Thien-An Le
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Oppositional Defiant Disorder
Intermittent Explosive Disorder
Antisocial Personality Disorder
Pyromania
Kleptomania
Other Specified Disruptive, Impulse-Control,
and Conduct Disorder
Unspecified Disruptive, Impulse-Control, and
Conduct Disorder
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Four+ symptoms for at least 6 months:
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Pattern of angry/irritable mood, includes:
◦ Often loses temper,
◦ Often touchy or easily annoyed,
◦ Often angry and resentful.
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Argumentative/defiant behavior, includes:
◦ Argues w/authority figures or adults,
◦ Actively defies or refuses to comply w/requests from
authority figures or w/rules,
◦ Deliberately annoys others,
◦ Often blames others for his/her mistakes or misbehavior.
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Vindictiveness, includes:
◦ Spiteful or vindictive at least twice within the past six
months.
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For children < 5 years, the behavior should occur on most
days for a period of at least 6 months.
◦ 5 + y/o, the behavior should occur at least once per week for at
least 6 months.
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Frequency and intensity of the behaviors are outside
normative range
◦ Including: developmental level, gender, and culture.
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Behavior associated with distress:
◦ individual or others in his or her immediate social context or,
◦ impacts negatively on social, educational, occupational, or other
important areas of functioning.
Do not occur exclusively during the course of a psychotic
disorder, substance use, depressive, or bipolar disorder
and criteria are not met for disruptive mood dysregulation
disorder.
Mild, Moderate and Severe Specifications
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ODD- Dr. Phil
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Angry/irritable
◦ Temper,
◦ Easily annoyed,
◦ Resentful.
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Argumentative/defiant behavior
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Argues w/mom
Defying mom
Refusing to comply w/requests from mom
Refuses to comply with mom
Deliberately annoyed mom elbowing her on plane
Blames mom for misbehaviors  “you jabbed me first”
Vindictiveness
◦ Spiteful or vindictive
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ODD is associated with increased risk of other mental disorders during
childhood AND adulthood beyond the effects of CD (Burke et al., 2005).
◦ Approximately 1/3 children CD (Hamilton & Armando, 2008)
◦ Approximately 40% Anti-Personality Disorder (Hamilton & Armando, 2008)
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Associated suicide attempts
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Increased risk for adjustment as adults
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Academic failure,
Antisocial behavior,
Rejection by peers,
Low self-esteem,
Impulse-control problems,
Substance abuse,
Anxiety, and
Depression.
Impairments in emotional, social, academic, and occupational adjustment.
◦ Parents, teachers, supervisors, peers, and romantic partners.
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Prevalence: 1-11%, avg. of 3.3%.
More prevalent in families in which child care is
disrupted by a succession of different caregivers
or families in which harsh, inconsistent, or
neglectful child-rearing practices are common.
Rate depends on age and gender of child.
Somewhat more prevalent in males prior to
adolescence.
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First symptoms usually appear during preschool and
behaviors are frequent during preschool and
adolescence.
◦ Important to evaluate intensity and frequency vs. normative levels.
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ODD often precedes development of CD.
◦ Childhood-onset type of conduct disorder.
◦ Many children and adol. w/ODD do not subsequently develop CD.
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Course: 3 years
Manifestations of ODD across development are
consistent.
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Temperamental: problems in emotional
regulation predictive of ODD.
◦ i.e.: High levels of emotional reactivity, poor frustration
tolerance angry/irritable moods.
◦ Related to abnormality of the amygdala and prefrontal
cortex (PFC).
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Neurobiological markers:
◦ Lower heart rate and skin conductance reactivity,
reduced basal cortisol reactivity, abnormalities in
the PFC and amygdala.
 Reduced basal cortisol reactivity associated with
higher rates of aggression and with poor social
relationships (Booth, Granger, & Shirtcliff, 2008).
 PFC regulation of behavior, cognition, and attention
(Arsten, 2006).
 Amygdala  emotion regulation.
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May not be specific to oppositional defiant
disorder, also similar in conduct disorder.
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Disrupted by a succession of different caregivers or
families in which harsh, inconsistent, or neglectful
child-rearing practices are common.
Associated w/distress in the individual or others in
his/her immediate social context.
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Could impact negatively on social, educational, occupational, or
other areas of functioning.
Often justify their behaviors as a response to
unreasonable demands/circumstances.
◦ Do not consider themselves as being angry, oppositional,
or defiant difficult to disentangle relative contribution of
the individual with the disorder to problematic interactions
◦ i.e.: Hostile parenting ODD? or ODD Hostile parenting?
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Higher rate of substance use disorders.
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ODD higher in samples of children, adolescents, and
adults with ADHD.
◦ Independent?
◦ Shared temperamental risk factors.
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Risk for development of anxiety disorders and major
depressive disorder.
◦ Defiant, vindictive, & argumentative symptoms carry most risk CD
◦ Angry-irritable mood symptoms emotional disorders.
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Symptoms are relatively the same.
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DSM-V:
◦ DSM-V categorizes the symptom groups.
◦ DSM-V more specific: spiteful or vindictive at least twice within the past 6
months.
