Oppositional Defiant Disorder and Parent Training

Transcription

1 CHAPTER 46 Oppositional Defiant Disorder and Parent Training Sheila M. Eyberg Kelly A. O Brien Rhea M. Chase WHAT IS OPPOSITIONAL DEFIANT DISORDER? Oppositional defiant disorder (ODD) is one of two disruptive behavior disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994), along with Conduct Disorder (CD). In the DSM-IV, ODD is characterized by frequent disregard for adult authority, and diagnostic criteria require that four of the following eight symptoms persist for at least six months: loses temper, argues with adults, actively defies or refuses to comply with adults requests or rules, deliberately annoys people, blames others for mistakes, is touchy or easily annoyed by others, is often angry or resentful, and is often spiteful or vindictive. In addition, these behaviors must occur more frequently than is typically seen in children of comparable age and developmental level and must cause significant impairment in social, academic, or occupational functioning. BASIC FACTS ABOUT OPPOSITIONAL DEFIANT DISORDER Disruptive behavior disorders are estimated to occur in 2 16% of school-age children, depending on the population sampled and the method of assessment; the rates are somewhat higher in samples of preschoolers (Loeber, Burke, Lahey, Winters, & Zera, 2000). Prevalence rates of ODD fall in late childhood and adolescence, largely due to the age-related increase in CD, which supercedes the diagnosis of ODD if characteristics of both disorders are present. If the CD behaviors are not considered, ODD tends to persist to middle adolescence and becomes more severe with age. Among children between one and eight years of age, no gender differences are found in the prevalence of ODD, although boys with ODD demonstrate higher rates of disruptive behavior than girls (Lumley, McNeil, Herschell, & Bahl, 2002). Onset of ODD is gradual, typically beginning before age eight, and the disorder tends to be chronic without treatment. Children with ODD demonstrate substantial rates of comorbid disorders, including Attention Deficit Hyperactivity Disorder (ADHD), depression, and the anxiety disorders (Maughan, Rowe, Messer, Goodman, & Meltzer, 2004). ETIOLOGICAL FACTORS Genetics Although no research suggests that the development of ODD is purely genetic, multi-rater interview data have revealed modest correlations of ODD and CD symptoms among twins, mothers, and fathers (Eaves, Rutter, Silberg, Maes, & Eyberg, S. M., O Brien, K. A., & Chase, R. M. (2006). Oppositional defiant disorder and parent training. In J. E. Fisher & W. T. O Donohue (Eds.), Practitioner s guide to evidence-based psychotherapy. New York: Springer. 461

2 462 C HAPTER F ORTY-SIX Pickles, 2000). However, it is difficult to separate genetic influences from the influences of both shared and nonshared environments, and much more work in this area is needed. It is critically important to explore genetic factors that might differentially influence the development of ODD versus CD, and particularly the genetic contributions to aggressive versus nonaggressive behaviors (Burke, Loeber, & Birmaher, 2002). Child Temperament Certain early temperamental characteristics, such as negative emotionality, reactive responding, inflexibility, and inhibition, are related to disruptive behaviour disorders later in childhood (Frick & Morris, 2004). The goodness of fit between child temperament and parenting style appears to be key. Problems are more likely to arise when child temperament and parenting style are incompatible on some dimension, such as rhythmicity. For example, if a child s sleeping and eating schedule is difficult to establish, this is more likely to cause problems if the parents are highly regimented. In general, difficult child temperament interacts with the quality of parental discipline to moderate the severity of disruptive behavior (Blackson, Tarter, & Mezzich, 1996). Parenting Behaviors Parenting plays a major role in the development of disruptive behavior disorders. Baumrind (1968) identified three parenting styles permissive, authoritarian, and authoritative and studied their effects on children s development. Authoritative parenting, which involves high parental warmth and firm control, results in the healthiest child outcomes. A low level of warmth combined with harsh disciplinary practices is linked to child disruptive behavior. Patterson (1982) described a coercive cycle of parent child interaction in which the negative behaviors of each partner function to increase the negative behaviors of the other through the process of negative reinforcement. These fundamental principles have