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This mining report provides readers with a concise yet comprehensive overview ofrecent developments related to Oppositional Defiant Disorder (ODD) in theresearch literature. The author manages to highlight the areas of pharmacological,neurobiological, gender, and case conceptualization studies that will beinformative to beginning and seasoned play therapists alike. Clinical Editor Jodi

Ann Mullen, PhD, LMHC, RPT-S

Mining Report November 2008

Oppositional Defiant Disorder

By Laura Tejada, PC, LMFT, NCC, RPT

Oppositional Defiant Behavior [ODD] is characterized by a recurrent pattern of negativistic, defiant,disobedient, and hostile behavior toward authority figures (American Psychological Association [APA],2000, p. 100). For a child to warrant a diagnosis of ODD, these behaviors must create impairment in oneor more contexts, persist more than 6 months, and occur more frequently than developmentally and/orsituationally expected non-compliant behavior in children (APA).

Research studies reviewed for this Mining Report included clinical populations in addition to thepopulation diagnosed with ODD, such as Conduct Disorder [CD] and Attention Deficit HyperactivityDisorder [ADHD]. Other studies included populations of children exhibiting symptoms of oppositionalbehavior and/or disruptive conduct, but were not fully diagnosed with ODD or CD. In this report, thiscategory of research participants is labeled oppositional-defiant behavior [OD].Pharmacological Interventions

Long-acting methylphenidate may be effective in reducing aggressive and/or OD behavior in childrenages 6-16 with comorbid ADHD (Sinzig, Dpfner, & Lemkuhl, 2007). This treatment effect was mostnoticeable on minor symptoms of aggression and defiance. The addition of quetiapine for 12-16 year oldsdiagnosed with comorbid ADHD and ODD/CD who did not respond sufficiently to methylphenidate wasshown to be effective, with 42% of the sample meeting clinical significance with combined treatment(Kronenberger, Giauque, Lafata, Bohnstedt, et al., 2007).

A differential response to methylphenidate in children with ADHD and comorbid anxiety or ODD,

when compared to children with ADHD alone, was found in a study by Goez, Back-Bennet, & Zelnik(2007). This study found a bimodal population (N=1122), with both groups of children with ADHD andcomorbid ODD or anxiety showing a clinically significant increase in symptoms of inattention whencompared to children with ADHD alone. These researchers hypothesize methylphenidate may beinappropriate for both subpopulations of children with ADHD and comorbid ODD/anxiety.Neurobiological Studies

Electroencephalogram [EEG] differences between two groups of males ages 8-12 years, one withADHD and comorbid ODD, and another with ADHD alone, were investigated (Barry, Clarke, McCarthy, &Selikowitz, 2007). Children with comorbid ADHD and ODD exhibited less impairment of the centralnervous system than did the group with ADHD. The study team asserts behavioral training focused onODD symptoms, in conjunction with medication therapy, may be most useful for children with comorbidADHD/ODD.

Two different studies on pre-school aged children with symptoms of ODD identified correlations

between sensory deficits and executive function and ODD behaviors. Sensory deficits were found tocorrelate with ODD-like behaviors and externalizing behaviors in children ages 1 to 5 years (Gunn,2008). Preschoolers with heightened levels of hyperactivity and oppositional defiant behavior wereassessed for attention/executive function, language, memory, and sensorimotor abilities (Youngwirth,Harvey, Gates, Hashim, & Friedman-Weieneth, 2007). Researchers found neuropsychological deficitswere correlated with the presence of oppositional-defiant behavior.

Assessment and Case ConceptualizationJ ohnson, Murray, & Ng (2007) categorized non-compliant behavior exhibited by children with ADHD

alone, in comparison to children with ADHD/OD behaviors. Children with ADHD/OD showed moreunskilled noncompliance (covert, confrontational, and emotionally labile behaviors) than did children with

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ADHD alone, who exhibited more skilled noncompliance (verbally skilled and/or emotionally regulatedbehaviors). Researchers suggested examining the type of noncompliance exhibited by children (skilledvs. unskilled) may provide important clinical information regarding the comorbidity of ODD with ADHD.Gender Factors

Internalizing disorders of anxiety or depression in children with ODD were shown to have differentpatterns of comorbidity between boys and girls, although further research is indicated (Boylan,Vaillancourt, Boyle, & Szatmari, 2007). This review of studies indicated that ODD tends to be associatedwith both major depression and anxiety in boys, but only with anxiety disorders in girls. Girls also tend todevelop more internalizing disorders in association with ODD, especially those girls who have later-onsetODD. Additional findings indicated children with ODD diagnoses at younger ages may have an increasedrisk for internalizing disorders.

The increased prevalence of boys with ADHD and ODD when compared to girls as based upon theConnors Teachers Rating Scale Revised: Short version was examined by Derks, Dolan, Hudziak, Neale,& Boomsma (2007). No gender differences in the factor structure of the instrument were found (N=1651).Researchers commented on the common finding that parents often report gender differences on theConnors, and stated this may be a contextual issue related to the setting in which ADHD and ODDbehaviors are observed.Family Factors

The reciprocal relationship between ODD symptoms and less assertive parental discipliningbehaviors was documented by Burke, Pardini, and Loeber (2008). Observations and results indicate child

behaviors were more influential on parent behaviors than were parent behaviors on those of children.ODD was found to predict less assertive parenting practices, poorer reciprocal communication, anddecreased involvement between parent and child.

