Treating Oppositional Defiant Disorder in Children and Adolescents

Copyright 2017 Danielle Leach All Rights Reserved

Characteristics and Prevalence of ODD
           
The Diagnostic and Statistical Manual for Mental Disorders (DSM-5) classifies Oppositional Defiant Disorder as a disruptive disorder typically diagnosed in childhood, among Intermittent Explosive and Conduct Disorders (American Psychiatric Association, 2014). It is one of the most stigmatizing disorders that a child or adolescent can receive and is reported to be the number one cause of referrals to youth mental health facilities (Nock, M.K. et al, 2007). Historically, ODD was associated with youth delinquency in the DSM-II and was broken down into the following three subtypes: runaway reaction, unsocialized aggressive reaction, and group delinquent reaction; whereby all three subtypes were explained by environmental factors (Pardini, D.A, et al, 2010). The unsocialized aggressive subtype, described in the DSM-II in 1987 consisted of behavior in children that was seen as hostile, aggressive, and disobedient, and was primarily due to parental neglect and lack of effective parenting and disciplinary control (Pardini, D.A, et al 2010). Conceptualization of ODD – unsocialized aggressive subtype is similar to the current understanding of ODD, described in the current DSM-5. Despite advances in the DSM-5 to make the criteria more specific and reliable, the current conceptualization of Oppositional Defiant Disorder is purported to be too general and broad in nature, making it easier to over-diagnose children and adolescents who wouldn’t otherwise meet the criteria (Grimmett, M.A., 2016).

According to the DSM-5 criteria for Oppositional Defiant Disorder, any child who is angry, loses his temper often, blames others for his or her mistakes/behavior, or refuses to obey and respect authority, would meet the criteria for ODD (American Psychiatric Association, 2014). To receive a diagnosis of ODD, the symptoms must be observed by someone who is not a sibling (American Psychiatric Association, 2014) – which is typically the child’s teacher at school - and must persist for at least 6 months, appear at least once per week, and cause distress to the client or others in the client’s environment (American Psychiatric Association, 2014). Other symptom criteria include: irritability, annoying others, and being vindictive/spiteful (American Psychiatric Association, 2014).

Understanding how the diagnosis of ODD has been formulated and conceptualized over the years is important to understanding how the disorder can become a crutch for school psychologists, teachers, and clinicians who work directly with children who exhibit problem behaviors. The American Academy of Child and Adolescent Psychiatry (2009) views Oppositional Defiant Disorder as a byproduct of various biological, psychological, and social contributing factors. Some of the biological factors that make a child more susceptible to acquiring ODD include the following: having a parent with a history of ADHD, ODD, Conduct Disorder, Substance Abuse Disorder or Mood Disorder; having traumatic brain imagery or impairment in the region of the brain responsible for impulse control and decision making; toxin exposure; and poor nutrition (American Academy of Child and Adolescent Psychiatry, 2009). Psychological factors linked to ODD include having an absentee or neglectful parent and poor social skills (American Academy of Child and Adolescent Psychiatry, 2009). Last, but not least, several social and environmental factors have been identified as possible causes of ODD that include poverty, growing up in an adverse environment, and parental divorce (American Academy of Child and Adolescent Psychiatry, 2009). While the definitive cause of ODD in children and adolescents remains unknown, it’s reasonable and helpful to conceptualize ODD as a disorder that occurs in the context of maladaptive environmental factors and social influences. 
 
Diagnosis of ODD in African-American Boys
           
A qualitative study conducted by researcher and doctor, Marc A Grimmett uncovered some of the contextual factors and diagnostic processes of licensed mental health professionals when assessing, diagnosing, and treating clients with ODD (Grimmett, M.A., et al, 2016). The study consisted of in-depth interviews, which lasted approximately 1.5 hours and what he and his research team found concerning the process for which clinicians were assigning mental health diagnoses was quite alarming. The results of the data analysis showed that there were four domains that influenced the clinician to assign a diagnosis of ODD to a client which included: managed health care/insurance demands; ODD criteria being too broad; stigmatization of ODD; and counselor bias in assessment that excludes cultural/external factors (Grimmett, M.A., et al, 2016).  The researchers found some consistency in responses given by the clinicians in the study across these four domains in which they were assessed, suggesting that there could be some external and internal factors within the therapist and within the context of the system in which he or she practices that directly influence his/her decision to assign a diagnosis of ODD.
           
Since the criteria for ODD in the DSM is broad in nature, it serves as a “catch-all phrase” for clinicians who may not quite be able to put a finger on why their student is misbehaving or acting out in class. One participant in the study described it as a “holding cell for behaviors that are not understood” (Grimmett, M.A, et al, 2016). This points to a major problem with the use of the DSM by clinicians who are culturally incompetent and who rely heavily on the DSM as a tool for labeling as opposed to an instrument for assessing, understanding, and conceptualizing. Many clinicians are so hard pressed to end each intake session with a diagnosis that they forget to do a complete, comprehensive evaluation, taking into account family, social, and cultural influences that could be impacting their client’s symptomology.

