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|Oppositional defiant disorder|
|Classification and external resources|
|Oppositional defiant disorder|
|Classification and external resources|
Oppositional defiant disorder (ODD) is defined by the DSM-5 as a pattern of angry/irritable behavior, or vindictiveness lasting at least 6 months, and is exhibited during interaction with at least one individual that is not a sibling. Individuals must display four symptoms from one of the following categories: angry/irritable mood, argumentative/defiant behavior, or vindictiveness. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals (even though this directly contradicts the "signs and symptoms"), do not destroy property, and do not show a pattern of theft or deceit. A diagnosis of ODD cannot be given if the child presents with conduct disorder.
Previously, DSM-IV-TR (that is now replaced by DSM-5) stated that the child must exhibit four out of the eight signs and symptoms listed below in order to meet the diagnostic threshold for oppositional defiant disorder. Furthermore, they must be perpetuated for longer than six months and must be considered beyond normal child behavior to fit the diagnosis.
These patterns of behavior result in impairment at school and/or other social venues.
Common features of oppositional defiant disorder (ODD) include excessive, often persistent anger, frequent temper tantrums or angry outbursts, as well as disrespect of authority. Children and adolescents with ODD often purposely annoy others, blame others for their own mistakes, and are easily disrupted. Parents often observe more rigid and irritable behaviors than in siblings. In addition, these young people may appear resentful of others, and when someone does something they don't like they prefer revenge over more sensitive solutions.
For a child or adolescent to qualify for a diagnosis of ODD, these behaviors must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations. These behaviors must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.
The exact cause of ODD is unknown, but it is believed that a combination of biological, psychological, and environmental factors may contribute to the condition.
Research indicates that parents pass on a tendency for externalizing disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. This heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behavior is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolizing enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behavior following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.
Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning, and mother’s use of nicotine, marijuana, alcohol or other substances during pregnancy may increase the risk of developing ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.
Deficits and injuries to certain areas of the brain can lead to serious behavioral problems in children. Brain imaging studies have suggested that children with ODD may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control. Children with ODD are thought to have an overactive behavioral activation system (BAS), and underactive behavioral inhibition system (BIS). The BAS stimulates behavior in response to signals of reward or nonpunishment. The BIS produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of nonreward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions. As well as this, if neurotransmitters in the brain are out of balance, or not working properly, they may not be able to communicate to each other in the brain effectively, causing behavioral deficits. Many children with ODD also have other mental illnesses, such as ADHD, learning disorders, depression, or an anxiety disorders which could also be strong contributors.
As many as 40% of boys and 25% of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behavior, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act.
A child has reciprocal influence, meaning that the child’s behavior is both influenced by and influences the behavior of others. Negative parenting practices and parent–child conflict may lead to antisocial behavior, but they may also be a reaction to the oppositional and aggressive behaviors of their children. Factors such as a family history of mental illnesses and/or substance abuse as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behavior disorders.
Coercion theory describes another hypothesis for how the family might contribute to development of ODD. Coercion theory contends that parent–child interactions provide a training ground for the development of antisocial behavior. According to this theory, through a 4-step, escape-conditioning sequence, the child learns to use increasingly intense forms of noxious behavior to avoid unwanted parental demands.
Insecure parent–child attachments can also contribute to ODD. There is often little internalization of parent and societal standards in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance abuse. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.
Low socioeconomic status is associated with poor parenting, specifically with inconsistent discipline and poor parental monitoring, which are then associated with an early onset of aggression and antisocial behaviors.
Socialization across cultures is one of the strongest predictors of aggressive acts. Externalizing problems are reported to be more frequent among minority-status youth, a finding that is likely related to such things as economic hardship, limited employment opportunities, and living in high-risk urban neighborhoods.
Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when CD is present. According to Dickstein, the DSM-5 attempts to:
One of the key factors in the development and maintenance of the negative behaviors associated with ODD symptoms is reinforcement, whether intentional or not, of the unwanted behaviors. The most effective way of treating disruptive behavior disorders is behavioral therapies. Behavioral therapy for children and adolescents focuses primarily on how to prevent problematic thoughts or behaviors from accidentally getting reinforced unknowingly within a young person's environment.
Positive reinforcement often unintentionally contributes to an increase in the frequency of ODD behaviors. Behavior therapies can be applied to a wide range of psychological symptoms among children, adolescents, and adults with ODD. Behavior therapists encourage children and adolescents to try new behaviors and not to allow unwanted reinforcement to dictate the ways in which they act. Furthermore, therapists may work with parents to discontinue ways in which they are unintentionally reinforcing unwanted behaviors. An example of how positive reinforcement can occur is when the patient is rewarded with attention when performing ODD behaviors. Attention is reinforcing itself and the reinforcing attention could be accidentally given, ironically, when trying to create a negative consequence to their behavior. Positive Punishment occurs when the patient is inadvertently punished by aversive stimuli for not performing the ODD behaviors (of revenge, dis-cooperation, and frequent anger). These aversive stimuli that punish patients for not performing ODD behaviors can include humiliation, isolation, not being told the reason of rules (e.g. being told "the reason you should is because I said so"), not having opinions taken seriously, as well as "being pushed around."
Researchers have found that the use of positive reinforcement and praise for appropriate behaviors are two key elements in effective interventions. If the majority of interactions with the child are focused around correcting their negative behaviors, a cycle of negative interactions is created, where the child expects attention after misbehaving. On the contrary, positive reinforcement and praise not only builds a child's self-esteem but also serves to strengthen the bond between a child and their caregiver. To accomplish this the positive reinforcement should occur immediately after a child has exhibited an appropriate behavior. The behaviors outlined for the child to be reinforced should be easy to evaluate and have very clear and easy to understand instructions. The type of reinforcement used should always depend on the child and should be developed together with both the family and the therapist.
Other approaches to the treatment of ODD include parent training programs, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents. There are several preventative programs that have had a positive effect on those who are at high risk for ODD. Both home visitation and programs such as Head Start have shown some effectiveness in preschool children. Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD. For adolescents at risk for ODD, cognitive interventions, vocational training, and academic tutoring have shown preventative effectiveness.
ODD has an estimated lifetime prevalence of 10.2% (11.2% for males, 9.2% for females). According to a 1992 article, if left untreated, about 52% of children with ODD will continue to meet the DSM-IV criteria up to three years later, and about half of those 52% will progress into conduct disorder. CD may progress into antisocial personality disorder. This strong correlation between strong defiance in childhood and adulthood may suggest similar mechanisms for hostility toward established authority by children and by adults.
According to The American Journal of Psychiatry, there are several sources of controversy around the diagnosis of ODD. One concerns the fact that the DSM-IV criteria differ slightly from those of the World Health Organization's criteria, as outlined in the ICD-10. Diagnosis of ODD is further complicated by the high occurrence of comorbidity with other disorders such as ADHD, though a 2002 study provided additional support for the validity of ODD as an entity distinct from conduct disorder.
In another study, the utility of the DSM-IV criteria to diagnose preschoolers has been questioned because the criteria were developed using school-age children and adolescents. The authors concluded that the criteria could be used effectively when developmental level was factored into assessment.