By: Amanda, Amy and Sarah

Pre-Test Cases Normal Behavior or ODD? History Diagnostic Criteria Cause/Risk Factors Prevalence Prognosis Co-morbidity Treatment 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 months at 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 CD Learning 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) COMORBIDITY ADHD 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) COMORBIDITY ANXIETY/MOOD DISORDERS

Can anxiety provide protective factors for children with ODD? The “Buffer Hypothesis” vs “Multiple Problem Hypothesis” (Drabick et al., 2010) COMORBIDITY ANXIETY/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 COMORBIDITY CONDUCT DISORDER (APA, 2013; Hinshaw & Lee, 2003) (Burke & Loeber, 2010)

Oppositional Defiant Disorder Dimensions (Burke & Loeber, 2010) COMORBIDITY ODD Behavior _____________ ODD Negative Affect CD Depression

COMORBIDITY LEARNING 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 Frustration  Understand 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 (5 th ed.). 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), Barkley, R. A. & Mash, E. J. (2003). Child psychopathology (2nd ed.). New York: Guilford Press. Behaviour Doctor (2009). Retrieved from: Burke, J. & Loeber, R. (2010). Oppositional Defiant Disorder & the Explanation of the Comorbidity Between Behavior Disorder & Depression. Clinical Psychology: Science & Practice, 17(4), Cunningham, N.R., & Ollendick, T.H. (2010). Comorbidity of Anxiety and Conduct Problems in Children: Implications for Clinical Research & Practice. Clinical Child & FamilyPsychology Review, 13: doi: /s 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), 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), Fulkerson, R. C., & Webb, A. R. (2005). What are effective treatments for oppositional and defiant behaviors in preadolescents?. Journal Of Family Practice, 54(2), Hamilton, S.S., & Armando, J. (2008). Oppositional Defiant Disorder. American Family Physician, Oct 1, 78(7), 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), Lavigne, J.V., Gouze, K.R., Hopkins, J., Bryant, F.B, & LeBailly, S.A. (2011). A multi-domain model ofrisk factors for ODD symptoms in a community sample of 4-year- olds.Journal of Abnormal Child Psychology, 40, pp Oppositional Defiant Disorder Resource Centre (2013). American Academy of Child and Adolescent Psychiatry. Retrieved from: Defiant_Disorder_Resource_Center/Home.aspx 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), REFERENCES

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