Transcript The Obstinate Child: Is it really Oppositional Defiant Behavior

The Obstinate Child:
Is it really Oppositional Defiant Behavior Disorder?
February 2017
John A Salvato MD FAAP
Developmental/Behavioral Pediatrician
Maine’s Center for Developmental and Behavioral Pediatrics
269 Old Belgrade Road, Augusta Maine
p 207-620-1430
f 207-620-1429
“It wasn’t me. It was him!”
-my daughter, age 4
Disclaimer
I will not be endorsing any products.
I do not receive any grants or stipends from
pharmaceutical companies.
I am the only one who really knows what I am
going to say.
Objectives
Review the differential diagnosis of Oppositional
Defiant Behavior Disorder
Understand some of the driving factors behind a
child’s defiance.
Understand the role of parent-child interactions in
patterns of behavior.
Epidemiology
ODBD
5 per 100 to 16 per 100
ADHD, all types
5 per 100 to 12 per 100
Anxiety Disorder
10 per 100
Depression
7 per 100
Conduct Disorder
5 per 100
Epidemiology
Electronic Media
insidious
99 per 100 children
passive learning
affects delta waves seen in an hypnotic state (TV)
back/blue light disrupts circadian rhythm via interference with
melatonin production
exposure for > 3 hours a day associated with hyperactivity,
aggression, and poor academic performance.
Oppositional Defiant Behavior
Disorder
An ongoing pattern of angry/irritable mood,
argumentativeness, defiance or vindictiveness
Not developmentally appropriate
Last more than 6 months
Leads to impairment in social, academic or
occupational functioning
F91.3
Oppositional Defiant Behavior
Disorder
M>F
Present by age 8
If < 10 consider disruptive mood dysregulation disorder
https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorderdmdd/disruptive-mood-dysregulation-disorder.shtml
If >17 consider antisocial personality disorder
https://www.nimh.nih.gov/health/statistics/prevalence/antisocial-personality-disorder.shtml
Low SES
Frick: Annual Rev Clinical Psychology, (2012)
Pardini: J Am Academy Child Adolescent Psychiatry, (2010)
Oppositional Defiant Disorder, Family Physician, 78 (7): 861-868, (2008)
Oppositional Defiant Behavior
Disorder
Associated with impairments across multiple
domains
family and peer relationships
self esteem
risk behavior
1/3 develop Conduct Disorder
1% Querulous Disorder
Oppositional Defiant Behavior
Disorder
May be driven by:
fear
anxiety
Fraire, M, Anxiety and ODD, Clinical Psychology Review 33,
229-240, (2013)
anger, resentment and retaliation
Oppositional Defiant Behavior
Disorder
The Neurobiology of ODBD, Development and
Psychopathology 25, 193-207, (2013)
low punishment sensitivity
hyposensitivity to rewards
impaired executive function
Oppositional Defiant Behavior
Disorder
Possible links
prenatal tobacco use
prenatal alcohol use
prenatal viral illness
maternal stress
maternal anxiety
low birthweight
peri-partum/neonatal complications
parental stress
early deprivation, adoption and separation
Oppositional Defiant Behavior
Disorder
Significant overlap with other chronic behavior
disorders (ADHD, CD, DMDD)
Wilson, P, Disruptive Behavior Disorders, Child: care, health
and development, 38, 611-628, (2012)
Disruptive Mood Dysregulation Disorder
Meyers E, DMDD, A Research Perspective, Journal Affective
Disorders, (2016)
Evaluation
History
prenatal
postnatal
early infancy/childhood
preschool/school
daycare
Evaluation
Habits
eating
sleeping
electronic
rituals/tics
activities
toileting/hygiene
Evaluation
Physical Exam
dysmorphology
hearing/vision
head circumference
abdomen
Evaluation
Mental Status
mood
social relatedness
worries, fears, goals
Who is the boss?
Evaluation
Risk Factors
A child’s vulnerability rests on the interaction of:
genetics
temperament
resiliency
medical issues
environmental exposures
Evaluation
Genetics
Family history of
depression
anxiety
mood disorders
substance use
stubbornness/defiance
Evaluation
Temperament
affect
emotional regulation; difficulty dealing wth negative emotions, high emotional
intensity c/w anxiousness
aggression
self-injurious behavior
hypomania symptoms
organizational skills
executive functioning skills
informational processing
effortful control
Evaluation
Temperament Factors
colicky
stubborn
child with eating and sleeping issues
baby
mother interactions
Evaluation
Parenting Behaviors
goodness of fit
mother
baby interactions
less autonomy granting, over controlling
less emotional warmth
Evaluation
Protective Factors
good nutrition
positive family environment
early recognition
Evaluation
Tests
Achenbach forms, CBCL, TRF, YSR
Vanderbilt forms, Teacher, Parent
Depression Inventory
Anxiety Scale
96127
ACES
Family drawing
Handwriting
96111
Review prior OT/ST/Psychology reports
Review IEP/504 plans
Treatment
Family
structure/routines/rules/mealtime
listen/love/limits
“Time In”
“Time Out”, modified
Catch them being good!
Predictable, non effusive, praise
Treatment
Behavioral
CBT, individual and group based parenting interventions, ages 3-12, reduced conduct problems, improved parent
mental health, parenting skills. modest cost compared to associated health, social, educational and legal costs.
Evidenced Based Child Health 2: 318-692 (2012)
parent training, Triple P (Positive Parenting Program), PCIT, COPE (Community Parent Education)
cognitive problem solving skills training
School
IEP
SMART: specific, measurable, achievable, realistic, time based
Social skills training
Individual insight oriented psychotherapy
Family psychotherapy
Mentor/peer support
Practice parameter: J Am Acad Child Adol Psychiatry (2007)
Treatment
Medication
Co-morbid conditions
ADHD
Depression
Anxiety
Psychopharmacological treatment, CNS Drugs, 23 (1): 1-17
(2009)
Disclaimer
The recommendations in these slides do not
indicate an exclusive course of treatment or serve
as a standard of medical care. Variations, taken
into account individual circumstances, may be
appropriate.