By: Amanda, Amy and Sarah

OPPOSITIONAL DEFIANT DISORDER

Pre-TestCases

Normal Behavior or ODD?History

Diagnostic Criteria Cause/Risk Factors

PrevalencePrognosis

Co-morbidityTreatment and Intervention

Strengths

OVERVIEW

1. In order to diagnose ODD, symptoms must occur in multiple settings.

2. Diagnostic criteria for ODD includes problems with emotional regulation.

3. Diagnostic criteria for ODD includes aggression toward people and animals.

4. There is no clear cause of ODD.

5. Parenting style can be a risk factor for ODD.

6. Anxiety can be a protective factor when co-morbid with ODD.

7. All children with ODD eventually receive a diagnosis of CD.

8. ODD is easily treated with medication.

9. Staying firm and saying NO is an effective way to curb defiance.

10. Steve Jobs was diagnosed with ODD.

TEST YOUR KNOWLEDGE

CASE

Jeremy is a 5 year old boy. His mother claims he has been a ‘handful’ since he was 2. She says when in daycare the workers would be pulling their hair out. Her home life is stressful, and

Jeremy enjoys going against the grain. He is constantly talking and is frequently annoyed by little things. Now in Kindergarten, he

does not make friends easily. His mother has received phone calls on a weekly basis saying that he has disrupted the class or

attacked another child. Recently he has started to ‘purposely annoy’ his younger sister, resulting in yelling and hitting. He

always says this is her fault and will not apologize. If asked to stop playing videogames before he is ready, this will often result in a

full blown tantrum with yelling, swearing, and throwing his toys.

Does Jeremy have ODD?

What is the difference between a strong willed child and one with oppositional

defiant disorder?

Children experience pockets of independence or defiant behaviours

throughout development.

NORMAL BEHAVIOUR OR ODD?

(Oppositional Defiant Disorder Resource Centre, 2013)

•In 1980’s, DSM-III included under Conduct Disorder the term “oppositional disorder”

•Included: irritable, stubborn, defiant behaviour features, displayed at developmentally deviant rates.

•DSM-III-R changed to ODD and included 9 behavioural symptoms with 5 required for diagnosis.

•DSM-IV ODD with 4/8 symptoms

HISTORY OF ODD

(Barkley & Mash, 2003).

A) A pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness at least 6 monthsat least 4 of the 8 symptoms from any categories

Seen during interaction with at least one individual who is not a sibling.

DSM-V CRITERIA FOR ODD

(American Psychiatric Association, 2013).

Angry/Irritable Mood• often looses temper

• often touchy or easily annoyed

• often angry and resentful

Argumentative/Defiant Behaviour• often argues with authority figures, or adults

• often actively defies or refuses to comply with requests or rules

• often deliberately annoys others

• often blames others for his or her mistakes or misbehaviours.

Vindictiveness• has been spiteful or vindictive at least twice within the past

6 months.

DSM CRITERIA FOR ODD

(American Psychiatric Association, 2013).

B) The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context, or it impacts negatively on social, education, occupation, or other important areas of functioning.

C) The behaviours 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 dysregulation disorder.

DSM CRITERIA FOR ODD

(American Psychiatric Association, 2013).

•Pay attention to the duration, severity and frequency of these behaviours.•Consider if behaviours are outside a range that is typical for the individuals developmental level, gender and culture. •Children under 5 the behavior should occur at least once per week for at least 6 months.

OTHER CONSIDERATIONS

(Barkley & Mash, 2003).

•DSM-IV: CD and ODD are separate disorders:

•four of eight symptoms for a diagnosis of ODD •three of fifteen symptoms for a diagnosis of CD.

•ICD-10: ODD is a subtype:

•fifteen ‘more severe items’ equivalent to the DSM-IV CD symptoms.•eight ‘less severe items’, equivalent to the DSM symptoms of ODD.