served as the theoretical foundation for many treatment programs designed to increase positive parent child interactions and decrease negative disciplinary practices (Brinkmeyer & Eyberg, 2003; Kazdin, 2003). ASSESSMENT What Should be Ruled Out? When diagnosing ODD in children, CD can be a difficult differential diagnosis. Although ODD and CD have been identified as distinct disorders in the DSM-IV, their symptomatology often co-occurs. CD is a more severe disorder than ODD, characterized by violation of social norms along with overt and covert aggression (Frick, Lahey, Loeber, & Tannenbaum, 1993). When ODD occurs with any other mental or physical disorders of childhood, both disorders are diagnosed. What is Involved in Effective Assessment? Few would argue that comprehensive initial assessment of the child with ODD is critical for determining the appropriate course of treatment. To obtain an accurate picture of the child s behavior, multiple informants and methods, including parent interviews, parent and teacher rating scales, and behavioral observation in the clinic and sometimes the school setting as well, are necessary. The integration of these assessment methods allows the clinician to evaluate the frequency, intensity, and duration of the child s behavior problems across settings and from different perspectives. Conducting a formal diagnostic interview with the child s primary

3 ODD AND PARENT T RAINING 463 caregiver, such as the NIMH Diagnostic Interview Schedule for Children Version IV (DISC IV; Shaffer, Fisher, Dulcan, & Davies, 1996) or the Child and Adolescent Psychiatric Assessment (Angold & Costello, 2000) is often a starting point for gathering thorough information on the primary symptoms of ODD and comorbid disorders, which influence the course of treatment. Because a child s disruptive behavior affects and is affected by many environmental factors, parent and teacher questionnaires and rating scales are used to collect information on specific problematic behaviors that vary with different individuals, situations, and task demands. Common measures include the Child Behavior Checklist (CBCL; Achenbach, 1994), the Conners Ratings Scales (Conners, 1997), and the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999). Rating scales can be particularly helpful in determining whether the severity of the child s behavior warrants an actual diagnosis, because they permit comparison of the child s behavior with a normative sample of children of the same age and gender. Measures of parenting stress and tolerance, parenting discipline practices, and parent psychopathology are also important in case conceptualization and treatment planning. Direct observation of the child s behavior and its functional determinants provides particularly important information. Standardized behavioral observation coding systems, such as the Dyadic Parent Child Interaction Coding System (DPICS), have been developed to assess parent child interactions efficiently in the clinic (Eyberg, McDiarmid, Duke, & Boggs, 2004). Information gained from these observations can identify the specific parent behaviors that maintain the child s disruptive behavior and how parents can change the interactions to change the child s problem behaviors. Overall, a comprehensive assessment of ODD requires multiple methods and informants to obtain an accurate picture of the child s presenting problems and the factors that sustain them, which guides treatment planning and outcome evaluation. TREATMENT What Treatments are Effective for ODD? Several effective treatments have been developed for ODD, and treatment gains have been found to generalize across settings and endure after treatment ends. Most of these treatments involve the parents, because parents are best able to identify and modify environmental factors that maintain and exacerbate their child s problem behaviors. Parent training programs share basic behavioral principles that inform positive child management skills. Parents are taught to ignore or punish negative child behaviors and to reward positive child behaviors, particularly those that are incompatible with the negative behaviors. Parents learn to identify child behaviors they wish to change and to apply consequences (rewards or punishment) predictably and consistently. Parents also learn to recognize situations that lead to negative child behaviors and to modify these situations so as to circumvent some problem behaviors entirely. Many parent training programs directly target parent child relationship skills as well as disciplinary techniques. The focus on training parents must always be balanced with recognition of the transactional nature of ODD. It is the interplay of parent and child factors that creates and maintains the dysfunctional interactions characteristic of ODD. Despite bi-directional causal factors, however, the success of treatment relies almost solely on parent compliance and change. It is therefore

