Oppositional Defiant disorder: Comorbid or stand alone diagnosis? Disruptive Behavior Disorders Jennifer Hanley NAPS 866 Teaching Project Spring 2008 UTHSC
Define and differentiate from other disruptive behavior disorders
Etiology-Thoughts, theories and research
Diagnosis and Clinical Features
Course and Prognosis-Is it all bad?
Treatment-Modalities. Just the Family?
Summary Handout and Questions/Quiz
Management to include web sites evidence based algorithms; therapy and medication
Assessment tools and keys
Key Findings/Results from Literature
Facts 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%)
Etiology ODD (odd kids)
Forming an identity
55% of children with language processing difficulties also met the diagnostic criteria for ODD, suggesting that, if a child does not possess the linguistic skills necessary to label and categorize emotions or communicate needs to others, the stage may be set for concurrent difficulties with frustration tolerance and problem solving (Greene and Ablon, 2003).
Numbers and More Numbers
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 Aggression
Lesions of prefrontal cortex , particularly orbital frontal cortex , early in childhood can result in antisocial disinhibited, aggressive behavior later
in life (160).
Reduced prefrontal gray matter has been associated with
autonomic deficits in patients with antisocial personality
disorders characterized by aggressive behaviors
The 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 Aggression 2
Twin, 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 Brain Increased Adrenal Androgen Functioning in Children With Oppositional Defiant Disorder: A Comparison With Psychiatric and Normal Controls DOI: 10.1097/00004583-200011000-00020 ISSN: 0890-85671527-5418 Accession: 2000-12258-019 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 ENGELAND, HERMAN M.D. Issue: 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 Features
Negativistic hostile defiant behaviors
DSMIV-TR: Pattern lasting >6mo with 4 or more:
Loses temper often
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 mistakes or misbehavior.
Touchy or easily annoyed
Often angry and resentful
Often spiteful or vindictive.
Only if more frequent than typical of comparable developmental age
DSM-IV-TR Continued ODD
B. The behavior causes clinically significant impairment in social, academic or occupational functioning.
C. Do not occur exclusively during psychotic or mood d/o
Criteria not met for Conduct d/o, or if over 18, antisocial personality d/o.
Differentials 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.
Normal 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
Course Prognosis and Treatment Course Comorbid development/pearls Result Comorbid/Prognosis 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 8 15-20% 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 intervention Possibly teacher training Parenting skills (PMT) Positive reinforcement psychotherapy/anger mgmt, preschool interventions Many 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 Manifestation of CD?
Does not have to progress
Does not share poor outcome of CD.
Minority of pts progress to CD.
Minority of CD progress to APD
Subtype : High Aggression is a predictor of CD-fighting/bullying
more antisocial traits
More severe habitual rule breaking with pattern of destruction , lying, higher addiction risk.
truancy (before age 12) stealing and aggression
Precursor to Adult Antisocial Personality Disorder (30-40%) higher w/ADHD
Strong predictor of substance 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 2000.1468-1484 Oppositional Defiant and Conduct Disorder: A Review of the Past 10 Years, Part I
Peplau When, “seeking assistance on the basis of a need, felt but poorly understood, is often the first step in a dynamic learning experience from which a constructive next step in personal-social growth can occur”(Peplau, 1991, 19).
293 articles ADHD, 276 on depression in kids, only 20 on ODD in 4 years (Chandler, 2004)
AACAP/National Clearinghouse : Recommends no meds unless nonpharms prove futile and s/s severe. If comorbid , use guidelines for comorbids and aggression if needed i.e. SSRI, stimulant, antipsychotic etc.
Resources/Algorithm ADHD with Aggression 30-50% Comorbid ODD
Flow chart depicting the systematic application of the Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY)
The findings support the continued use of clonidine in combination with psychostimulant medication to reduce conduct symptoms associated with attention-deficit/hyperactivity disorder. Treatment is well tolerated and unwanted effects are transient. (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 Child and Adolescent Psychiatry. 42(8):886-94, 2003 Aug. Journal Name Journal of the American Academy of Child and Adolescent Psychiatry Publication Date 2003 Aug Volume 42 Issue/Part 8 Page 886-94
Clonidine may reduce conduct problems in children with ADHD and ODD/CD ( level 2 [mid-level] evidence
J Fam Pract 2005 Feb;54(2):162 EBSCO host Full Text )
Atypicals 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. 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 psychopharmacology Volume 20 Issue/Part 5 Page 275-83
Pediatric Dosing and Titration of Atypical Antipsychotics
Report of the Working Group on Psychotropic Medications for
Children and Adolescents:
Psychopharmacological, Psychosocial, and Combined Interventions for Childhood
Disorders: Evidence Base, Contextual Factors, and Future Directions
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 Discussion
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. firstname.lastname@example.org BACKGROUND: 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.