​Cognitive Affective Symptoms of ODD
           
According to the American Academy of Child & Adolescent Psychiatry (2009), “difficulty or inability to form social relationship or process social cues,” is a likely leading contributing factor leading to the development of Oppositional Defiant Disorder. Although the development of ODD can be conceptualized in the context of the child’s social environment, it’s also helpful to see the cognitive aspects of behavior that impact ODD symptomology. Two theories serve to be very helpful in investigating the cognitive-affective role and relationship in the presentation of ODD, which include Appraisal Theory and Network Theory. According to Appraisal Theory, “Unconscious appraisal of stimuli takes place prior to the emotion whereas conscious attribution of the emotion to a cause and/or labelling of the emotion (e.g., as fear or anger) takes place after the emotion” (Houwer, J.D., 2010). Under this principle, emotions can be understood as happening both on the subconscious and conscious level. So that it’s likely that some emotions we experience happen in response to stimuli from our environment that we aren’t always aware of. Take for example the stimulus of the colors red and yellow. Typically, red and yellow are known to evoke a feeling of hunger in us, which happens on a subconscious level that we are unaware of. On the contrary, some emotional experiences happen more on a cognitive level (i.e. a person getting angry when they become aware that their rights have been violated). Differentiating between emotional responses that are conscious vs unconscious lends very important information for clinicians when treating disorders that encompasses an element of emotional dysregulation, a mechanism that is in within the client’s control.
           
Network Theory provides another explanation for understanding the connection between cognition and emotion which assumes that “initially only a handful of biologically relevant stimuli elicit unconditioned emotional responses and that the range of stimuli that evoke these emotional responses is progressively elaborated through conditioning procedures” (Houwer, J.D., 2010). This is to say that the majority of emotional responses experienced by humans occurs through the process of conditioning and learning. So while emotional responses linked to our biological adaptations to the environment may serve to protect us in life-threatening situations, those emotional responses can be manipulated through social learning and conditioning. This reality can be comforting for many clients who struggle with the challenge of regulating their emotions, regardless of their social context or historical background. Within the premise of Network Theory lies the notion of schemas (Houwer, J.D., 2010), which are cognitive networks formed through learning and conditioning over time. To illustrate this idea, consider a teen who is being raised in a single parent household, with an absentee father, living in a crime-ridden, poverty stricken neighborhood. Over time, the teen may have learned to institutively put up his defenses and become combative and argumentative, in an effort to protect himself, his mother, and his family. His unique experience of growing up in a neighborhood where murder and violent crime are rampant has caused him to develop various cognitive schematic networks in his brain surrounding safety and survival that aren’t necessarily healthy adaptive mechanisms in other social contexts (i.e. school). These schematic networks will directly impact his overall perception and ultimately his worldview. So subconsciously, he makes the mistake of generalizing the conditions of his current adverse environment to all environments, that forces him to wear a protective psychological guard with him everywhere he goes. The world, through his eyes, is unfair, dangerous, and unsafe. This negative cognitive schema directly impacts his emotional state, leading him to feel a need to always defend himself, become easily annoyed and angry, and become confrontational with others.
           
Cognition and affect are two inseparable systems that are constantly working together. What a person thinks inevitably affects how he or she feels. So it’s not unlikely for a kid who is experiencing parental neglect, poverty, and negativistic thinking to feel angry, isolated, and oppositional. It’s also not uncommon for a kid who is presenting with symptoms of ODD to endorse symptoms of other disorders, specifically ADHD, Mood Disorders, and PTSD (Boat, T.F., & Wu, J.T., 2015). The likelihood that a clinician will accurately assess and treat a person who has multiple diagnoses decreases as the number of presenting symptoms and provisional diagnoses increases. So the difficulty in being able to appropriately ascertain whether symptoms presented by a client are a function of his or her culture, environment, psychological state, or another diagnosis can present some serious challenges for clinicians working with children and adolescents with problematic behaviors. It’s much easier to narrow the etiological causes of these symptoms down to cognitive-affective factors that may help better explain the innerworkings of ODD. It takes the burden off of society and partially relieves the clinician of the responsibility to work from a cultural framework, therefore embodying more of a cognitive-affective, individualistic approach.

Current Treatments for ODD

The good news is that ODD is treatable and typically involves an interdisciplinary approach for optimum therapeutic outcomes. The American Academy of Child & Adolescent Psychiatry (2009) states that a combination of therapeutic approaches is necessary for the treatment of clients with ODD which include: parent training and family therapy, cognitive problem-solving skills training, social skills training, and medication (in severe circumstances). Cognitive problem-solving and social skills training typically involve a cognitive-affective component where the clients receive training on being able to identify and understand social cues (i.e. non-verbal communication, emotional expressions) and learn techniques and skills on ways they can better communicate and express their thoughts and feelings with others (American Academy of Child & Adolescent Psychiatry, 2009). Cognitive problem-solving involves teaching the child/adolescent how to make appropriate choices in stressful situations, which allows them the chance to learn emotional regulation, whereby they come to a greater understanding of how their cognition influences their emotion and behavior and vice versa. Such techniques have been used in camp settings, group therapy, and in the context of individual and family therapy.