◦ Includes consideration of environmental factors in Criteria.
◦ Includes caveat for substance use, depressive, or bipolar disorder in
Criteria.
◦ Distinguishes the age-specific behavioral criteria.
 Before and after 5 years of age criteria.
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DSM-IV-TR:
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Classified in different categories.
◦ Criteria D: Criteria are not met for Conduct Disorder, and, if the individual
is age 18 years or older, criteria are not met for Antisocial Personality
Disorder
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Recurrent pattern of developmentally
inappropriate levels of negativistic, defiant,
disobedient and hostile behavior toward
authority figures.
◦ Including actively defying or refusing to comply with adult
rules and requests, frequent temper outbursts, and
excessive arguing
◦ (Anderson et al., 1986; Dumas and LaFrenier, 1993; Dumas
et al., 1995; Lytton, 1990; Rey et al., 1988; Schacher and
Wachsmuth, 1990; Stormchack et al., 1997)
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Arguing with adults, losing one’s temper, and
angry or intentionally annoying behavior (Dick
et al., 2005).
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Early childhood
(Dick et al., 2005)
Children with ODD often are diagnosed with
CD when they reach adolescence (Dick et al.,
2005)
◦ Not all individuals with CD have had a previous
diagnosis of ODD.
◦ 3x as likely to develop CD (Lahey, McBurnett, &
Loeber, 2000).
◦ Lahey-Loeber Model of comorbity:
 Only children with ADHD who also exhibit comorbid ODD will
develop CD. Then later develop APD (Loeber et al., 2000).
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Temperament:
◦ Predictive of externalizing behavior problems by
late childhood (Sanson and Prior,1999).
◦ Temperamental difficulties due to psychosocial
early life risk factors
 Low income Maternal depression, social stress, and
support and home environment (Shaw et al., 2001).
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Attachment?
◦ (Burke et al., 2002)
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Coercive parenting behaviors
et al., 2000)
(Patterson, 1984; Eddy et al., 2001; Stormshak
Low parental warmth and involvement  Oppositional child
behavior (Stormashak et al., 2000)
Child abuse (Dodge et al.,1995)
◦ Demonstrated social processing deficit conduct problems
Association with deviant peers
1995; Simons et al., 1996) :
(Elliott and Menard, 1996; Keenan et al.,
◦ Initiation of delinquent behavior in boys
◦ For girls, more common with an early onset of pubertal maturation
(Stattin and Magnusson, 1990)
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Peer Rejection conduct problems and aggressive
responding
◦ Peer rejection
Conduct problems
◦ (Coie and Dodge, 1998; Coie and Lenox, 1994; Dodge et al., 1990; Bolger and Patterson,
2001).
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Community Factors:
◦ Community disorganization, drug availability, presence of
neighborhood adults involved in crime (Herrenkohl et al., 2000)
◦ Exposure to violence and exposure to racial prejudice (Hawkins
et al., 1998)
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Unemployment (Fergusson et al.,1997),
Neighborhood violence (Guerra et al.,1995)
Family poverty and children’s aggression (among
white children alone) (Guerra et al.,1995)
Low income (Shaw et al., 2001) and
Duration of poverty (McLoyd,1998)
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Prenatal smoking (Landgren et al., 1998; Hill et al., 2000)
Prenatal maternal alcohol use (Hill et al., 2000)
Maternal viral illness (Mellins et al., 2006)
Parental separation (Fergusson et al., 1994; Sullivan et al.,
1995)
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Early deprivation (Zeanah et al., 2005)
Adoption (Sullivan et al., 1995)
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Based on the Coercion theory.
Patterson hypothesized that aggressive behavior develops
in families when parents use coercion as the primary mode
for controlling their children.
A child who has received abundant negative reinforcement
for aversive behaviors and little positive reinforcement for
appropriate behaviors
◦ Likely to encounter major difficulties in academic and peer
settings middle childhood.
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Parental failure to discipline, which is thought to be a
major determinant for increases in antisocial child
behavior.
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Behavioral event is initiated by the child
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Caregiver terminates aversive state by “caving in”
to the demands of the child
◦ Arguing, crying, etc…
◦ Highly aversive to the caregiver
◦ Negative reinforcement conditioning mechanism
◦ Escape behavior
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Strengthens the child's behavior of exhibiting
ODD
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Strengthening the caregiver's inappropriate
behavior.
Intra-Individual level of analysis: Two conditionals for a contingency
model.
Infant irritable cries /
Infant is hungry
Mother attends and
terminates aversive state
Mother attends / All other infant behavior
Infant irritable crying is
reinforced
Mother reinforces infant prosocial behavior
Child irritable,
active, has
difficult
temperament
Mother
Depressed
Antisocial
Pregnancy and birth
Complications
Hyporesponsive
Divorce
Parenting
Discipline
Tracking
Teaching
Involved
Relative rate
reinforce
coercive behavior
Relative rate
reinforce
prosocial
behavior
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Genetic influences on behavior (twin studies):
◦ Delinquent set of behaviors:
 Rule-breaking behaviors:
 30-79% (Bartels et al., 2003).