4 464 C HAPTER F ORTY-SIX imperative that clinicians develop a strong working alliance with the parent and remain supportive throughout treatment. For younger children, and particularly preschoolers, behavioral parent training approaches are the treatment of choice. For older children with disruptive behavior, effective cognitive-behavioral treatments have been developed as well. It is important to note, however, that most treatment options require family involvement at some level. This reflects the importance of addressing environmental and family variables that affect the development and course of ODD. What are Effective Therapist-based Treatments for ODD? Parent training programs The earliest and most extensively studied program is Patterson s Parent Training model based on the operant principles of behavior change set forth in Living with Children (Patterson & Gullion, 1968). Parents are first introduced to basic social learning principles. They then work with the therapist to identify and monitor specific child behaviors that are most disruptive or frequent. The goal of therapy is to decrease these problem behaviors by ignoring or punishing them each time they occur and rewarding incompatible behaviors. Parents are also counseled on how to work with teachers and implement behavioral interventions in the school setting. This parent training program has evidenced significant reductions in deviant child behavior compared to a wait-list control group (Patterson, Chamberlain, & Reid, 1982). Parent Child interaction therapy (PCIT) is a parenting skills training program that places emphasis on improving the quality of the parent child relationship and changing parent child interaction patterns (Brinkmeyer & Eyberg, 2003; Eyberg, 1988). The parent and child attend treatment together, which allows monitoring and coaching of parenting skills and child behavior changes in vivo. Parents are taught relationship enhancement skill and an effective application of timeout that emphasizes parental consistency. Outcomes include statistically and clinically significant improvements in interaction quality, child disruptive behavior, parenting stress, and confidence in parenting skills when compared to a wait-list control group (Nixon, Sweeny, Erickson, Touyz, 2002; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Webster-Stratton s (1994) Incredible Years is a group parent training program for children with disruptive behavior. Parents learn positive child management practices and stress management techniques by viewing videotaped vignettes, followed by discussion with other parents. The treatment also provides parents with strategies to enhance child social skills. This effective program has been expanded to include a teacher component with a focus on academic and social skills. The added teacher component results in greater reduction in child behavior problems both at school and at home when compared to a control condition (Webster-Stratton, Reid, & Hammond, 2001). Multilevel programs The Triple P-Positive Parenting Program is a multilevel, prevention-oriented program with five levels of increasing strength and various delivery modalities designed to provide the minimally sufficient intervention required (Sanders, 1999). Level 1, the least intensive, is a universal approach providing parenting information and awareness of resources. The next four levels range from brief interventions targeting specific child behavior problems to family interventions targeting multiple problems (e.g., parent depression) in addition to child behavior. Depending on family need, interventions may occur in a number of settings from primary care to the home. In the Level 4 and 5 (clinician-

