Analysis of Oppositional Defiant Disorder - Research Paper Example

ABSTRACT Oppositional Defiant Disorder is a mental disorder characterized by recurrent incidences of negative, hostile disobedient and defiant behavioral attribute directed towards people of authority, existing for a period longer than six months. These behavior types are common among toddlers and preschoolers and specific guidelines for diagnosis are listed by the Diagnostic and statistical manual of mental disorders DSM-IV-TR. The disorder is identified commonly in children aged 3 -9 years, occurs irrespective of gender and is usually observed as comorbidity with ADHD. Biological, temperamental as well as behavioral factors contribute to origin and development of the disorder, and management is possible through parent child training programs to alter environmental factors; as well as medication in some cases. The review is a comprehensive study of the researches that have contributed in developing an understanding of the disorder. Keywords: ODD, Diagnosis, biological factors, environmental factors, ADHD, comorbidity. 1. OBJECTIVE: The paper aims to compile a comprehensive review of studies done on Oppositional Defiant Disorder (ODD), with reference to the symptoms, causes, therapies, relation with Attention Deficit Disorder (ADHD) and the latest researches done on the disorder. 2. BACKGROUND 2.1. INTRODUCTION: Mental, emotional and behavioral problems have kept quite a few children from living a life enjoyed by their peers and many a parents have been burdened with an additional task of understanding a not so normal child while simultaneously trying to cope with the unexplained behavioral deviations. It is true that every child is unique, and should be dealt with in a different way, still some children, for reasons attributed to their genetic makeup, environment or many other as yet unknown influences; are so different from others, that their behaviors cannot be generalized and demand a special name and treatment. With advances in field of psychiatry, it has been possible to identify many of these behavioral disorders and help parents as well as children understand and cope with them. One of these behavioral disorders is oppositional defiant disorder (ODD), which is found to be prevalent in approximately 1-16% of the children, however the prevalence estimates are highly variable due to non referral of most of the milder cases (Steiner and Ramsing, 2007). Moreover, the occurrence rates are lower when the diagnostic criteria are strictly adhered to and the diagnosis is based on parental as well as teachers’ remarks. The disorder is a big hurdle in the process of social adjustments and is usually manifested along with ADHD and other conduct disorders (Hamilton and Armando, 2008). Treatment of the disorder is possible with a proper understanding of the problem, trained approach in dealing with the individual assisted with appropriate medication. 2.2. SYMPTOMS: The Diagnostic and statistical manual of mental disorders DSM-IV-TR defines ODD as “a recurrent pattern of negativistic, defiant, disobedient and hostile behavior toward authority figures that persists for at least 6 months”. The diagnostic criteria of ODD are listed in table 1. Table1: Oppositional Defiant disorder: Diagnostic criteria A A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four (or more) of the following are present 1 Often loses temper 2 Often argues with adults 3 Often actively defies or refuses to comply with adults’ requests or rules 4 Often deliberately annoys people 5 Often blames others for his/her mistakes or misbehaviors 6 Often touchy or easily annoyed by others 7 Often angry and resentful 8 Often spiteful or vindictive Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. B The disturbance in behavior causes clinically significant impairment in social, academic and occupational functioning C The behaviors do not occur exclusively during the course of a psychotic or Mood disorder D Criteria is not met for conduct disorder, and if the individual is age 18 yrs or older, criteria are not met for antisocial personality disorder. The above mentioned behavioral attributes are common in toddlers and preschoolers, especially in their domestic settings, as well as in schools; where acts of whining and throwing tantrums persist till the time they achieve their objective, which may be an object of interest or just attention. These behavioral attributes gradually diminish with age and training, and should not be identified as ODD. However if the same persists in a child to a degree not in accordance with his age and developmental stage and occurs consistently for a period of more than 6 months, irrespective of the mood, an ODD can be suspected. The children with ODD are different from normal non compliant toddlers in that they are highly argumentative, irrespective of the rationality of the parents’ gestures or requests, and respond to them by misbehaving, quarrelling and swearing. The behavior is aggressive, violent and even mildly destructive expressed as deliberate slamming of doors, banging of objects and breaking stuff. They tend to lose temper easily, question authority, are deliberately ill mannered, rude, and defy the notions of etiquettes; thereby tending to try patience of the parents, teachers or those in authority. The children tend to be stubborn, ignore orders and refuse to accept accusations directed at them for their misdeeds, often blaming others for their mistakes. The intention is usually that of inducing provocation, confrontations and harassing others. The target, in the initial stages is, usually the mother but with advancing stage fathers too are involved and progresses on to schools and peer group as