1. Oppositional Defiant disorder: Comorbid or stand alone diagnosis? Disruptive Behavior Disorders Jennifer Hanley NAPS 866 Teaching Project Spring 2008 UTHSC
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10. 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
11. 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.
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16. 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.
19. 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
23. Flow chart depicting the systematic application of the Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY)
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25. 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
28. 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 .
29. Quiz About ODD Jennifer Hanley January 2008 ] August 11, 2009
39. 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.
40. 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.edu 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.
Editor's Notes
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Def: An enduring pattern of negativistic hostile and diefiant behaviors in theabsensce of serious violations of social norms or of the right of others” lasting at least 6 months- DSM to follow. (Saddock 9 th ed p. 548). Basicall y 2 sets of problems: aggressiveness and purposefully irritating and bothering others (Chandler 2002, ODD nd CD in Children and Adolesdcents: Diagnosis and Treatment). -temper outbursts, active refusal to comply with rules and “annoying” behaviors Exceed the expectations for these behaviors commpared with others others of The same age. Epi: -as early as 3, noticed by 8 or by adolescence. -Found in 16-22% of nonclinical school age children. ODD 2-16 percent reported (Sadock). -Boys>girls until puberty, then equal. -Almost all PARENTS have an overconcern with issues of power control and autonomy. Etiology: -We think, we do not KNOW. Dx Differentials Prognosis Tx comorbids
The Important stuff: quick, get through the vagueness of behavior disorders without undue stress on you and me.
Antisocial behaviour is defined as behaviour by which people are disadvantaged and basic norms and values are violated. Examples of such behaviours are lying, stealing and truancy. Before age 13. Aggressive behaviour tmay differ in females in the form of less overt gestures than bullying and hitting. Gossiping in this group to hurt others emotionally is a form of oppositional behavior. Terrible two’s : forming autonomy: normal oppositional behavior. “ ODD is when the behavior persists or is more severe or more often than in others of the same age grou Authority figures overreact. Also normal at separation from parents to define autonomy. Chronic illness in late childhood, env trauma or illness as well as MR can trigger oppositionalism as a defense against helplessness and loss of self esteem (normal) so rule out chronic illness in these kids as a causative factor. Psychoana theory: unresolved conflicts expressed with all authority figures. Behaviorists: oppositionalism is a reinforced learned behavior through which a child exerts control over an adult (temper tantrum results in long talk or end of the request reinforces the behavior. Tend to agree here because in other d/o such as GAD, there is almost always a hx of criti cal parent. Ask bad parents? Bad kids? T
PATHOPHYSIOLOGY AND TREATMENT OF AGGRESSION EMIL F. COCCARO LARRY J. SIEVER
Children with a conduct disorder (CD) or 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). However, although an association between androgens and aggression has been clearly established in animals, the evidence in humans is less clear-cut (Archer, 1991). 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 not focus on testosterone, but on adrenal androgens , such as dehydroepiandrosterone (DHEA), its sulfate (DHEAS), and androstenedione. Of these, DHEA and DHEAS are particularly interesting because they are also endogenously synthesized by the brain (Robel and Baulieu, 1994), they increase neuronal excitability, enhance neuronal plasticity and have neuroprotective properties (Wolf and Kirschbaum, 1999), and, finally, they appear to have potent antagonistic effects on central [gamma]-aminobutyric acid (GABA) mechanisms, which are involved in aggressiveness (Majewska, 1992). One would therefore expect to find elevated DHEA/DHEAS levels in individuals who are aggressive. Whereas other studies have found evidence of lower levels of cortisol in individuals with ODD (McBurnett et al., 1991; Vanyukov et al., 1990), we found in the present study and a previous one (van Goozen et al., 1998b) that levels of adrenal androgens were elevated in children with ODD. It is interesting that the opposite pattern is observed in depressed patients, namely relatively high levels of cortisol and low levels of DHEA/DHEAS (Goodyer et al., 1996). Although no study to date has analyzed levels of cortisol and DHEA/DHEAS simultaneously in ODD, is possible that a pattern of increased androgen production and decreased cortisol production reflects a change in balance of ACTH–[beta]-endorphin/ joining peptide production, with all fragments arising from the same precursor molecule, pro-opiomelanocortin (Clarke et al., 1996). At present, however, this idea remains speculative. We also do not know whether this process, if it exists, is initiated by early stress or genetic factors. However, there is a growing body of research showing how early stressful experiences can have permanent effects on the developing neurobiological systems in the brain, including the HPA axis (Carlson and Earls, 1996). The results demonstrate that adrenal androgen functioning is an important topic for future research into the causes of persistent oppositional and antisocial behavior. A better understanding of the mechanisms involved in the development of antisocial behavior, including a better knowledge of the biological predispositions to aggression, should ultimately result in earlier and more effective interventions.
