Oppositional Defiant Disorder - Essay Example

 Oppositional Defiant Disorder The psychiatric category of Oppositional Defiant Disorder (ODD) was introduced in The Diagnostic and Statistical Manual, Third Edition (DSM-III). The disorder generated serious scholarly debate in the years following its introduction. Some authors questioned the proclaimed notion that ODD differed sufficiently from normal oppositional behavior to justify its inclusion as a distinct diagnostic category (Rutter & Shaffer, 1980). Another stance suggested the criteria for ODD implied a milder form of conduct disorder (Werry, Reeves & Elkind, 1987). The debate led to considerable revision of the ODD category. DSM-IV defines Oppositional Defiant Disorder (ODD) as an ongoing pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that goes beyond the reasonable bounds of childhood behavior (DSM-IV, 2000). Several conditions must be observed in order the condition could meet the requirements of DSM-IV, namely: the defiant behavior must interfere with the ability to function in home, school or the community; the defiant behavior should not be caused by other childhood disorder such as attention deficit, anxiety, depression or others; and finally, defiant behavior must be observed for at least six months. In addition to these requirements, the following diagnostic criteria are identified for ODD: Losing temper; Arguing with adults; Refusing to follow the rules; Deliberately annoying people; Blaming others for own mistakes; Easily annoyed; Angry and resentful; Spiteful or even vengeful (DSM-IV, 2000). A case when a child meets at least four of eight criteria granted that they are interfering with his ability to function is considered to be the case ODD. However, accurate diagnosis is often associated with serious difficulties caused by high comorbidity of ODD with other anxiety disorders and depressive disorders (Caron & Rutter, 1991; Rey, 1993). Thus, Rey (1993) reports “approximately one-third of all of the children with any disorder had a diagnosis of opposition defiant disorder, showing that this disorder is one of the most common psychiatric conditions” (p.1772-1773). For example, many symptoms of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder overlap while comorbidity of ODD with ADHD has been reported to occur in 50-65% of affected children (Tynan, 2003). The base prevalence of oppositional defiant disorder is estimated within the range of 1.7% -almost 10% depending upon the population being surveyed (e.g. parents, teachers, pediatricians, etc). During the early years of puberty, ODD is more common in boys; in later years of puberty, the incidences of the disorder is practically equal in boys and girls (Rey, 1993). Etiology of ODD is not fully clear, while there is no evidence that it has a unique etiology. Similarly to other developmental and behavioral childhood disorders, the origins of ODD is explained from several distinct stances including strict parenting style (Meeks, 1979), psychodynamic approach (ODD is a fixation in the anal stage of the child’s psychological development (Egan, 1991), behaviorist positions (negative reinforcement of inappropriate child behavior and parent-child conflict about issues of control and autonomy (Gard & Berry, 1986), genetics and others. Modern research leans toward the multi-causal theory suggesting ODD may be caused by several etiological factors, either alone or in combination, including genetic, social, constitutional and psychological mechanisms. Though the multi-causal approach (i.e. agreement that several factors combine to result in one or other type of disorder) seems to prevail in modern research, there are still several major perspectives that view one or other group of factors as dominant in etiology of childhood disorders. Presence of these perspectives is largely due to varying views on the process of child development adopted by proponents of different psychological schools. The balance established between different stances is unique for each disorder and inevitably changes over time. Thus, the recent research of children with ADHD disorder finally rebutted the previously popular theory of the ‘minimal brain damage’ (Swanson et. al., 1998). Instead, the advances in genetic engineering and technology allowed more accurate and comprehensive research of genes allegedly responsible for ADHD and led to identification of two genes: a dopamine-receptor (DRD) gene on chromosome 11 and the dopamine-transporter gene (DAT1) on chromosome 5 (US Public Health Service, 2000). The genetic research revealed clear evidences that children with ADHD have genetic variations in one of the dopamine-receptor genes, namely DRD4. Many studies report that abnormalities of the dopamine-transporter gene (DAT1) have been present in children and adolescents with especially severe forms of ADHD (US Public Health Service, 2000). However, the situation with ODD is even more complicated due to the controversy surrounding the very possibility of this disorder as a separate category. Consequently, as Rey (1993) notes “one cannot argue for oppositional defiant disorder as a separate diagnostic category on the basis of a characteristic response to treatment” (p.1775), and systematic research drawing a comparison between ODD children whom received different kinds of treatment – like in ADHD treatment research – is still scarce despite the recent splash of attention to the issue. Modern practitioners utilize various cognitive-behavioral and psychological approaches, either alone or in combination, to treat ODD children. The most popular among them are behavior therapy, family therapy, parent management training, and child psychotherapy. Parent Management Training (PMT) is a variation of cognitive-behavioral therapy which seeks to modify the child’s behavior by modifying the style of parenting. This therapy proved highly effective for ODD children: some recent studies define the amount of responders around 40-50% (Greene, Ablon & Goring, 2003). Effectiveness of this method was also found in one of the earliest works in the field of ODD treatment, namely Wells and Egan’s (1988) report demonstrating that parent training was superior to family systems therapy. The most commonly used variation of (PMT) consists of several procedures used to train parents to modify own behaviors and thereby positively affect the behavioral problems experienced by their children in the home setting. Evidently, this method relies