, not their

fault.

Subsyndromal Subsyndromal Manifestation of CD?Manifestation of CD?

• ODDODD• Does not have to Does not have to

progressprogress• Does not share poor Does not share poor

outcome of CD.outcome of CD.• Minority of pts Minority of pts

progress to CD. progress to CD. • Minority of CD progress Minority of CD progress

to APDto APD• SubtypeSubtype: High : High

Aggression is a predictor Aggression is a predictor of of CD-fighting/bullyingCD-fighting/bullying

more antisocial traitsmore antisocial traits

• Conduct DisorderConduct Disorder• More More severesevere habitual habitual

rule breaking with rule breaking with pattern of pattern of destructiondestruction, , lying, higher addiction lying, higher addiction risk.risk.

• truancy (before age 12) truancy (before age 12) stealing and aggressionstealing and aggression

• Precursor to Adult Precursor to Adult Antisocial Personality Antisocial Personality Disorder (30-40%) Disorder (30-40%) higher w/ADHDhigher w/ADHD

• Strong predictor of Strong predictor of substance abusesubstance abuse

J Clinical Psychiatry 2006/67 27-31 Spencer, Thomas ADHD and comorbidity in Childhood; Sadock p.1232-1234.)

LOEBER: J Am Acad Child Adolesc Psychiatry, Volume 39(12).December 2000.1468-1484

LOEBER: J Am Acad Child Adolesc Psychiatry, Volume 39(12).December 2000.1468-1484Oppositional Defiant and Conduct Disorder: A Review of the Past 10 Years, Part I

Nursing MutualityNursing Mutuality

• Peplau When, “seeking assistance on the Peplau When, “seeking assistance on the basis of a need, felt but poorly understood, basis of a need, felt but poorly understood, is often the first step in a dynamic learning is often the first step in a dynamic learning experience from which a constructive next experience from which a constructive next step in personal-social growth can step in personal-social growth can occur”(Peplau, 1991, 19).occur”(Peplau, 1991, 19).

• 293 articles ADHD, 276 on depression in 293 articles ADHD, 276 on depression in kids, only 20 on ODD in 4 years (Chandler, kids, only 20 on ODD in 4 years (Chandler, 2004)2004)

Article Article Nonpharmacologic Nonpharmacologic

Treatment-Guidelines Treatment-Guidelines speakspeak• Best: Multisystem intervention. Best: Multisystem intervention.

• AACAP/National ClearinghouseAACAP/National Clearinghouse: : Recommends no meds unless Recommends no meds unless nonpharms prove futile and s/s nonpharms prove futile and s/s severe. If severe. If comorbidcomorbid, use guidelines , use guidelines for comorbids and aggression if for comorbids and aggression if needed i.e. SSRI, stimulant, needed i.e. SSRI, stimulant, antipsychotic etc.antipsychotic etc.

Resources/Algorithm ADHD with Resources/Algorithm ADHD with Aggression 30-50% Comorbid Aggression 30-50% Comorbid

ODDODD

Flow chart depicting the systematic Flow chart depicting the systematic application of the Treatment application of the Treatment

Recommendations for the Use of Recommendations for the Use of Antipsychotics for Aggressive Youth Antipsychotics for Aggressive Youth

(TRAAY)(TRAAY)

Treatments-LiteratureTreatments-Literature

The findings support the continued use of clonidine in combination The findings support the continued use of clonidine in combination with psychostimulant medication to reduce conduct symptoms with psychostimulant medication to reduce conduct symptoms associated with attention-deficit/hyperactivity disorder. associated with attention-deficit/hyperactivity disorder. Treatment is well tolerated and unwanted effects are transient. Treatment is well tolerated and unwanted effects are transient. (Note: 5-10% have depression with clonidine so beware).(Note: 5-10% have depression with clonidine so beware).A randomized controlled trial of clonidine added to psychostimulant medication for hyperactive and aggressive children. Source Journal of the American Academy of A randomized controlled trial of clonidine added to psychostimulant medication for hyperactive and aggressive children. Source Journal of the American Academy of Child and Adolescent Psychiatry. 42(8):886-94, 2003 Aug.Child and Adolescent Psychiatry. 42(8):886-94, 2003 Aug.Journal Name Journal of the American Academy of Child and Adolescent PsychiatryJournal Name Journal of the American Academy of Child and Adolescent PsychiatryPublication Date 2003 AugPublication Date 2003 AugVolume 42Volume 42Issue/Part 8Issue/Part 8Page 886-94Page 886-94

• Clonidine may reduce conduct problems in children with ADHD and Clonidine may reduce conduct problems in children with ADHD and ODD/CD (ODD/CD (level 2 [mid-level] evidencelevel 2 [mid-level] evidence• J Fam Pract 2005 Feb;54(2):162J Fam Pract 2005 Feb;54(2):162     EBSCOEBSCOhosthost Full Text Full Text) )

By study endpoint, aggression among risperidone-treated subjects had declined by 56.4% (mean baseline AS 10.1; mean endpoint AS 4.4), which was more than twice that of placebo-treated Subjects (mean baseline AS 10.6; mean endpoint AS 8.3; 21.7% reduction). Risperidone was efficacious in reducing symptoms of aggression in boys of below average IQ with disruptive behavior disorders.