well; leading to impaired relationships of these children. The children tend to express the defiance in settings which are comparatively familiar to them and therefore clinical diagnosis is difficult and dependent on interviews of parents, teachers etc. ODD is usually identified in children below 9 to 10 years of age, and is more prevalent in the male sex compared to the female, as reported by some researchers, while others report these differences to be restricted to stages before puberty, post puberty the rates of ODD in the two sexes are comparable. However the data to this effect is inconclusive, since the traits of expression of defiance in girls is different from boys; who are more openly and physically aggressive (Angold and Castello, 1996). Besides, ODD is more common in children belonging to lower income groups the prevalence increasing with increasing age (Hamilton and Armando, 2008). 2.3. CAUSES: Kandel (1998), proposed an integrative framework for the study of Psychiatry, which even though generalized, is highly relevant in the study of causes of development of ODD. The basic principles of Kandel’s framework are listed in table 2. Table 2: Kandel’s framework of Psychiatry (Kandel, 1998) 1 All mental processes are neural 2 Neural connections are determined by genes and their proteins 3 Gene expressions are altered by experiences 4 Experiences alter neural connections 5 Psychotherapy changes gene expressions Thus Kandel suggests that the brain and psychology interact in a multifaceted manner, both influencing each other and also affecting gene expressions, social behavioral responses; while simultaneously being affected by them. Proceeding to understand causes of ODD development based on this theory, it can safely be said that ODD development is a culmination of numerous collaborative factors. The same has been proved by the researches and on the basis of literature available the factors responsible for ODD development are tabulated in figure 1. Figure 1: A balance of individual and environmental factors determines the development of ODD. It should also be remembered that the causal factors of ODD are not the determining factors of development of ODD, but only raise the probability of occurrence of the disorder. Hence it would be more appropriate to use the term risk factors for them, instead of causative factors. Risk Factors: The risk factors for ODD can be broadly classified in to two categories: A. Biological Factors: The individual factors that pose a risk for the development of ODD are: i. Heritability: A meta-analysis of antisocial behavior done by Rhee and Waldman (2002) revealed an overall heritability estimate of 41% which is moderate, but the estimates are higher for younger children (3 years and below), since in these cases the effect of environment is less. This also shows that gene effect is modified by environmental influence which can be either positive or negative. Moreover, a study by Hicks et al. (2004) shows that children inherit a general vulnerability to behavioral disorders from parents, the heritability estimates of which can be as high as 81%. Gene effect and its correlation with the environment is another risk factor associated with ODD. Parents pass on both genes for the disorder vulnerability and also provide the conditions, viz, inconsistent discipline which again has its origin in parents’ genetic makeup. Moreover, the response that the child evokes from the parent again has its roots in the genes involved, which are shared by the child and the parents. Thus improper parenting coupled with abnormal behavior raise the probability of occurrence of ODD. ii. Hormonal Factors: Individual response to stress is determined by the secretion of cortisol which in turn is controlled by Hypothalamus Pituitary Adrenal (HPA) Axis. A study by Snoek et al., (2004) showed that individuals with ODD showed a low cortisol secretion under stress, in comparison to healthy individuals. This could be due to the individual being accustomed to repeated negative behavior around him in general or in response to his own behavior. A behavioral training could reverse the effect of this risk factor and can be used as preventive measure. iii. Neurocircuitry: Children with ODD were found to show below normal functioning of amygdala which is involved in identifying emotional stimuli such as fear recognition, evaluating and avoiding threats etc (Marsh et al., 2008). B. Environmental Factors: Environment determines the brain activity and therefore psychological development of a child right from pre natal stage. Studies on a number of environmental factors have proved beyond doubt that both fetuses as well as children exposed to adverse environments develop behavioral and other psychological disorders along with other health problems. Some of the adverse environmental factors studied are (Delaney- Black et al., 2000; Kelly et al., 2000): i. Malnutrition ii. Drug and alcohol use iii. Abusive parenting iv. Poverty v. Family strife or single parenting Coexistence of genetic and environmental factor (which usually is the case), lead to many fold increase in the probability of ODD occurrence, for e.g. higher activity or difficult temperament, coupled with neglect by the parent; or highly reticent or fearful child subjected to physical abuse by the parent can lead to higher risk. Also birth complications which under normal rearing do not pose a risk, when followed by maternal indifference or difficult parenting can lead to aggressive behaviors in later years. 