•All children who receive a diagnosis by DSM-IV criteria also receive an ICD-10 diagnosis, but a number of children who meet ICD-10 criteria for CD (ODD sub-type) would not receive a diagnosis in DSM-IV

CONTROVERSY

DSM-IV/V VS. ICD-10

(Rowe, Maughan, Costello, & Angold, 2005)

Does Jeremy meet the criteria for ODD?

- if you think Jeremy does meet criteria

- if you think Jeremy does NOT meet criteria

- if you are unsure or need more information to tell

CASE STUDY

No clear cause, contributing causes may be a combination of inherited and environmental and may result in the development of ODD and effect on prognosis of ODD.

Contextual factors

• Low Socioeconomic status

• Stress and conflict in home(Lavigne, Gouze, Hopkins, Bryant, & LeBailly, 2011).

CAUSE AND RISK FACTORS

Parental characteristics • Parent psychopathy

• Insecure attachments associated with ODD related symptoms

Parenting

• Lack of supervision

• Abuse or neglect

• Harsh or inconsistent punishment(Barkley & Mash, 2003; Lavigne, Gouze, Hopkins, Bryant, & LeBailly, 2011).

CAUSES AND RISK FACTORS

Child characteristics • natural disposition • Insecure attachments are associated with ODD

related symptoms• Limitations or developmental delays in a child's

ability to process thoughts and feelings• Imbalance of Brain chemicals (serotonin) or

subtle differences in brain chemistry

(Barkley & Mash, 2003; Lavigne, Gouze, Hopkins, Bryant, & LeBailly, 2011).

CAUSE AND RISK FACTORS

•Ranges from 1% to 11% with an average prevalence estimate of around 3.3% (APA, 2013; Dunsmore, Booker & Ollendick, 2013)

•More common in males than females- ratio 1.4:1 prior to adolescence (APA, 2013)

• More prevalent among youth from low socio-economic status (Loeber et al., 2000)

•Prevalence is consistent across race & ethnicity (APA, 2013)

•Lifetime prevalence estimated at 10.2% (males 11.2%. Females 9.2%) (Nock et al., 2007)

PREVALENCE

•Less attention to outcomes of ODD as much of the focus of research has been on developmental relationship between CD & ODD (Burke & Loeber, 2010)

•Children diagnosed with ODD have a greater risk of adjustment problems as adults (APA, 2013)

•Anti-social behavior

•Impulse-control problems (68.2%)

•Substance abuse (47.2 %)

•Anxiety (62.3%)

•Depression (Mood Disorders 45.8%)

Nock et al., 2007

PROGNOSIS

ODD is associated with high rates of co-morbidity with other disorders (Burke &

Loeber, 2010)

ODD

ADHD

Anxiety/Mood Disorders

CDLearning Disabilities

Substance Abuse

COMORBIDITY

•40% of children with ADHD meet criteria for ODD; these children tend to be:

• more aggressive

• more persistent behavior issues

• more rejection from peers

• severely underachieve

(Hamilton & Armando, 2008)

COMORBIDITYADHD

•Rates of ODD higher in samples of children and adults with ADHD possibly the result of shared tempermental risk factors (APA, 2013)

•Poor impulse control, attention deficits and aggression predict negative outcomes (Hinshaw & Lee, 2003)

•Children with ODD are at a higher risk for anxiety disorders & major depressive disorder (APA, 2013)

*twice as likely to have severe major depressive disorder or bipolar disorder compared to control group (Burke & Loeber, 2010; Hamilton & Armando, 2008)

•When anxiety disorder & ODD co-occur, the clinical presentation is more severe & includes additional academic, social & familial complications (Drabick, Ollendick & Bubier, 2010)

COMORBIDITYANXIETY/MOOD DISORDERS

Can anxiety provide protective factors for children with ODD?

