O PPOSITIONAL D EFIANT D ISORDER

DEFINITION

A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that is clearly more frequent, more intense, and more persistent across the child's development than is typically observed in individuals of similar age and developmental level for at least 6 months and cause impairment in the child's social, academic, or occupational functioning.

H ISTORY

In 1966-childhood oppositional personality emphasizing the symptoms of disobedience and pervasive negativism. DSM II-list of Unsocialized aggressive reaction of childhood( or adolescence), Group delinquent reaction and runaway reaction as equivalent to CD 1st time in DSM-III the idea of an oppositional disorder was first introduced and links to the notion of a passive-aggressive personality were retained.

Evidence - early onset oppositional behaviors linked to increased risk for later antisocial behaviors, ODD grouped with CD under disruptive behavior disorders and links to passive-aggressive personality traits were dropped Subsequent editions of the DSM added a defiant label

2 of 5 possible items (DSM-III), to 5 of 9 items (DSM-III-R), and finally to 4 of 8 items (DSM-IV and DSM-IV-TR).

DSM-IV organizes ODD, CD, and ASPD hierarchically and developmentally, reflecting age-dependent expressions of the same underlying disorder. ( more applicable to boys than girls, who are more prone to develop depression, and anxiety in later years rather than CD) ODD (F91.3) was not in ICD-9, but included in ICD-10 b/c of evidence of its predictive potential for later conduct problems.

C OMPARITIVE N OSOLOGY

while DSM-IV-TR treats CD, ODD separately in DBB , ICD-10 considers ODD jointly with CD. Both require the absence of CD to allow a diagnosis of ODD (ie implying a heirarchial relationship) ICD explicitly conceptualizes ODD as part of same dimension as CD, the former being a milder version of the latter( thus the term conduct disorder means ODD and CD) ICD 10 criteria seems to result in more children qualifying for ODD than when using DSM criteria

E PIDEMIOLOGY

In nonreferred epidemiological samples prevalence -4.5 - 15.4 % in males and 1.5 -15.6% in females aged 7 to 21 years old variations appear to be related to methodological differences such as age range of sample, criteria employed, data collection procedures and whether functional impairment. disorder is diagnosed more often in males than females. The disorder is present in children, adolescents, and in adults

I N I NDIA

In India, in a major epidemiological study initiated by ICMR, the prevalence of ODD was 0.9% in 4-16 year old children.

The rates were highest in the urban sample (2%) and least in the rural sample (0.2%).
more prevalent among children and adolescents from families of low SES living in inner city disadvantaged neighborhoods

ETIOLOGY

Biological Genetic and other temperamental factors may interact with adverse social factors in the production of ODD frequently cluster in siblings and biological relatives of the ODD child proband Other factors - pulse rates are lower; their skin conductance is less, as is their rate of adrenaline and cortisol excretion(decreased CNS inhibition)

T EMPERAMENT

Temperament is defined as the characteristic style of emotional and behavioral response of an individual in a variety of differing situations and to a variety of differing environmental stimuli difficult temperament : generally characterized by infant or young child qualities of overactivity, undercontrol, high intensity of responses, inattention, predominantly negative mood, and low adaptability to new situations

Studies - relationship between difficult temperament and externalizing behavioral problems including ODD & CD Difficult temperament itself -weak predictor So negative child temperament + family dysfunction, marital conflict, poverty, upbringing in a high crime neighborhood, or parental psychopathology, prediction for disruptive behavior disorder is stronger Social anxiety on the other hand is protective

Other temperament dimensions novelty- or sensation-seeking: Outgoing, actively seeking stimulation, impulsive, and lacking in anxiety and fear So they have more difficult time learning from experience and inhibiting their behaviors Genetic basis: polymorphisms in D2 and D4 receptors significantly associated with personality traits of novelty-seeking in population-based studies

P SYCHOLOGICAL

coercion theory focuses on learning theory - oppositional and conduct problem behaviors are behaviorally reinforced In coercion theory the negative behavior of one member of a parentchild dyad serves to terminate the ongoing negative behavior of the other, thereby negatively reinforcing the first member's original negative behavior Over time, the child learns that aversive behavior works to solve social problems and may begin to generalize learned aversive and oppositional IP behavior out of the home to interactions with authority figures at school and in the community