 Girls: 56%-72% of variance in Rule-breaking accounted by genetic
factors.
 When assessed by both parents: 80% covariance for rule-breaking due
to genetics.
 Aggression:
 51%-72% (Bartels et al., 2003).
◦ Familial negativity and adolescent antisocial behavior
 51%-60% (Pike et al., 1996).
◦ Functioning of PFC
 Composite genotypes (Nigg et al., 2007).
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Genetic correlation between CD and ODD.
◦ Joint Construct (Eaves et al., 2000; Nadder, Rutter,
Silberg, Maes, & Eaves, 2002).
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Genetic influences contributes to covariation
between ADHD and ODD (Dick et al., 2005)
CD, ADHD, and ODD are largely explained by
shared genetic influences (Dick et al., 2005).
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PFC
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(Baving et al., 2000):
Atypical EEG in frontal lobe activation patterns.
Brain asymmetry in oppositionally defiant girls and boys ((F1,33=4.45, p <.05) and (F1,24=4.75, p <.05)
respectively)
(van Goozen et al., 1998).:
Lower levels of baseline heart rate
Experimentally induced HIGHER heart rate.
Left orbitofrontal cortex.
Less white matter
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Pathways to serious conduct and delinquent problem behavior.
Less gray matter (Fahim et al., 2012):
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(Burke et al., 2002):
Autonomic Nervous System
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May be involved in overcoming psychosocial adversity.
Dopamine
Frontal Lobe
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:
Developmental pathways
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(Nigg et al., 2007).
(Fahim et al., 2012):
Left Superior frontal area.
Increase in left temporal area
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(Fahim et al., 2012):
Associated with aggressive, impulsive, and antisocial personality.
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Low salivary cortisol level
(van Goozen et al., 1998).
Dopamine transporter, dopamine D4 receptor,
noradrenergic alpha-2 receptor (Nigg et al., 2007).
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Testosterone and aggression
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Serotonin and aggression
et al., 1992).
(Pliszka, 1999).
(Clarke et al., 1999; Kruesi
◦ Regulation of mood and impulsive behavior
(Davidson et al., 2000).
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Early physical maturation:
◦ Increased problem behaviors in girls (Graber et al.,
1997; Laitinen- Krispijn et al., 1999; Stattin and
Magnusson, 1990),
◦ but not in boys (Graber et al., 1997).
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“Off-time” in pubertal development:
◦ associated with deviant social status and thus
contributes to antisocial behavior (Williams and Dunlop,1999).
◦ Delayed pubertal onset Estrogen and testosterone
administration increased aggression (Finkelstein et al., 1997).
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Developmental Pathway (Loeber and Stouthamer-Loeber, 1998):
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Pathways to serious conduct and delinquent problem behavior:
◦ Behavioral development of a group of individuals that is different from
the behavioral development of another group or other groups of
individuals.
◦ Overt Pathway:
 Minor aggression to physical fighting and then violence
◦ Covert Pathway:
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Before age 15
Minor covert behaviors to property damage (fire setting
or vandalism), and then
Moderate to serious forms of delinquency
◦ Authority Conflict Pathway:
 Before age 12
 From stubborn behavior to defiance
 Authority avoidance
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Latimer et al., 2012:
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Prenatal cigarette smoking and alcohol use,
Prenatal viral illness,
Maternal stress and anxiety,
Low birthweight,
Peripartum and early neonatal complications,
Parental stress and parenting styles in infancy,
Early deprivation,
Adoption and
Separation.
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Prevention
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(Burke et al., 2002; Coie and Jacobs, 1993; Loeber and Farrington, 1998):
Parent-directed component
Social-cognitive skills training
Academic skills training
Proactive classroom management
Teacher training
Interventions on parenting factors:
◦ Focus is on multiple domains and needs (Catalano et al., 1998)
Individual Intervention (Brestan and Eyberg, 1998):
◦ Anger control/stress inoculation
◦ Assertiveness training
◦ Rational-emotional therapy
◦ Problem-solving skills training (Kazdin, 1996; Webster-Stratton and Hammond, 1997)
◦ Moral development interventions (Arbuthnot, 1992)
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Parent and Family Treatment:
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Integration of universal, targeted, and clinical intervention strategies
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Multisystemic Therapy (MST)
◦ Parent management training (Brestan and Eyberg, 1998)
◦ Parent child interaction training (Schuhmann et al., 1998)
1998)
(Offord et al.,
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In order to best deal with a youth in trouble, treatment
must target the many "systems" that impact the youth:
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Family,
School environment,
Friendships and,
Peer pressures.
Works closely with the parents and child for 3-5
months in their home and community.
◦ Emphasizes recognized risk factors associated with
antisocial behavior.
◦ Goal-oriented and focuses on helping the caregivers manage
and nurture their challenging children more effectively.
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Project LIFT
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(Reid et al, 1999)
Parent training + classroom social skills + playground behavior +
systematic communication
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Psychopharmacological Treatment
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Mood stabilizers,
Antipsychotics,
Clonidine,
Stimulants (Burke, 2002)
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