The Aggressive Child: Oppositional Defiant Disorder

1. The Aggressive Child: Oppositional Defiant Disorder Robert Hilt, MD, FAAP May 5th, 2012 PAL Conference

2. PAL Conference Disclosure Statement • I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

3. PAL Conference Some examples of child aggression

4. PAL Conference Case “A” • 6 year old boy • Angry if video games limited • Talks back to mom and teachers • Bossy with friends • Hits younger sister • During tantrum, poked mom’s face out of a family portrait

5. PAL Conference Case “B” • 10 year old girl • Hyperactive & inattentive since preschool • Gets frequent timeouts for being “bad” • Is disliked by peers at school • Seems bright, but has poor grades • Now hitting parents/peers when doesn’t get her way

6. PAL Conference Case “C” • 15 year old boy now in Wyoming Boy’s School • Assault, burglary, arson, shoplifting • Using and selling drugs • Parents have criminal history • History of school failure • Aggression problems since elementary school

7. PAL Conference What is Aggression? • Forceful action or procedure, often with intent to dominate or master • Usually results from an inability to resolve a self-perceived vital conflict or need through a non-forceful means • Is not always pathological: aggression can be socially appropriate or developmentally normal

8. PAL Conference Developmental Aggression • Infants promote bonding with early behavior • Anger appears by age 6 months • Toddlers show defiance as they individuate • Tantrums diminish, social conformity increase in school age children • Testing new limits, impulses in early teens

9. PAL Conference Development of Aggression From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)

10. Hitting, Biting, Kicking age 2-11 years PAL Conference From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)

11. PAL Conference Violent Crime in Young Adults From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)

12. PAL Conference Oppositional Defiant Disorder: What Is It? • Recurrent pattern of negativistic, hostile, defiant behavior • More frequent than typical for age • Causes impaired functioning • Usually present by age 8 years

13. PAL Conference DSM-IV ODD checklist:4 + symptoms within past 6 months • Often loses temper • Often argues with adults • Often actively defies or refuses to comply with adult requests or rules • Often deliberately annoys people • Often blames others for his or her mistakes or misbehavior • Often touchy or easily annoyed by others • Often angry or resentful • Often spiteful or vindictive

14. PAL Conference Gender Differences in Aggression • Males: relatively more physical attacks • Females: relatively more verbal or relational attacks

15. PAL Conference Prevalence of ODD • About a 5% current prevalence rate • Pre-pubertal boys > girls • Fairly persistent symptoms • About 3/4 still meet criteria ~2 years after diagnosis

16. PAL Conference Causes of ODD • Research consistently points toward a multifactorial origin • Psychology • Biology • Social/School • Family

17. PAL Conference Psychological Contributing Factors • Disordered processing of social information: • Underutilize social cues • i.e. don’t respond to a frown • Misattribute hostile intent • i.e. think accidental contact was an attack • Generate fewer solutions to problems • Expect a reward from aggression • Intermittent reinforcement

18. PAL Conference Psychological Contributing Factors • Insecure attachment • Reactive Attachment Disorder a clear example • Found in chronic neglect/maltreatment • Honeymoon phase, then mistrust of new caregivers • Extreme oppositional limit testing

19. PAL Conference Social Contributing factors • Community violence • Especially antisocial behavior within the family • Lack of parental supervision • Lack of positive parental involvement • Inconsistent discipline • Marital discord • Child abuse • Bullying • School failure

20. PAL Conference Biological Contributing Factors • Exogenous biological factors • drugs in utero, toxins, malnutrition • Endogenous biological factors • Low sympathetic responsiveness • Low cortisol • High testosterone • Cognitive processing deficits • Communication deficits especially • Temperament

21. PAL Conference What is Temperament? • Stable personality traits traceable from infancy through adulthood • Some of these traits are noted as more difficult to parent: • High intensity • More negative moods • Irregular patterns • Negative first impressions • Less readily adaptable to change Chess & Thomas, NY Longitudinal Study

22. PAL Conference Temperament and ODD • Helpful to think that most ODD is related to mismatch in fit between: • Child’s temperament • Parent’s (& society’s) expectations Chess & Thomas, NY Longitudinal Study

23. The Vicious Cycle PAL Conference

24. PAL Conference ODD and the Vicious Cycle • Break the cycle by • Parenting education • Including behavior management training • Show parent that other responses to child can yield better results • Special time/positive time for parent and child • Parent support, therapy • an un-nurtured parent can’t help their difficult child

25. PAL Conference Teaching Skillful Parent Responses to a Tantrum

26. PAL Conference Example of less skilled response • “Put the toy away” • Child yells or tantrums • Parent yells back, aversively demands compliance • Child may learn: • they only mean it when they explode • this is the only attention I get, which is better than nothing

27. PAL Conference Another Example of less skilled response • “Put the toy away” • Child yells or tantrums • Parent removes the demand • Child learns that tantrums work

28. PAL Conference A more skillful response • “Put the toy away” • Child yells or tantrums • One calm repetition of the request • Follow with firm limit regarding any continued or worsening behavior • i.e. withdraw attention/praise until task is completed • No parent “explosion”