5 ODD AND PARENT T RAINING 465 assisted) formats of Triple-P, parents report fewer child behavior problems and greater parent competence and satisfaction after treatment than wait-list families (Sanders, Markie-Dadds, Tully & Bor, 2000). The Adolescent Transition Program (ATP) is a multilevel approach that begins within the middle school setting (Dishion & Kavanagh, 2003). ATP involves three levels: (a) a universal level, which provides information to all parents in the school; (b) a level that identifies high-risk families; and (c) a family treatment level. Services range from parenting groups to behavioral family therapy, depending on family need. This proactive and supportive approach within the public school setting has been shown to increase engagement of high-risk families in needed interventions that improve parenting practices and reduce disruptive behavior (Dishion & Kavanagh, 2003). Individual Child Interventions Treatment for ODD ideally involves a parent or caregiver, to address the transactional nature of the disorder and the various environmental contributions to the development and maintenance of problem behavior. Some research examining individual, child-focused interventions has supported a cognitive-behavioral approach for school age children with ODD (Southam-Gerow, 2003). Cognitive Behavioral Therapy (CBT) directly addresses the core symptoms of ODD by providing tangible problem-solving techniques such as self-monitoring, self-evaluation, and self-reinforcement. What are Effective Self-Help Treatments? Several self-help books are available for parents of children with oppositional behavior. Athough few studies have examined the effectiveness of self-help books as stand-alone treatments, the following books for parents are based on sound principles of behavior change and are often used by child therapists as an adjunct to parent training: Clark, L. & Robb, J. (1996). SOS: Help for Parents. Bowling Green, KY: Parents Press. Dishion, T. J. & Patterson, S. G. (1996). Preventive Parenting with Love, Encouragement, and Limits: The Preschool Years. Eugene, IL: Castalia Publishing. Forehand, R. & Long, N. (2002). Parenting the Strong-Willed Child, Revised and Updated Edition: The Clinically Proven Five-Week Program for Parents of Two- to Six-Year- Olds. Chicago, IL: Contemporary Books. Patterson, G.R. (1976). Living with Children: New Methods for Parents and Teachers. Champaign, Illinois: Research Press. Parents and providers are also directed to the following websites for information on treatment options and links to references on ODD: (National Institute of Mental Health) (Society of Clinical Child and Adolescent Psychology; Division 53, American Psychological Association). What is Effective Medical Treatment? The limited research on pharmacological treatments for disruptive behavior disorders has focused on CD, as a means of controlling the aggression and violence associated with the disorder. Stimulants decrease aggression in children with a primary diagnosis of ADHD and may have a similar effect on children with ODD alone (Waslick, Werry, & Greenhill, 1999). Clonidine may also reduce aggression in children with ADHD and comorbid ODD or CD (Connor, Barkley, & Davis, 2000). In general, findings on pharmacotherapy for aggression in children are limited and inconclusive.

6 466 C HAPTER F ORTY-SIX Combination Treatments Evidence suggests that even when medication is found to reduce aggression effectively, children with disruptive behavior benefit most from a combination of medication and behavioral treatment (Burke et al., 2002). Any treatment for ODD should include some level of parent/caregiver involvement to address the environmental contributions to the disorder. How Does One Select Among Treatments? The appropriate treatment for a particular child with ODD depends on many factors assessed in the initial evaluation, including child age, behavior problem severity, and the child s home environment. If medication is considered, it is typically used adjunctively and reserved for severe aggression and violent behavior. Parent training programs can be highly effective, but their effectiveness requires active parent involvement in treatment, and may not be possible if parents have cognitive deficits limiting their ability to learn the necessary skills. Other potential barriers to parent training programs include fees for service and needs for transportation and child care to attend therapy sessions regularly. It is necessary to consider what is feasible for the child and family in terms of cost, time, and parent willingness and ability to change. FUTURE DIRECTIONS Child treatment research on ODD has greatly increased our understanding of treatment options for children with ODD. For some children and families, however, effective options do not yet exist. Both advocacy and research are needed to increase treatment options for many disadvantaged children. Even with existing treatments, little is known about their efficacy for children in ethnic minority groups or for girls (Brestan & Eyberg, 1998). Establishing the efficacy of parent training approaches within diverse demographic groups is an important direction for future study. At the same time, much more specificity in our understanding of treatments for ODD is needed. Most treatment studies of disruptive behavior combine