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. It is interesting that the opposite pattern is observed in depressed patients, namely relatively high levels of cortisol and low levels of DHEA/DHEAS (Goodyer et al., 1996). Although no study to date has analyzed levels of cortisol and DHEA/DHEAS simultaneously in ODD, is possible that a pattern of increased androgen production and decreased cortisol production reflects a change in balance of ACTH–[beta]-endorphin/ joining peptide production, with all fragments arising from the same precursor molecule, pro-opiomelanocortin (Clarke et al., 1996). At present, however, this idea remains speculative. We also do not know whether this process, if it exists, is initiated by early stress or genetic factors. However, there is a growing body of research showing how early stressful experiences can have permanent effects on the developing neurobiological systems in the brain, including the HPA axis (Carlson and Earls, 1996). The results demonstrate that adrenal androgen functioning is an important topic for future research into the causes of persistent oppositional and antisocial behavior. A better understanding of the mechanisms involved in the development of antisocial behavior, including a better knowledge of the biological predispositions to aggression, should ultimately result in earlier and more effective interventions. Reactive and proactive aggression in children A review of theory, findings and the relevance for child and adolescent psychiatry European Child & Adolescent Psychiatry (2005) Vol. 14, No. 1 by Kempes et al.
Think 2 year old or 14 year old
APA DSM 4 th Ed.Washington DC. 2000.
Differential diagnoses. From Sadock Synopsis of Psychiatry 9 th edition. Labs-may have low serotonin levels when older with physical aggression and violating the rights of others (in the CNS). Oppositional Defiant Disorder Last Updated: March 30, 2006 from Emedicine W Douglas Tynan, PhD
ODD can lead to conduct disorder but not predictor of substance abuse. Hypothesis that ODD is a sybsyndromal manifestation of conduct disorder.
Bullies, weapon, cruelty animals, stolen, forced, deliberate destroyed property, lies, truant before 13. difference in externalizing/internalizing behavior in girls has led to queries about the current dsm’s applicability to this population for conduct d/o.
Fig. 1 Developmental sequences between disruptive behavior disorders and comorbid conditions. The dotted arrow indicates a relationship in which attention-deficit/hyperactivity disorder (ADHD) serves to hasten the onset and worsen the severity of conduct disorder (CD), but only in the presence of oppositional defiant disorder (ODD). Lines without arrowheads indicate relationships in which the direction is not clear. Antisocial personality disorder (APD) in young adulthood is a primary likely outcome of the disruptive behavior disorders pathway but was not expressly reviewed here. From: ISSN: 0890-8567 Accession: 11128323
parent training effective (level 1 [likely reliable] evidence) ; 8 well-done systematic reviews studied effectiveness of parent training programs; parent training programs are standardized short-term interventions that teach parents specialized strategies (positive attending, ignoring, effective use of rewards and punishments, token economies, time outs); most rigorous review evaluated 16 randomized trials for parents of children ages 3-10 years with "externalizing problems" (such as temper tantrums, aggression, noncompliance), all trials compared group-based parent training program with no treatment or wait list control (J Fam Pract 2005 Feb;54(2):162 collaborative problem solving may provide improvements in functioning at 4 months compared with parent training (level 2 [mid-level] evidence) , based on randomized trial of 47 affectvely dysregulated children with oppositional-defiant disorder (J Consult Clin Psychol 2004 Dec;72(6):1157) other psychosocial treatments with evidence of benefit in randomized trials include Anger Coping Therapy, Problem Solving Skills Training, Dina Dinosaur Social Emotional and Problem Solving Child Training, and Incredible Years Teacher Training (J Fam Pract 2005 Feb;54(2):162 EBSCO host Full Text
Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY). Part II. PAPPADOPULOS, ELIZABETH, MACINTYRE , JAMES, CRISMON, M., FINDLING, ROBERT, MALONE, RICHARD, DERIVAN, ALBERT, SCHOOLER, NINA, SIKICH, LIN, GREENHILL, LAURENCE, SCHUR, SARAH, FELTON, CHIP, KRANZLER, HARVEY, RUBE, DAVID, SVERD, JEFFREY, FINNERTY, MOLLY, KETNER, SCOTT, SIENNICK, SONJA, JENSEN, PETER Link to... Abstract Table of Contents Database Journals@Ovid Full Text Accession Number 00004583-200302000-00008. Author PAPPADOPULOS, ELIZABETH PH.D.; MACINTYRE , JAMES C. II M.D.; CRISMON, M. LYNN PHARM.D.; FINDLING, ROBERT L. M.D.; MALONE, RICHARD P. M.D.; DERIVAN, ALBERT M.D.; SCHOOLER, NINA PH.D.; SIKICH, LIN M.D.; GREENHILL, LAURENCE M.D.; SCHUR, SARAH B. B.A.; FELTON, CHIP J. C.S.W.; KRANZLER, HARVEY M.D.; RUBE, DAVID M. M.D.; SVERD, JEFFREY M.D.; FINNERTY, MOLLY M.D.; KETNER, SCOTT B.A.; SIENNICK, SONJA E. B.A.; JENSEN, PETER S. M.D. Title Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY). Part II.[Article] Source Journal of the American Academy of Child & Adolescent Psychiatry. 42(2):145-161, February 2003. Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY). Part II. PAPPADOPULOS, ELIZABETH, MACINTYRE , JAMES, CRISMON, M., FINDLING, ROBERT, MALONE, RICHARD, DERIVAN, ALBERT, SCHOOLER, NINA, SIKICH, LIN, GREENHILL, LAURENCE, SCHUR, SARAH, FELTON, CHIP, KRANZLER, HARVEY, RUBE, DAVID, SVERD, JEFFREY, FINNERTY, MOLLY, KETNER, SCOTT, SIENNICK, SONJA, JENSEN, PETER Link to... Abstract Table of Contents Database Journals@Ovid Full Text Accession Number 00004583-200302000-00008. Author PAPPADOPULOS, ELIZABETH PH.D.; MACINTYRE , JAMES C. II M.D.; CRISMON, M. LYNN PHARM.D.; FINDLING, ROBERT L. M.D.; MALONE, RICHARD P. M.D.; DERIVAN, ALBERT M.D.; SCHOOLER, NINA PH.D.; SIKICH, LIN M.D.; GREENHILL, LAURENCE M.D.; SCHUR, SARAH B. B.A.; FELTON, CHIP J. C.S.W.; KRANZLER, HARVEY M.D.; RUBE, DAVID M. M.D.; SVERD, JEFFREY M.D.; FINNERTY, MOLLY M.D.; KETNER, SCOTT B.A.; SIENNICK, SONJA E. B.A.; JENSEN, PETER S. M.D. Title Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY). Part II.[Article] Source Journal of the American Academy of Child & Adolescent Psychiatry. 42(2):145-161, February 2003.
parent-training and child-focused skill training. (Table 1) A combination of approaches results in better outcomes than either approach in isolation.2 Parent-training elements should include psychoeducation about the importance of parental monitoring of behavior, establishing and implementing clear, consistent contingencies (rewards and consequences), limit setting, and strategies to improve the quality of the parent-child relationship through child-directed play, for example. Parent training would utilize active approaches such as modeling of skills/communication styles and behavioral rehearsal or role-playing with specific constructive feedback. Child-focused skill training would target affect education, anger management, and problem-solving skills. Affect education teaches children to recognize, label, and interpret emotions (their own and others). Effective anger management skill building includes teaching skills such as self-talk, relaxation methods such as deep breathing or imagery, recognition of physiological “warning signs” for anger, and gaining insight into anger “triggers” by keeping logs. Problem solving skill training includes learning to generate alternative solutions or choices and evaluating the likely consequences of alternative options through self-evaluation.
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 risperidone maintained efficacy for 48 weeks in open-label extension study of 77 patients following this trial; 76 patients had adverse effects including somnolence (52%), headache (38%), and weight gain (36%) (Pediatrics 2002 Sep;110(3):e34), Issue/Part 5 Page 275-83 reactive aggression is considered to be related to poor self-control, pharmacological treatment, e. g. the administration of methylphenidate, may reduce the disinhibition problems [26]. Besides, both risperidon and lithium are recommended for the treatment of impulsive outbursts of aggression [22].
Pediatric dosing chart for atypicals. Remember risperidone is about half that of the usual dose if treating aggressive children. risperidone may be helpful for children with disruptive behavior disorders ; 100 children 5-12 years old with sub-average IQ (35-84) and conduct disorder, oppositional defiant disorder or disruptive behavior not otherwise specified underwent 1-week placebo run-in and were then randomized to risperidone 0.02-0.06 mg/kg/day vs. placebo for 6 weeks; statistically significant differences in disruptive behaviors were seen at 1 week and throughout the trial; risperidone also improved irritability, lethargy/social withdrawal, stereotyped behavior and hyperactivity; 41.5% vs. 14% somnolence (NNH 3), 17% vs. 7% headache (NNH 10), 15.1% vs. 3.5% increased appetite (NNH 8), 11.3% vs. 0 hyperprolactinemia (NNH 8)
From Our texas algorithm friend stimulants associated with reduction in oppositional/aggression-related behaviors in children with ADHD and ODD/CD based on meta-analysis of 28 studies with children aged 7-15 years (J Am Acad Child Adolesc Psychiatry 2002 Mar;41(3):253
NOT a wheel of continuity should know by now. Precursor to conduct d/o sometimes. When most likely? Bullying, high antisocial behavior and more aggression. Think APS over 18. If ADHD, screen for ODD with one instrument if possible and with parent input-teacher if applicable.
Substance use was debatable from the ODD standpoint in the literature according to other studies and Sadock. Debatable point.
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