The “Buffer Hypothesis”

vs

“Multiple Problem Hypothesis” (Drabick et al., 2010)

COMORBIDITYANXIETY/MOOD DISORDERS

•The majority of children diagnosed with ODD will not progress to CD

•ODD is presumed present when CD is diagnosed and can be a precursor to CD, 1/3 of kids with ODD develop CD

COMORBIDITYCONDUCT DISORDER

(APA, 2013; Hinshaw & Lee, 2003)

(Burke & Loeber, 2010)

Oppositional Defiant Disorder Dimensions (Burke & Loeber, 2010)

COMORBIDITY

ODD Behavior

_____________

ODD Negative

Affect

CD

Depression

COMORBIDITYLEARNING DIFFICULTIES

•When controlling for ADHD in the research, children with ODD without ADHD do not have problems with attention, executive functioning or learning. (Mayes & Calhoun, 2007).

“GIVE ME THE SMILEY FACE STICKER NOW!”

WHAT TO DO?

•Early Intervention may be helpful for preschool children in high risk populations.

• Social skills training for school aged children.

• For adolescents educational programs help reduce disruptive behaviour.

CAN ODD BE PREVENTED?

(American Academy of Child and Adolescent Psychiatry)

One size doesn’t fit

all…

HOW IS ODD TREATED?

• Individual Therapy: Problem-Solving Therapy Cognitive Behavioural

Therapy Social Skills Therapy

•Family Therapy

•Medication

•Classroom intervention

INTERVENTION OPTIONS

•Problem-Solving Therapy

•Cognitive Behavioural Therapy

•Social Skills Therapy

(Johnson, 2012)

INDIVIDUAL THERAPY

•Empowers families to effectively solve problems and conflict

•Individualized programs

•Help deal with the family’s immediate needs as well as their long term goals

•Be aware of how change affects every member of the family

(Markward, 2001)

FAMILY THERAPY

Medications is not typically prescribed

CONSIDERATIONS:

•Other treatment options are exhausted?

•Extreme aggression?

•Co-morbid disorders?

=Antipsychotic -Risperidone

MEDICATION

The research emphasize the importance of a MULTIDISIPLINARY

approach in the care of these children and their

families.

THINK ABOUT YOUR REACTION…

•Raise Voice

•React

•Frustration

•Threat

•Demand

•Punishment

POSSIBLE INITIAL REACTIONS

•Raise Voice Make sure we are calm

•React Be Proactive not reactive

•FrustrationUnderstand purpose of challenging behaviors and the developmental level of students. Change your perspective.

•Threat Avoid power struggles

•Demand Instead of telling the child what “NOT” to do- tell them what to do by labeling it when you see it.

•Punishment Increase positive interactions between students and adults and have students meet realistic expectations.

TRAIN YOURSELF TO RESPOND DIFFERENTLY

TO GET:

Attention from adults or peers

Access to materials/ resources / sensory

TO AVOID:

Work

Peers

Adults

Demands

Sensory overload

Emotion or physical pain

FUNCTIONS OF BEHAVIOUR

(Riffel, 2009)

WHAT SETTING

PRECEEDS THIS

BEHAVIOUR

WHAT IS THE PAY OFF FOR

THE CHILD?WHAT

BEHAVIOUR CAN YOU USE TO REPLACE

THIS BEHAVIOUR?

HOW COULD YOU

BE PROACTIVE

TO CHANGE

THIS?

WHAT CAN WE DO SO THE CHILD

AVOIDS THE PAY

OFF?

WHAT TARGET BEHAVIOUR DO YOU WANT TO CHANGE

(Riffel, 2009)

DURING A WORK JOB

WORK AVOIDANCE

CHOOSE A DISTRACTION:

FIGET TOY, SPECIAL

SUPPLIES,HELP

ANOTHER CHILD

PRE-TEACH AND CHOOSE APPORPRIATE

WORK FOR THE CHILD’S

LEVEL

REWARD WORK JOBS

ANNOYING OTHER CHILDREN ON PURPOSE

•Oppositional Defiant Disorder may improve over time!

• Studies have shown that symptoms of ODD may resolve within 3 years in approximately

67% of children diagnosed with the disorder.

(American Academy of Child and Adolescent Psychiatry)

THE GOOD NEWS!