Parenting interventions shown to be effective for children with ODD/OD symptoms are Parent-ChildInteraction Therapy (Chase & Eyberg, 2007) and Parent Management Training (Costin & Chambers,2007). Both studies also found effectiveness of these treatment interventions for ODD/OD with thepresence of comorbid disorders.

Stressors for families of children diagnosed with ODD/OD were identified as paternalanxiety/depression, maternal personality disorders, and unresolved couple conflict (Goldstein, Harvey,Friedman-Weineneth, Pierce, Tellert, & Sippel, 2007). Differences in family functioning based on genderof the child receiving treatment for disruptive behaviors were minimal (Fossum, Mrch, Handegrd, &Drugli, 2007). However, overall levels of stress were higher in the homes of girls. Mothers of girls reportedhigher levels of maternal depressive symptoms than did mothers of boys.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,Text Revision). Washington, D. C.: Author.

Barry, R. J ., Clarke, A. R., McCarthy, R., & Selikoweitz, M. (2007). EEG coherence in children withAttention-Deficit/Hyperactivity Disorder and comorbid Oppositional Defiant Disorder, ClinicalNeuropsychology, 118(2), 356-362.

Boylan, K., Vaillancourt, T., Boyle, M., & Szatmari, P. (2007). Comorbidity of internalizing disorders inchildren with oppositional defiant disorder, European Child & Adolescent Psychiatry, 16, 484-494.

Burke, J . D., Pardini, D. A., & Loeber, R. (2008). Reciprocal relationships between parenting behaviorsand disruptive psychopathology from childhood through adolescence, Journal of Abnormal ChildPsychology, 36, 679-692.

Chase, R. M., & Eyberg, S. M. (2007). Clinical presentation and treatment outcome for children withcomorbid externalizing and internalizing symptoms,Anxiety Disorders, 22, 273-282.Costin, J ., & Chambers, S. M. (2007). Parent Management Training as treatment for children with

Oppositional Defiant Disorder referred to a mental health clinic, Clinical Child Psychology andPsychiatry, 12(4), 511-524.

Derks, E. M., Dolan, C. V., Hudziak, J . J ., Neale, M. C., & Boomsma, D. I. (2007). Assessment andetiology of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder in boys and girls,Behavioral Genetics, 37, 559-566.

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Fossum, S., Mrch, W., Handegrd, B. H., & Drugli, M. B. (2007). Childhood disruptive behaviors andfamily functioning in clinically referred children: Are girls different from boys? Scandinavian Journal ofPsychology, 48, 375-382.

Goez, H., Back-Bennet, O., & Zelnik, N. (2007). Differential stimulant response on attention in childrenwith comorbid anxiety and Oppositional Defiant Disorder. Journal of Child Neurology, 22(5), 538-542.

Goldstein, L. H., Harvey, E. A., Friedman-Weieneth, J . L., Pierce, D., Tellert, A., & Sippel, J . C. (2007).Examining subtypes of behavior problems among 3-year-old children, Part II: Investigatingdifferences in parent psychopathology, couple conflict, and other family stressors. Journal of

Abnormal Child Psychology, 35, 111-123.Gunn, T. E. (2008). Relationship between sensory deficits, Oppositional Defiant Disorder, and

externalizing behaviors in an urban preschool population. (Doctoral dissertation, Azuza PacificUniversity, California, 2008). ProQuest Dissertations & Theses, AAT 3292175.

J ohnson, C., Murray, C., & Ng, L. (2007). Types of noncompliance in boys with Attention-Deficit/Hyperactivity Disorder with and without oppositional behavior. Child & Family BehaviorTherapy, 29(1), 1-20.

Kronenberger, W. G., Giauque, A. L., Lafata, D. E., Bhonstedt, B. N., et al. (2007). Quetiapine addition inmethylphenidate treatment-resistant adolescents with comorbid ADHD, Conduct/Oppositional-DefiantDisorder, and aggression: A prospective, open-label study, Journal of Child and AdolescentPsychopharmacology, 17(3), 334-347.

Sinzig, J ., Dpfner, M., Lehmkuhl, G. (2007). Long-acting methylphenidate has an effect on aggressive

behavior in children with Attention-Deficit/Hyperactivity Disorder. Journal of Child and AdolescentPsychopharmacology, 17(4), 421-432.

Youngwirth, S. D., Harvey, E. A., Gates, E. C., Hashim, R. L., & Freidman-Weieneth, J . L. (2007).Neuropsychological abilities of preschool-aged children who display hyperactivity and/or oppositional-defiant behavior problems. Child Neuropsychology, 13(5), 422-443.

Author

Laura Tejada, PC, LMFT, NCC, RPT

Tejada is a doctoral candidate in Marriage and Family Therapy at the University ofAkron and a contract therapist at Childrens Advantage in Ravenna, Ohio.ljt7@uakron.edu

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Mining Reports: Mining Reports are brief reports (limits 500-600 words) authored by prominent play therapists who review (mine)the latest multi-disciplinary mental health literature on a specific topic and then report emerging mega-trends, cutting-edge bestpractices or techniques, and other wisdom (intelligence) to help busy play therapy practitioners. Transmit submissions as WordDOCs to Executive Director Bill Burns, bburns@a4pt.org, with photo and bio caption. Authors relinquish copyright of reports to theAssociation for Play Therapy which reserves the sole right to accept or reject submissions and to edit papers for clarity or spatiallimitations without altering intent.