2.4. ODD & ADHD: Attention deficit hyperactivity disorder and ODD have been found to frequently coexist in affected individuals, along with conduct disorder. In children the comorbidity of ODD and ADHD has been reported to be up to 46% and in adolescents, up to 33% (Biederman et al, 1998). Children having both the disorders have long term behavioral problems, are prone to more frequent bouts of aggressiveness and suffer higher levels of behavioral and emotional difficulties. A study by Kim et al. (2009), attempted to make a comparative study of individuals with ODD only and those with comorbid ADHD and found that the children and adolescents with both ODD and ADHD had alleviated persistence and self directedness, along with along with higher anxiety or depression, attention deficits, delinquent attitudes and aggression; in comparison to individuals with ODD only. The accurate explanation for the high frequency of comorbidity of ADHD and ODD is not known but there can be several reasons, which either partially or totally contributes to the comorbidities. Some of these probable explanations can be; Common underlying risk factors One condition can be a precursor or risk factor for another The disorders share common symptoms. There have also been studies on the neurobiological aspects of these diseases which have recently been directed to gene studies. Noradrenergic genes have been implicated in comorbid ODD and ADHD (Comings et al., 2000). Another study has found the dopamine type 4 receptor genes as the culprit (Seeger et al., 2004). However, it is too early to comment conclusively on the genetic aspect of the disorder and thorough research is needed. 2.5. TREATMENT A. Nonpharmacological Treatment: Psychological intervention for ODD involves parent counseling and training, which involves analyzing behavior of parents and helping them develop a positive and more effective approach in dealing with their defiant offspring. Using media and involving children too in these sessions are two variations of the training programs which have given better results (Webster-Stratton and Hammond, 1997). Collaborative approaches that involve helping parents and children to identify issues and try to resolve them have also been found to be equally productive. Identifying real life situations and trying a community based approach to intervene and resolve the issues is another approach that has been attempted, termed as multisystemic therapy, however the success rates of this method are yet to be established. B. Pharmacological Treatment: Certain medications such as methylphenidate, atomoxetine, amphetamine, and clonidine have been identified for treatment of ODD as a comorbid condition with ADHD, however the studies for medication of ODD in absence of ADHD is not available (Hamilton and Armando, 2008). 3. PREVENTIONS: Parent preparedness and training can be the only suitably effective program for management of ODD. Suspecting parents of preschoolers need to start taking professional advice and attend both school based and self directed support programs. Diagnosis followed by behavioral interventions can be a measure for disorder management at an early stage (figure 2). Figure 2: Preventive measures for ODD 4. METHODS: A thorough study of the material available on the subject in peer reviewed journals was done and the information was compiled. 5. RESULTS: A study of the symptoms, risk factors and treatments available for ODD was done and comorbidity with ADHD was analyzed and it was found that vast amount of researches have been done to understand and manage ODD, helping practitioners, parents and teachers cope with the disorder and help child live a better life. 6. DISCUSSION: A defiant behavior not restricted to mood swings in children in the age range of 3 to 10 years, accompanied by frequent tantrums, aggression, rudeness, intolerance and argumentativeness spanning a period of more than six months, must not be overlooked. ODD is a mild conduct disorder which is a culmination of the child’s biological make up. Even though the child seems deliberately defiant and disobedient, the fact remains that the child himself has no control over his outbursts (Hamilton and Armando, 2008). Studies have proved beyond doubt that the neurological as well as hormonal responses of the ODD victim under potential threat situations to be lower than healthy controls. Moreover, genes have also been identified and the heritability of the conduct disorders in general has been established. This added to the fact that the parents, who have transferred the genes for disorder vulnerability, are also responsible for providing the environment, in fact are the sole providers in the early years; thus further complicating the situation. Hence awareness of the diagnostic factors as well as risk factors becomes imperative for parents and educators. 7. CONCLUSION: ODD is a stressful situation to deal with both for the family as well as teachers. While the symptoms are identifiable even in the preschool years, they become obvious at much later stages, sometimes during adolescence. The risk of individuals with ODD developing severe conduct disorders is also high. However, early intervention and proper management can help an individual cope with ODD and lead a normal life. Thus it is important on one hand to be aware of the various aspects of the disorder, and on the other to develop more effective therapies for treatment of the disorder. References 1. Angold, A. And Costello, E. J. (1996). Toward establishing an empirical basis for the diagnosis of oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 35(9), 1205-12. 2. Comings, D. E., Gade-Andavolu, R., Gonzalez, N., Wu, S., Muhleman, D., Blake, H., Chiu, F., Wang, E., Farwell, K., Darakjy, S., Baker, R., Dietz, G., Saucier, G., and MacMurray, J. P. (2000). Multivariate analysis of associations of 42 genes in ADHD, ODD and conduct disorder. 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