29. PAL Conference Therapy for ODD • Behavior management training (often called parent training) • Evidence based treatment for age <5 • Child training • EBT for middle/high school age • Requires active child participation • Multicomponent treatment • Delinquent adolescents • Use both of the above • Examples are MST, MTFC SM Eyberg et al 2008

30. PAL Conference Behavior Management Training • Generally done by a psychologist or other skilled mental health therapist • Teaches behavioral techniques to reduce family stress and child oppositionality • Including proper use of “time out” • Often uses “token economy” system • Parents learn better communication with school

31. PAL Conference Specific Examples of Behavior Management Training Programs • Helping the Noncompliant Child (HNC) • Incredible Years • Parent-Child Interaction Therapy (PCIT) • Parent Management Training Oregon Model (PMTO) • Positive Parenting Program (Triple P)

32. PAL Conference Common Elements in ODD Therapy that works From 2007 Hawaii CAMHD review, n=88 studies

33. PAL Conference Encourage Regular “Special Time” • Pick a multiple times a week occasion • 15-30 minutes long • Child selects the activity • Label it “special time” • Happens regardless of good vs. bad day • 1:1 without interruption • End on time • Parent needs their own time too From www.palforkids.org

34. PAL Conference Problem with good behavior training • Parents often resist treatments centered on them • Child-only treatment is unlikely to succeed • Manual based, evidence based treatments are hard to find • If therapist works directly with parents, greater chance of success • Parenting skills groups can help • Supplement with self-help learning/readings

35. PAL Conference Value of Self-Directed Treatment • “Bibliotherapy” worked just as well as therapist lead therapy in a RCT of “Incredible Years” program • Unless family attended 9 or more therapist sessions, then the therapist group did better JV Lavigne et al 2008

36. PAL Conference Self-Help Behavior Management Excerpt from Hilt 2010 Primary Care Principles for Child Mental Health, www.wyomingpal.org

37. PAL Conference Give Time Out Tips for success • Set limits that are consistent • Focus on changing only one misbehavior at a time • After announce the time out, do not continue to engage • Time outs occur immediately after the misbehavior • If use warnings, make them count • Keep your cool • You (not child) determine when time out is done • Need to have other positive times with your child • Key is an immediate, temporary withdrawal of positive parent attention From www.wyomingpal.org

38. PAL Conference After making a therapy referral: • Encourage good parent/teacher communication • Suggest self help supplements • Monitor if the intervention helps • Consider co-morbidities • Especially if not improving

39. PAL Conference ODD Comorbities • ADHD • about 10x the frequency as general population • Major Depression • about 7x the frequency as general population • Substance Abuse • about 4x the frequency as general population

40. PAL Conference ADHD and ODD • About 50% of ADHD cases have co-morbid ODD • Still, need to be cautious about over-calling presence of ADHD • Particularly if very young

41. PAL Conference Young Children and ADHD • Some degree of inattention, hyperactivity and defiance is developmentally normal for preschool children • So is it normal for the age? • At least 1/3rd of all preschoolers in one survey noted by their parents to have significant inattention or hyperactivity • compare to the ~7% lifetime prevalence of ADHD Smidts DP and Oosterlaan J 2007; JAACAP practice parameter 2007

42. PAL Conference Sorting “Normal” from ADHD • Peer context • Persistence across settings • Functional impairment • Increase skepticism with lower age • Age 6 and up, rating scale impairment assessments of home/school are thought to be reliable • 4-5 years I have more skepticism • 3-4 years I’m very skeptical • <3 years very few in psychiatry would say is possible to make an ADHD diagnosis

43. PAL Conference Classroom Interventions for ADHD • You can recommend the following: • Smaller Class size • Sit in front • Clear rules and consequences • Slower assignment pace • Untimed tests • Daily parent to teacher communication • Homework tutoring

44. PAL Conference First Line Medications for ADHD • Two general groups of medicines • Stimulants • Non-stimulants • When one fails, stop it and try another • If med. treatment unsatisfactory: • Think comorbidity • Re-evaluate diagnosis • Consider behavior therapy and/or alternative medications

45. PAL Conference If determine has ADHD and ODD • Treating ADHD is shown to significantly improve the ODD • Stimulants, in particular • Less evidence for other medications

46. PAL Conference Review of Comorbid ODD/ADHD trials • Methylphenidate • 7 RCTs all show decreased aggression • Effect size ~0.75 • Atomoxetine • 4 RCTs show mildly decreased aggression • Effect size ~0.15 E Pappadopulos et al, 2006

47. PAL Conference What About Conduct Disorder? • Often follows ODD • Aggression to people and animals • Destruction of property • Fire setting • Deceitfulness or theft • Lies to obtain goods • Serious violations of rules • Running away, frequently truant

48. PAL Conference Conduct Disorder • About ½ of conduct disorder children continue these problems into adulthood • Often associated with • Substance abuse • Mood disorders • Anxiety disorders • Learning/cognitive disorders

49. PAL Conference Conduct Disorder • Inherent failure of parental authority • Are there other parenting arrangements that would work better? • Occasionally substitute authority (even a judge) can make a positive difference • Inherent rejection of available motivations to do “good” • Other ways to motivate in a positive direction?

50. PAL Conference Multi-Systemic Therapy • Steer teens into positive peer group associations • Support parents • Support school • Behavior management training • Problem solving skills training • Research supported for chronic, violent juvenile offenders