Social learning theory posits that children learn by modeling the behaviors of caregivers and important others in their lives

Link b/w attachment to a caregiver & oppositional defiant behaviors

insecure attachment, especially anxious-avoidant attachmentoppositional behavior is seen as a child's attempt to gain attention from an unresponsive parent

S OCIOLOGICAL

Ecological and environmental variables associated Family characteristics, including poor family cohesion (Inconsistencies due to multiple parenting figures grandparents vs parents), punitive parenting, parental discord, inconsistent discipline practices, poor parental monitoring of the child's whereabouts, family stress, and poverty, Parental psychopathology such as maternal depression is associated with child disruptive behaviors.

D IAGNOSIS AND C LINICAL F EATURES

The diagnosis is not limited to a particular age group, but most commonly emerges between the ages of 6 to 8 years old Problem behaviors are usually evident at home in relationships with those most familiar to the child and may not appear upon clinical examination in the office setting. the clinical evaluation should include multiple reporters such as parents or teachers in addition to the child

C LINICAL

EVALUATION

History from multiple sources Child interview and MSE Physical examination Rating scales / checklists Psychological testing

Period of ward observation

ICD 10

CRITERIA

Essential feature is a pattern of persistently negativistic, hostile, defiant, provocative, and disruptive behaviour,

outside the normal range of behaviour for a child of the same age in the same sociocultural context,
Absence of more serious violations of the rights of others (such as theft, cruelty, bullying, assault, and destructiveness) as reflected in the aggressive and dissocial behaviour specified for conduct disorder

frequently and actively defy adult requests or rules and deliberately annoy other people. angry, resentful, and easily annoyed by other people whom they blame for their own mistakes or difficulties. low frustration tolerance and readily lose their temper. Typically, their defiance has a provocative quality, so that they initiate confrontations and generally exhibit excessive levels of rudeness, uncooperativeness, and resistance to authority.

oppositional defiant behaviour, is often found in other types of conduct disorder. If another type (F91.0-F91.2) is present, it should be coded in preference to ODD. Exclusion criteria -schizophrenia, mania, pervasive developmental disorder, hyperkinetic disorder, and depression. Diagnosis- not recommended unless the duration has been 6 months or longer

DSM-IV-TR

A.A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

often loses temper (ICD 10: usually frequent or severe temper tantrums for developmental level) 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 or misbehavior is often touchy or easily annoyed by others

is often angry and resentful

is often spiteful or vindictive Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B.The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C.The behaviors do not occur exclusively during the course of a psychotic or mood disorder.
D.Criteria are not met for CD, and, if the individual is age 18 years or older, criteria are not met for ASPD.

ICD 10

DCR

G1. There is a repetitive and persistent pattern of behavior, in which either the basic rights of others or

major age-appropriate societal norms or rules are violated,

lasting at least 6 months, during which some of the following symptoms are present.

The individual: 1. Has unusually frequent or severe temper tantrums for his or her developmental level; 2. Often argues with adults; 3. Often actively refuses adults' requests or defies rules; 4. Often, apparently deliberately, does things that annoy other people; 5. Often blames others for his or her own mistakes or misbehavior

6. Is often touchy or easily annoyed by others; 7. Is often angry or resentful; 8. Is often spiteful or vindictive;

9. Often lies or breaks promises to obtain goods or favors or to avoid obligations;

10. Frequently initiates physical fights (this does not include fights with siblings);

11. Has used a weapon that can cause serious physical harm to others (e.g., bat, brick, broken bottle, knife, gun);

12. Often stays out after dark despite parental prohibition (beginning before 13 years of age); 13. Exhibits physical cruelty to other people (e.g., ties up, cuts, or burns a victim); 14. Exhibits physical cruelty to animals; 15. Deliberately destroys the property of others (other than by fire-setting);

16. Deliberately sets fires with a risk or intention of causing serious damage; 17. Steals objects of nontrivial value without confronting the victim, either within the home or outside (e.g., shoplifting, burglary, forgery); 18. Is frequently truant from school, beginning before 13 years of age; 19. Has run away form parental or parental surrogate home at least twice or has run away once for more than a single night (this does not include leaving to avoid physical or sexual abuse);

20. Commits a crime involving confrontation with the victim (including purse-snatching, extortion, mugging); 21. Forces another person into sexual activity;

22. Frequently bullies others (e.g., deliberate infliction of pain or hurt including persistent intimidation, tormenting, or molestation);
23. Breaks into someone else's house, building, or car.