AtypicalsAtypicals

Risperidone reduces aggression in boys with a disruptive behaviour disorder and below average intelligence quotient: analysis of two placebo-controlled randomized trials.LeBlanc JC, Binder CE, Armenteros JL, Aman MG, Wang JS, Hew H, Kusumakar V International clinical psychopharmacologyVolume 20Issue/Part 5Page 275-83

Pediatric Dosing and Titration of Atypical Antipsychotics

Substances that Affect Atypicals

The Texas Children's Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder PLISZKA, STEVEN R. M.D.; CRISMON, M. LYNN Pharm.D.; HUGHES, CARROLL W. Ph.D.; CORNERS, C. KEITH Ph.D.; Issue: Volume 45(6), June 2006, pp 642-657Publication Type: [SPECIAL COMMUNICATION]Publisher: Copyright 2006 © American Academy of Child and Adolescent Psychiatry

Stimulants: reduction oppositional behaviors in ADHD/ODD. Risp-least wt gain but most EPS. Remember about ½ adult dose for aggression in peds. (J Am Acad Child Adolesc Psychiatry 2002 Mar;41(3):253 .

Quiz About ODDQuiz About ODD

Jennifer HanleyJennifer Hanley

January 2008January 2008

]]

April 10, 2023April 10, 2023

1. A true fact about 1. A true fact about ODD is:ODD is:

A.A.Medication is an acceptable first line Medication is an acceptable first line intervention for ODD after a thorough intervention for ODD after a thorough evaluation.evaluation.

B.B.Boys are generally given more positive Boys are generally given more positive reinforcement than girlsreinforcement than girls

C.C.Harsh punitive punishment may be a Harsh punitive punishment may be a major cause of ODD.major cause of ODD.

D.D.Family intervention is the primary Family intervention is the primary treatmenttreatment

2. ODD is classified as:2. ODD is classified as:

1.1. Possible consequence of chronic Possible consequence of chronic illnessillness

2.2. An enduring set of behaviors An enduring set of behaviors characterized by aggression and characterized by aggression and violation of the rights of othersviolation of the rights of others

3.3. A consequence of bad parentingA consequence of bad parenting

4.4. Disruptive Behavior DisorderDisruptive Behavior Disorder

3. Where is ODD found?3. Where is ODD found?

1.1. More in girls until adolescentMore in girls until adolescent

2.2. More in boys until adolescenceMore in boys until adolescence

3.3. Equal in preschoolersEqual in preschoolers

4.4. None of the AboveNone of the Above

4. What is ODD a 4. What is ODD a possible precursor of?possible precursor of?

1.1. Conduct disorderConduct disorder

2.2. Antisocial Personality DisorderAntisocial Personality Disorder

3.3. ADHDADHD

4.4. Alcohol and Drug AbuseAlcohol and Drug Abuse

AnswersAnswers

1.1.DD

2.2.DD

3.3.BB

4.4.AA

ConclusionConclusion• ODD: Precursor, start 1-3, found by 8ODD: Precursor, start 1-3, found by 8• Tx is nonpharmacologic first-Safety! Meds: Tx is nonpharmacologic first-Safety! Meds:

Slow and Low. Slow and Low. • No specific algorithm for ODD but ADHD/ODD No specific algorithm for ODD but ADHD/ODD

available.available.• Parents: support reinforce and guide-don’t Parents: support reinforce and guide-don’t

judge. Kids: counseling, anger mgmt, judge. Kids: counseling, anger mgmt, preschool/school intervention or at least child preschool/school intervention or at least child intervention (see article in handout for intervention (see article in handout for approaches).approaches).

• Vague DSM-IV?: research needed specific to ODD; female Vague DSM-IV?: research needed specific to ODD; female specific attributes; adrenal androgen functioningspecific attributes; adrenal androgen functioning

Jhanley@utmem.edu for slide show with notesJhanley@utmem.edu for slide show with notes..

UnityUnity

• National Guideline Clearinghousehttp://www.guideline.gov/summary/summary.aspx?

view_id=1&doc_id=10550• J Child Psychol Psychiatry. 2007 Jul;48(7):703-13. Guideline

Patient handouts:•http://aacap.org/page.ww?name=Children+with+Oppositional+Defiant+Disorder&section=Facts+for+Families (Single sheet-also in Spanish)•http://www.mayoclinic.com/health/oppositional-defiant-disorder/DS00630/DSECTION=8 (Mayo Clinic Multipage handout)

Report of the Working Group on Psychotropic Medications forChildren and Adolescents:Psychopharmacological, Psychosocial, and Combined Interventions for ChildhoodDisorders: Evidence Base, Contextual Factors, and Future Directions

•http//www.apa.org/pi/cyf/childmeds.pdf

American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for assessment and treatment of children and adolescents with oppositional defiant disorder links:

Links

Questions and Questions and DiscussionDiscussion

Aristotle (384-322 BC) knew that touching the brain did not cause any sensation. He concluded that the heart must be the structure which controlled sensations.

Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication.Nock MK, Kazdin AE, Hiripi E, Kessler RC.Department of Psychology, Harvard University, Cambridge, MA 02138, USA. nock@wjh.harvard.eduBACKGROUND: Oppositional defiant disorder (ODD) is a leading cause of referral for youth mental health services; yet, many uncertainties exist about ODD given it is rarely examined as a distinct psychiatric disorder. [PubMed - indexed for MEDLINE]

RESULTS: Lifetime prevalence of ODD is estimated to be 10.2% (males = 11.2%; females = 9.2%). Of those with lifetime ODD, 92.4% meet criteria for at least one other lifetime DSM-IV disorder, including: mood (45.8%), anxiety (62.3%), impulse-control (68.2%), and substance use (47.2%) disorders. ODD is temporally primary in the vast majority of cases for most comorbid disorders. Both active and remitted ODD significantly predict subsequent onset of secondary disorders even after controlling for comorbid conduct disorder (CD). Early onset (before age 8) and comorbidity predict slow speed of recovery of ODD. CONCLUSIONS: ODD is a common child- and adolescent-onset disorder associated with substantial risk of secondary mood, anxiety, impulse-control, and (substance use) disorders.