They possess strengths like: •determination•strong will • courage to be different•strong need for control and will do just about anything to gain power

STRENGTHS

“Discipline without a relationship leads to rebellion.” -Dr. Josh McDowell

1. In order to diagnose ODD, symptoms must occur in multiple settings.

F

2. Diagnostic criteria for ODD includes problems with emotional regulation.

T

3. Diagnostic criteria for ODD includes aggression toward people and animals.

F

4. There is no clear cause of ODD.

T

5. Parenting style can be a risk factor for ODD.

T

6. Anxiety can be a protective factor when comorbid with ODD.

T

7. All children with ODD eventually receive a diagnosis of CD

F

HOW DID YOU DO?

8. ODD is easily treated with medication.

F

9. Staying firm and saying NO is an effective way to curb defiance.

F

10. Steve Jobs was diagnosed with ODD.

T

HOW DID YOU DO?

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders

(5thed.). Washington, DC: APA.

Axelrad, M. E., Garland, B. H., & Love, K. (2009). Brief Behavioral Intervention for Young Children with Disruptive Behaviors. Journal Of Clinical Psychology In Medical

Settings, 16(3), 263-269.

Barkley, R. A. & Mash, E. J. (2003). Child psychopathology (2nd ed.). New York: Guilford Press.

Behaviour Doctor (2009). Retrieved from: http://www.behaviordoctor.org/

Burke, J. & Loeber, R. (2010). Oppositional Defiant Disorder & the Explanation of theComorbidity Between Behavior Disorder & Depression. Clinical

Psychology: Science & Practice, 17(4), 319-326.

Cunningham, N.R., & Ollendick, T.H. (2010). Comorbidity of Anxiety and Conduct Problems in Children: Implications for Clinical Research & Practice. Clinical Child & Family

Psychology Review, 13: 333-347. doi: 10.1007/s10567-010-0077-9

REFERENCES

Drabick, D.A., Ollendick, T.H., & Bubier, J.L. (2010). Co-occurrence of Oppositional Defiant & Anxiety Disorder: Shared Risk Processes &

Evidence for a Dual Pathway Model. Clinical Psychology: Science & Practice, 17(4), 307-318.

Dunsmore, J.C., Booker, J.A., & Ollendick, T.H. (2013). Emotion Regulation as Protective Factors for Children with Oppostional Defiant Disorder. Social Development, 22(3), 444-466.

Fulkerson, R. C., & Webb, A. R. (2005). What are effective treatments for oppositional and defiant behaviors in preadolescents?. Journal Of Family Practice, 54(2), 162-165.

Hamilton, S.S., & Armando, J. (2008). Oppositional Defiant Disorder. American Family Physician, Oct 1, 78(7), 861-866.

Hinshaw, S.P. & Lee, S.S. (2003). Conduct & Oppositional Defiant Disorders. In Eric J. Mash & Russell A. Barkley. Child Psychopathology. New York: The Guilford Press.

REFERENCES

Johnson, M., S., Fransson, G., Landgren, M., Nasic, S., Kadesj, B., & ... Fernell, E. (2012). Attention-deficit/hyperactivity disorder with oppositional defiant disorder in Swedish children - an open study of collaborative problem solving. Acta Paediatrica, 101(6), 624-630.

Lavigne, J.V., Gouze, K.R., Hopkins, J., Bryant, F.B, & LeBailly, S.A. (2011). A multi-domain model of risk factors for ODD symptoms in a community sample of 4-year-olds. Journal of Abnormal Child Psychology, 40, pp. 741-757.

Oppositional Defiant Disorder Resource Centre (2013). American Academy of Child and Adolescent Psychiatry. Retrieved from: http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Oppositional_Defiant_Disorder_Resource_Center/Home.aspx

Rey, J. M., Walter, G., Plapp, J. M., & Denshire, E. (2000). Family environment in attention deficit hyperactivity, oppositional

defiant and conduct disorders. Australian & New Zealand Journal Of Psychiatry, 34(3), 453-457.

REFERENCES

QUESTIONS? COMMENTS? EXPERIENCES?