OPPOSITIONAL DEFIANT DISORDER. PRESENTATION OUTLINE DSM-IV ODD Criteria Secondary Symptoms...
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Transcript of OPPOSITIONAL DEFIANT DISORDER. PRESENTATION OUTLINE DSM-IV ODD Criteria Secondary Symptoms...
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 n
Age
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 n
Age
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 3.0-11.0 421
Table: 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 FO R W ELL-ESTA BLISH ED TH ERA PY
1. There m ust be at least tw o good group-design experim ents, conducted in at least tw o independent research setti ngs and by independent investi gatory team s, dem onstrati ng effi cacy by show ing the treatm ent to be: (requires 1 of 2)
1 . Stati sti cally sign ificantly superior to p ill or psychological p lacebo or to another treatm ent.
2. Equivalent ( or not sign ificantly d ifferent) to an already estab lished treatm ent in experim ents w ith stati sti cal pow er being suffi cient to detect m oderate d ifferences
2. Treatm ent m anuals or logical equ ivalent w ere used for the treatm ent
3. Conducted w ith a populati on, treated for specific prob lem s, for w hom inclusion criteria have been delineated in a reliab le, valid m anner
4. Reliab le and valid outcom e assessm ent m easures, at m in im um tapping the program s targeted for change w ere used
5. A ppropriate data analyses
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 FO R PRO BA BLY EFFICACIO U S
(requires 1 of 2)
1. There m ust be at least tw o good experim ents show ing the treatm ent is superior (stati sti cally sign ificantly so) to a w ait-list contro l group.
2. O ne or m ore good experim ents m eeti ng the W ell-Established Treatm ent Criteria w ith the one excepti on of having been conduct3ed in at least tw o independent research setti ngs and by independent investi gatory team s.
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 FO R PO SSIBLY EFFICACIO U S
1. At least one “good” study show ing the treatm ent to be effi cacious in the absence of conflicti ng evidence.
CRITERIA FOR POSSIBLY EFFICACIOUS
1. At least one “good” study showing the treatment to be efficacious in the absence of conflicting evidence.
Possibly EfficaciousCBT
Group Anger Control Training
Reaching Educators, Children, and Parents (RECAP)
BEHAVIOR THERAPY
Triple 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