Proposal of Novel Treatment for ODD that address Cognitive Affective Component
           
A treatment model that involves a multi-disciplinary approach and takes into consideration psychological, biological, cultural, social, and environmental factors that contribute to the onset, development, and maintenance of ODD would likely be most effective in treating children and adolescents with ODD. Current treatments typically fail to take into consideration cultural and societal factors when assessing and treating clients which often lead to over-diagnosis, stigmatization, and worsening of the symptoms (Grimmett, M.A, 2016). Having a sensitivity to cultural influences not only informs diagnosis, but it informs the process of therapy as well. It shapes how the counselor perceives and treats the client, whereby strengthening the relationship between client and therapist, or creating a divide. A counselor who views a kid’s symptoms as a matter of choice and free will may be insensitive to what their client is experiencing, thus taking a harsher more punitive approach in treatment. However, a therapist who views the client as a product of his or her environment and understands the social, political, and environmental factors that help influence the development of maladaptive behaviors will be more cautious in his/her approach to working with the client and less likely to judge them by their inappropriate behaviors. This distinction points to one of the most important aspects of therapy – the therapeutic relationship – which lays the foundation for everything else that happens thereafter.

An understanding of the client’s problem through a socio-cultural lens is important to the success of therapy, but isn’t all encompassing. There still needs to be a level of responsibility taken on behalf of the individual client, so this is where the cognitive-affective component comes in to play. Utilizing an approach that has a healthy balance within the cognitive-affective-socio-cultural framework would be optimum for treating a client with ODD because they give the power back to the client, while at the same time, not undermining the significance that external factors beyond the client’s control play in leading them to come to a therapist’s office in the first place. Teaching a client about their emotions, makes them more cognitively aware and puts them in control of their own behavior. Being able to identify and recognize symptoms before they get out of control is also empowering for the client who has a history of reacting to social situations in an impulsive, aggressive manner. Creating a treatment protocol that teaches the client mindfulness, relaxation, and impulse control appears to be a likely effective approach in working with a client who has trouble regulating their emotions, which is typical for children who present with ODD. Psychoeducation has been used with a variety of client populations from various socio-economic statuses and educational levels, and can be effective when the curriculum is adapted to the client’s cognitive level and ability. Lastly, incorporating opportunities where youth can express themselves outside the context of therapy, and in the real-world, whether it is through art, music, dance, or sports can also be effective. Typically, when an individual attempts to assert their rights and power, when they feel powerless, they do it by resisting the “system,” which would include authority figures like teachers and law enforcement. So, in theory, it’s likely that children who come from oppressed families and communities are more likely to be engaged in behavior that makes them feel “powerful.” For teenagers, these behaviors typically are risky in nature and include drug use, promiscuity, breaking the law, and the list goes on. So directing them to positive outlets that support and encourage emotional expression would be beneficial and necessary.

It’s one thing to spend an hour a week with a child telling them the appropriate way to think, act, and behave; it’s another thing to be able to direct them to resources that provide opportunities for them to shine. More often than not, children enter therapy just to return to a bad environment that overpowers the effect four hours per month of therapy has done anyway. So the approach one takes in working with one client from one demographic, may be much different than the approach and techniques used with a client from another demographic, age, and socio-economic status. The important thing to take away from this is that behavior, to a certain extent, is within an individual’s control. Meeting the client where he or she is at through empathic listening and maintaining a non-judgmental attitude is the first step; broadening their understanding of the world and themselves, within the context of a cognitive affective approach, would be the next. Helping them create new healthy schemas in their brain that allows them to be more functional and adaptive in the world could serve them well; and the reality that the client’s environment (which they may or may not have control over) is always constantly shaping how they think, feel and behave should always be in the back of the therapist’s mind when working with a client who presents with ODD.
 
 
References

American Psychiatric Association. (2014). Desk Reference to the Diagnostic Criteria from DSM-
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Boat, T.F., & Wu, J.T. (2015). Mental disorders and disabilities among low-income children.
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Grimmett, M.A., Dunbar, A.S., Williams, T., Clark, C., Prioleau, B., & Miller, J.S. (2016). The
Process and Implications of Diagnosing Oppositional Defiant Disorder in African
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Houwer, J.D. (2010). Cognition and emotion: reviews of current research and theories. New
York, NY: Psychology Press. pp 13, 18

Nock, M.K, Kazdin, A.E., Hirpi, E., & Kessler, R.C. (2007). Lifetime prevalence, correlates, and
persistence of oppositional defiant disorder: results from the National Comorbidity
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10.1111/j.1469-7610.2007.01733.x

ODD – American Academy of Child and Adolescent Psychiatry. (2009). Retrieved July 6, 2017, from www.aacap.org

Pardini, D.A., Frick, P.J., & Moffitt, T. E. (2010). Building an evidence base for DSM-5
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