Note: The symptoms in 11, 13, 15, 16, 20, 21, and 23 need only have occurred once for the criterion to be fulfilled.

F91.3 Oppositional defiant disorder The general criteria for conduct disorder (F91) must be met. Four or more of the symptoms listed for F91 Criterion G1 must be present, but with no more than two symptoms from items 923. The symptoms in Criterion B must be maladaptive and inconsistent with the developmental level. The symptoms must have been present for at least 6 months.

R ATING

SCALES

Revised Conners Parent and Teacher Rating Scales IOWA Conners Achenbach Child Behavior Checklist (CBCL) and Teacher Rating Form (TRF) BASC-2, SNAP-IV, BRIEF, Vanderbilt ADHD Rating Scale (Parent and Teacher versions)

Barkleys Current Symptoms Scale

D IFFERENTIAL D IAGNOSIS

distinguished from disruptive behaviors that occur as part of normal development by its severity, impairment, and persistence across development Because of the need to distinguish the disorder from disruptive behaviors occurring normally as part of development, the reliability and validity of oppositional defiant disorder has not yet been established for preschool children

diagnosis generally becomes clear around 6 to 8 years old New onset oppositional and defiant behaviors in early adolescence may be due to the process of normal separation or individuation Defiant and disruptive behaviors may occur after a stressor such as a traumatic event or the loss of a loved one. If the disturbance lasts less than 6 months, adjustment reaction is the more appropriate diagnosis

MR

In persons with MR, a diagnosis of ODD is only given if the oppositional behaviors are markedly greater than is commonly observed among individuals of comparable age, gender, and severity of mental retardation

Irritable, defiant, and oppositional behaviors are common associated features of mood disorders such as depression, dysthymia, or anxiety disorders such as OCD or separation anxiety disorder in young children

Bipolar disorder in < 18 years old- severe aggression, disruptive behaviors, defiance of authority, oppositionality, and irritability.

Oppositional behaviors may be a feature of psychotic illness in youngsters.

Children with hearing loss or receptive language disorders may look oppositional on the basis of a failure to hear or understand spoken commands

X ADHD

Children and adolescents with ADHD are often disruptive as a result of the core ADHD symptoms of inattention to tasks requiring sustained vigilance and deficits in impulse control. The willful defiance of children with ODD must be distinguished from the poor compliance of children with ADHD.

X CD

ODD typically does not involve violation of the basic rights of others, violation of age-appropriate social norms, severe aggression toward people or animals, recurrent destruction of property, or a pattern of covert theft or deceit.

C OMORBIDITY

C OMORBID C ONDITIONS

Population-based studies: 14 % have comorbid ADHD, 14 % have accompanying anxiety disorders, and 9 % have depressive disorders. Learning impairments and language disorders are also common clinically referred :major comorbidity is ADHD. Studies - 60 to 80% of ODD youngsters assessed in clinics may meet criteria for ADHD, and about 50% of ADHD elementary school children will meet diagnostic criteria for ODD

15 to 20 percent of clinically referred children and adolescents with ODD have comorbid depression, bipolar disorder, anxiety disorders, or language disorders Concurrent substance abuse and cigarette use should be considered especially in teenagers

C OURSE

AND

P ROGNOSIS

varies by the age of onset of ODD, by symptom severity, and with the presence of comorbid psychiatric disorders About 2/3 rd of children initially meeting diagnostic criteria - eventually exit from the diagnosis over a 3-yr follow-up. earlier age of onset of the disorder and more severe baseline ODD symptoms convey a poorer prognosis in terms of risk for progression to CD Studies -children with an earlier age of onset -a threefold increase in risk for the eventual development of CD compared with later onset in the elementary school years or beginning in adolescence