upon the etiological perspective identifying the maladaptive parent-child interactions as the key factor contributing to development of ODD. PMT seeks to modify such pattern by encouraging the parent to focus on pro-social behavior, use effective, brief, non-aversive punishments, etc. Treatment is conducted mainly with the parents: the professional shows them specific procedures positively modify their relationships with their child. On the first stage of PMT course, parents are trained to simply have periods of positive play interaction with their child; the second stage consists of practices which help identify the child’s positive behaviors and reinforce them. During this period of training, parents receive knowledge on how to use brief negative consequences – equivalent of punishment – for the child’s misbehavior. Repeated sessions provide the parents with opportunities to properly master and refine the techniques (Kazdin, 2005). Behavior and psychosocial therapies involving children is also effectively used in treatment of ODD. The core idea underlying such therapies is to help children model behaviors and reactions which would allow them better adapt to the real-life setting. Effectiveness of such interventions may vary considerably and they are often conducted in parallel to a PMT course for their parent to achieve better outcomes (Webster-Stratton & Hammond, 1999). However, the most recent studies estimate the response rate to cognitive therapies as high as 74% (Greene, Ablon & Goring 2003). Medications are not considered an appropriate alternative in treatment of ODD: there is no credible study up to now that explored the effects of medication therapy for children with ODD. However, pharmacological interventions have been consistently found effective in fighting oppositionality and aggression, but in patients who had other comorbid conduct disorders or ADHD. In cases of comorbidity pharmacological treatment of, for example, ADHD can also help alleviate the symptoms of ODD. Thus, the efficacy of haloperidol and lithium for aggression, noncompliance and temper outbursts in aggressive patients was shown more than two decades ago, while treatment with buspirone given to patients with ADHD and ODD demonstrated a striking improvement in 82% of participants (Serra-Pinheiro et al, 2004). Such data leaves a possibility that further research in the field of specific pharmacological therapies for children with ODD may reveal interesting results and provide basis to those whom believe ODD is a distinct disorder. Although behavioral-cognitive and psychosocial interventions are the only strategies that have been consistently verified as effective, it might be misleading to consider that further research in the field of ODD treatment is not necessary. Any serious effort to explore new therapies and interventions is likely to contribute to our understanding of the disorder in terms of etiology and prevention. Similarly further versatile and sometimes contradictory research in etiology and prevalence of ODD is needed to contribute to the existing body of knowledge on how to treat the disorder. Thus, even the theory of genetic factors causing ODD is perhaps the least acceptable alternative, but even in this case it will not be correct to stat that genetic theory lacks value in terms of its implications for treatment: exact knowledge of biological and genetic underpinning helps better understand the potential of any intervention strategy or therapy (e.g. biomedical interventions), design new more efficient methods and accurately predict treatment outcomes. Cognitive theories are also critical for a full understanding of Odd and have huge implications for psychosocial and behavioral interventions which up to now remain the only verified approach in the treatment of ODD. References American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). Washington, D.C.: The Association, 1980. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Association Barkley, R. A., Edwards, G., & Robin, A. (1999). Defiant Teens: A Clinicians Manual for. Family Training. New York: Guilford. Caron, C. & Rutter, M. (1991). Comorbidity in child psychopathology: concepts, issues and research strategies. Journal of Child Psychology and Psychiatry, 32, 1063-108. Egan, J. (1991). Oppositional defiant disorder. In Wiener, J. M. (Ed), Textbook of Child and Adolescent Psychiatry, Washington, DC, American Psychiatric Press. Gard GC, Berry KK: Oppositional children: taming tyrants. Journal of Clinical Child Psychology 1986; 15:148-1 Greene, R. W., Ablon, J. S., Goring, J. C. (2005). A transactional model of oppositional behavior: underpinnings of the Collaborative Problem Solving approach. Journal of Psychosomatic Researh, 55(1), 67-75. Kazdin, A. E. (2005). Parent Management Training: Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents. New York: Oxford University Press Meeks, J. E. (1979). Behavioral and antisocial disorders. In Noshpitz, J. D. (Ed.), Basic Handbook of Child Psychiatry, Vol. 2, New York, Basic Books. Rey, J. M. (1993). Oppositional Defiant Disorder. Am J Psychiatry ; 150:1769-1778) Rutter M, Shaffer D: DSM-III: a step forward or back in terms of the classification of child psychiatric disorders. J Am Acad Child Psychiatry 1980; 19:371-394 Serra-Pinheiro, M. A., Schmitz, M., Mattos, P. & Souza, I. (2004). Oppositional defiant disorder: a review of neurobiological and environmental correlates, comorbidities, treatment and prognosis. Review of Brasilian Psiquitra, 26(4), 272-275. Tynan, W. D. (2003). Oppositional Defiant Disorder. eMedicine, November. Retrieved May 7, 2007 from http://www.emedicine.com/ped/topic2791.htm US Public Health Service (2000). Mental Health: A Report of the Surgeon General [electronic version]. Retrieved May 2 2007 from http://mentalhealth.samhsa.gov/features/surgeongeneralreport/toc.asp Webster-Stratton, C. & Hammond, M. (1999). Treating children with early-onset conduct problems: a comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65(1), 93-109. Wells, K. C., Egan, J. (1988). Social learning and systems family therapy for childhood oppositional disorder: comparative treatment outcome. Comprehensive Psychiatry, 29:138-1 46 Werry, J. S., Reeves, J. C., Elkind, G. S. (1987). Attention deficit, conduct, oppositional, and anxiety disorders in children: a review of research in differentiating characteristics. Journal of American Academy of Child and Adolescent Psychiatry, 26, 133-143. Read More