Good, Bad or Ugly? Treating Oppositional Defiant Disorder in the Primary Care Setting John A. Biever, MD Child and Adolescent Psychiatrist Central Pennsylvania Institute of Mental Health Clinical Professor of Psychiatry, Penn State M. S. Hershey Medical Center

Life is too important to be taken seriously. -Oscar Wilde

ODD: Diagnostic Criteria [1] 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 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

ODD Diagnostic Criteria, cont’d.  NB: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. ...i.e. oppositional behavior normally increases in early toddlerhood and early adolescence

ODD Diagnostic Criteria, cont’d. 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 Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Associated Features  Symptoms usually more prevalent at home than in community or school (often minimal in clinical setting)  Child usually considers behavior justified.  Increased incidence in [boys] with difficult temperaments, high activity in preschool years (10% are “difficult” children)  Higher incidence of illicit substance use

Nine Dimensions of Temperament (Chess and Thomas)  Activity level  Attention span- persistence  Distractibility  Threshold  Intensity  Mood quality  Approach vs. withdrawal  Adaptability  Rhythmicity

Associated Features, cont’d.  More prevalent in families with multiple caregivers ...in families with harsh, inconsistent or neglectful parenting  Associated with ADHD (~50% comorbidity, with poorer prognosis) LD, Communication Disorders

Prevalence and Course  Estimated anywhere between 2-16%  Boys>girls pre-puberty; even in adolescence  Symptoms emerge gradually over months or years, usually by age 8  Sometimes, but not inevitably, followed by development of Conduct Disorder (~1/3 [2])

Familial Pattern  Often at least one parent has history of Mood d/o, ODD, Conduct d/o, ADHD, Antisocial PD, or substance use d/o.  ? mothers with depression (cause or effect)  Increased incidence in families with high marital discord

Mothers of Children with ODD vs. GAD [3]  ODD mothers had negative emotional valence and detached personalities  GAD mothers had somatic preoccupations, were over-controlling and overprotective

Additional Predisposing Factors [2]  Insecure attachment patterns in infancy  Poverty, crowding, high crime neighborhoods  Deficient information processing of social stimuli (Dodge, [4]): underutilization of social cues, misattribution of hostile intent, generate fewer solutions to problems, expect to be rewarded for aggressive behavior.

Neurobiology of ODD  Diminished parietal event-related potentials in children with ODD—i.e. reduced orienting to cues [5]  N.B. comorbidity with ADHD

Treatment Considerations  Individualize  Be mindful of safety issues for child/family/community  Long-term treatment is the rule  Empirical support for: family therapy (including psychodynamic,) parent counseling

Treatment Considerations, cont’d  Collaborate with schools  Psychopharmacological treatment of comorbid conditions  The earlier the treatment, the better

The Oppositional Defiant Child in the Primary Care Office

Prevention Is the Best Medicine  Temperament stabilizes by about 4 months of age. So, about 10% of babies will begin to show signs by then of being “difficult” children: dysrhythmic sleep/feeding patterns; withdrawal- prone; slow-to-adapt; high intensity; negative mood.  Mothers need to understand their child’s temperament, and need extra support in order to woo the child into a hopeful feeling about the world.

Prevention, Prevention  Infants are capable of forming 2-3 significant attachments within the first 18 months of life.  If mother is temperamentally mismatched with her difficult infant or otherwise limited in her ability to develop a secure attachment bond with her baby, all is not lost!

Prevention, Prevention, Prevention  Mother (and father) need to “feel felt” by the doctor and treatment team, whose greatest contribution may be to instill hope unrelentingly. (e.g. Nurse-family Partnership)  Heads up: Identification and treatment of the depressed mother can prevent subsequent mental illness in the baby.

And More Prevention  When we’re out of rest, we’re all ODD!—stress adequate sleep...for parents as well as child.  When we’re hungry, we’re all ODD!—stress excellent nutrition.  When we’re sick, we may temporarily become ODD—be sure significant physical illness is ruled out.

Know the Family System  Authoritarian parenting style: Oppositional- defiant behavior as defense against domination help the parents toward an authoritative style  Permissive parenting style: Oppositional-defiant behavior as lingering omnipotence help the parents toward an authoritative style

Know the Family System II  Brothers and sisters: Oppositional-defiant behavior as a means to secure one’s position within the family appraisal of and focus on the child’s positive strengths  The single parent household: the Oedipal victory assert the parent as authoritative, the child as a child

Know Yourself  What’s your style of relating to parents and children? authoritarian? Not good for the ODD child! authoritative? Works better  The “Dutch Uncle (Aunt)”—the benevolent but no-nonsense authoritative confrontation of the ODD child.  Keep a sense of humor.

Life is too important to be taken seriously. -Oscar Wilde

Your Treatment Team  Be sure that they are educated regarding oppositional defiant disorder.  Be vigilant about “countertransference” feelings and behavior and confront it empathically but quickly, firmly.  Have ready access to a seasoned mental health professional, within or outside your practice, and foster in all patients a sense that mental health care is as normative as physical health care.

Case Presentation: Jeremy H.

Bones of Wisdom  Carefully manage “countertransference” reactions to angry or rejecting behavior by patients/parents.  Understand the oppositional defiant behavior as an effort by a mind to adapt to the stresses of life and relationships.  Be an ally of every family member. Empathize with the unique position and challenges of each, and avoid the pitfall of inadvertently aligning with one of opposing forces in the family system.  Always be prepared to counter despair with hope.

“God did not make this person as I would have made him. He did not give him to me as a brother for me to dominate and control, but in order that I might find above him the Creator. Now the other person, in the freedom with which he was created, becomes the occasion of joy, whereas before he was only a nuisance and an affliction.” -Dietrich Bonhoeffer

References 1. DSM-IV TR. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Text Revision. American Psychiatric Association, Washington, D.C., Sadock B, Sadock V, eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 7 th ed. Lippincott Williams & Wilkins, Philadelphia, Nordhal, H, et. al.: Does maternal psychopathology discriminate between children with DSM-IV generalised anxiety disorder vs. oppositional defiant disorder? The predictive validity of maternal axis I and axis II psychopathology. Eur Child Adolesc Psychiatry 16(2), Dodge K: Social-cognitive mechanisms in the development of conduct disorder and depression. Annu Rev Psychol 44:559, Baving L, et. al.: Children with oppositional-defiant disorder display deviant attentional processing independent of ADHD symptoms. J Neural Transm 113(5), 2006