Oppositional Defiant Disorder (ODD)

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) After adolescence, rates even out 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 Often studies with both 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 Different symptoms of ODD may be predictive of different problems later on 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 Symptoms
Criterion 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
Inconsistent parenting Environmental Factors Harsh/neglectful parenting Reduced basal cortisol reactivity Oppositional Defiant Disorder Risk for: CD Anxiety Depression Genetic/Physiological Factors Abnormal prefrontal cortex Abnormal amygdala High levels emotional reactivity Core Features -angry/irritable mood -argumentative/defiant behavior -vindictiveness Secondary Features Problematic interactions with others Temperamental Factors Low levels frustration tolerance

Part 3 ODD: The Research Neurobiological Underpinnings Parenting
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

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. Why would skin conductance level be lower?; markers come out mostly during stress

ANS and HPA Activity Van 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. opposite pattern of SCL from last experiment; negative mood

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 RSA/PNS with emotional regulation PEP/SNS with reward insensitivity

Played “Perfection” Results:
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) 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 Self ordered pointing- point to a picture hadn’t pointed to before. DGT: delay for more desired outcome: press button 1 with 40% chance of winning nickel vs. delayed 12 second option button 2 with 80% chance of winning nickel

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 ODD Matthys 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 Authors say maybe this can be attributed to awareness IQ’s less than 80 excluded

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 stimulates growth hormone, possibly through 5HT?

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 Point of consideration: Are impulsivity and aggression inherent to ODD?

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 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 NC: greater left than right frontal activation 8 yr. old boys *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. authors discuss frontal brain differences related to expressions of emotions and affect and cite: Davidson, R.J. (1995) Cerebral asymmetry, emotion, and affective style

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

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) Parenting practices can have long term effects

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= 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 Gerald Patterson

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 Neither ODD nor CD predicted ADHD. Participants older than last study

Results ODD symptom count predictors: CD 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) 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

Prevention, Intervention, and Treatment Family interactions seem to be highly related to symptoms

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 Some interventions target parent, some target children. Goes back to mutually reinforcing behaviors.

Results Symptoms at Home: Symptoms at school: Academic Functioning
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 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? Challenges: 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 ) Less negative parenting for mothers in all PT conditions, and CT condition vs. control (d ranging ) More positive parenting for mothers in all PT conditions vs. control (d ranging ) Less negative parenting for fathers in all PT conditions vs. control (d ranging )

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 Implications regarding ADHD and special ed. No control at 2 year follow up

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)

4 assessments, 4 months apart (WL group 4 month lag “behind” IT)
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 Even though parent intervention, children still involved

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 Forced escalation

Intent to Treat (ITT) population: 96. 4% ; 79. 1% comorbid ADHD, 29
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 MAS XR 10, 20, and 30 greater improvements vs. placebo MAS XR 10, 20, 30, 40 greater improvements vs. placebo Effect sizes?

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 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 What does the effectiveness of targeting parents say about the relative contributions of genes and environment?

Schematic ODD Risk for: Neurobiological Factors
Brain anatomical differences Schematic ANS underarousal Risk for: CD Anxiety Depression Substance abuse HPA underarousal Neurobiological Factors ODD Parent, Child, and Teacher Interventions Frontal brain differences Neurotransmitters Treatment/Interventions Medication Discipline Styles Family Risk Factors/Parenting Styles Negative emotions Core Features -angry/irritable mood -argumentative/defiant behavior -vindictiveness Secondary Features Problematic interactions with others Poor Communication

DSM V Visual Schematic for ODD
Inconsistent parenting Environmental Factors Harsh/neglectful parenting Reduced basal cortisol reactivity Oppositional Defiant Disorder Risk for: CD Anxiety Depression Genetic/Physiological Factors Abnormal prefrontal cortex Abnormal amygdala High levels emotional reactivity Core Features -angry/irritable mood -argumentative/defiant behavior -vindictiveness Secondary Features Problematic interactions with others Temperamental Factors Low levels frustration tolerance

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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