30 % of ODD children will eventually develop CD 10 % of ODD youngsters will grow up to meet ASPD in adulthood. combination of early onset ADHD and ODD also confers more risk of progression to CD largely male samples, it remains unclear if risk for progression to conduct disorders is also true for females

exhibit additional psychiatric disorders later in childhood including ADHD, anxiety disorders, and mood disorders

T REATMENT

primary and secondary prevention of at-risk

children and families to be fundamental aspects of the treatment for oppositional defiant disorder and other disruptive behavior disorders

treatment early in the child's life, preferably during preschool for at-risk youngsters, sustained treatment durations of longer than 2 years, intensive treatment occurring several times weekly, and simultaneously targeting multiple domains of the child's environment for therapeutic interventions including the child, parents, family, and school

PARENT

MANAGEMENT TRAINING

(PMT)

rationale - based on child oppositional behaviors are inadvertently learned, developed, and sustained in the home by chronic and maladaptive parentchild interactions Therapy emphasizes the behavioral principles of a prior agreement on the most important oppositional behaviors to be targeted by therapy, developing a hierarchy of problem behaviors to be targeted for change

The treatment includes teaching them behavioral techniques such as positive reinforcement (e.g. the use of social praise and tokens or stars), mild punishment (e.g. use of time out from reinforcement, loss of privileges), negotiation, and contingency contracting 812 sessions lasting 1.52 hours each

Step 1: Promoting a child-centered approach Step2: Increasing acceptable child behavior Step 3: Setting clear expectations Step 4: Reducing unacceptable behavior Step 5: Strategies for avoiding trouble

Step 6: identifying and rectifying long-standing maladaptive patterns

C HILD - FOCUSED

THERAPY

older school-aged children and adolescents focus -alter the experiences or the interpretation of experiences By changing consequences Behavioral Management By changing behavior and social interaction the child witnesses modeling Childs response to events social problem solving Interpretation of events - cognitive restructuring and self management

S CHOOL RELATED
INTERVENTION

Relaxation techniques Recognition of emotions and empathy training Social problem-solving skills Anger management Friendship skills

Communication skills

P SYCHOPHARMACOLOGY

little scientific evidence to suggest that ODD responds directly to medications Psychopharmacological interventions in ODD are limited to the treatment of commonly occurring comorbid conditions severity of ODD symptoms covaries with the severity of ADHD symptoms

improvement in ADHD symptoms occurs with appropriate medication, studies have shown that the severity of ODD symptoms also improves

CONTOVERSIES

controversies remain in the concept of ODD as a categorical psychiatric disorder. The question remains still open whether distinction between ODD and CD is qualitative or quantitative

it remains unclear if criteria for the diagnosis are equally valid when applied to girls versus boys.
Since girls express hostility more indirectly and more in a social-relational context than boys, some of the criteria items for oppositional defiant disorder may be less informative for girls. it remains unclear how best to apply the diagnosis of ODD to preschool children.

DSM V

A. A persistent pattern of angry and irritable mood along with defiant and vindictive behavior as evidenced by four (or more) of the following symptoms being displayed with one or more persons other than siblings. Angry/Irritable Mood 1. Loses temper

2. Is touchy or easily annoyed by others.

3. Is angry and resentful

Defiant/Headstrong Behavior 4. Argues with adults 5. Actively defies or refuses to comply with adults request or rules 6. Deliberately annoys people 7. Blames others for his or her mistakes or misbehavior Vindictiveness 8. Has been spiteful or vindictive at least twice within the past six months

DSM V

For children < 5 yrs of age, the behavior must occur on most days for a period of at least 6 months unless otherwise noted (symptom #8). For individuals 5 years or older, the behavior must occur at least once per week for at least 6 months, unless otherwise noted (symptom #8). other factors should also be considered such as whether the frequency and intensity of the behaviors are non-normative given the persons developmental level, gender, and culture. The behaviors may be confined to only one setting or in more severe cases present in multiple settings.

CONCLUSION

importance of ODD lies in the fact that it is distinct from ADHD and CD, and that it is a significant risk factor for CD which is more serious disorder Evaluation of children with suspected ODD should focus not only on establishing the diagnosis, but also on comorbidities and on mapping all the predisposing, precipitating, and maintaining factors intervention mostly psycho-social in nature. Medications have a role only if there are comorbidities

THANK U