children from different diagnostic groups (e.g., ODD, CD, ADHD) and with diverse comorbid conditions. Optimal treatments for ODD may differ from those for other disruptive behavior disorders and among children with different comorbidities. Few studies have examined the mechanisms by which a treatment reverses the course of ODD. The question originally posed by Paul in 1967 still remains: What treatment, by whom, is most effective for this individual with that specific problem, and under what set of circumstances? (p. 111). This is perhaps the most important of all questions as we work to find the most effective, efficient, and feasible treatment options for each child with ODD. REFERENCES (DOES NOT INCLUDE LIST OF SELF-HELP BOOKS UNLESS OTHERWISE CITED). Achenbach, T. M. (1994). Child Behavior Checklist and related instruments. In: M. E. Maruish (Ed.), Use of psychological testing for treatment planning and outcome assessment. (pp ), Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), Washington, DC: Author. Angold, A., & Costello, E. (2000). The Child and Adolescent Psychiatric Assessment (CAPA). Journal of the American Academy of Child & Adolescent Psychiatry, 39, Baumrind, D. (1968). Authoritarian vs. authoritative parental control. Adolescence, 3,

7 ODD AND PARENT T RAINING 467 Blackson, T. C. Tarter, R. E., & Mezzich, A. C. (1996). Interaction between childhood temperament and parental discipline practices on behavioral adjustment in preadolescent sons of substance abuse and normal fathers. American Journal of Drug & Alcohol Abuse, 22, Brestan, E., & Eyberg, S. M. (1998). Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psychology, 27, Brinkmeyer, M. Y., & Eyberg, S. M. (2003). Parent child interaction therapy for oppositional children. In A. E. Kazdin & J. R. Weisz (Eds.). Evidence-based psychotherapies for children and adolescents (pp ). New York: Guilford. Burke, J. D., Loeber, R. & Birmaher, B. (2002). Oppositional defiant disorder and conduct disorder: A review of the past 10 years, part II. Journal of the American Academy of Child and Adolescent Psychiatry, 41, Conners, C. K. (1997). Conners Rating Scales Revised. Multi-Health Systems Inc.: North Tonawanda, NY. Connor, D. F., Barkley, R. A., & Davis, H. T. (2000). A pilot study of methylphenidate, clonidine, or the combination in ADHD comorbid with aggressive oppositional defiant or conduct disorder. Clinical Pediatrics, 30, Dishion, T. J. & Kavanagh K. (2003). Intervening in adolescent problem behavior: A familycentered approach. New York: Guilford. Eaves, L., Rutter, M., Silberg, J. L., Maes, H., & Pickles, A. (2000). Genetic and environmental causes of covariation in interview assessments of disruptive behavior in child and adolescent twins. Behavior Genetics, 30, Eyberg, S. M. (1988). Parent-child interaction therapy: Integration of traditional and behavioural concerns. Child & Family Behaviour Therapy, 10, Eyberg, S. M., McDiarmid, M. D., & Boggs, S. R. (2004). Manual for the Dyadic Parent Child Interaction Coding System (3rd ed.) Available at Eyberg, S. M., & Pincus, D. (1999). Eyberg Child Behavior Inventory and Sutter-Eyberg Student Behavior Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources. Frick, P. J. & Morris, A. S. (2004). Temperament and developmental pathways to conduct problems. Journal of Clinical Child and Adolescent Psychology, 33, Frick, P., Lahey, B., Loeber, R., & Tannenbaum, L. (1993). Oppositional defiant disorder and conduct disorder: A meta-analytic review of factor analyses and cross-validation in a clinic sample. Clinical Psychology Review, 13, Kazdin, A. E. (2003). Problem-solving skills training and parent management training for conduct disorder. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp ). New York: Guilford. Loeber, R., Burke, J. D., Lahey, B. B., Winters, A., & Zera, M. (2000). Oppositional defiant disorder and conduct disorder: A review of the past 10 years, part I. Journal of the American Academy of Child and Adolescent Psychiatry, 39, Lumley, V. A., McNeil, C. B., Herschell, A. D., & Bahl, A. B. (2002). An examination of gender differences among young children with disruptive behavior disorders. Child Study Journal, 32, Maughn, B., Rowe, R., Messer, J., Goodman, R., & Meltzer, H. (2004). Conduct disorder and oppositional defiant disorder in a national sample: Developmental epidemiology. Journal of Child Psychology and Psychiatry, 45, Nixon, R. D. V., Sweeny, L., Erickson, D. B., & Touyz, S. W. (2003). Parent-child interaction therapy: A comparison of standard and abbreviated treatments for oppositional defiant preschoolers. Journal of Consulting and Clinical Psychology, 71, Patterson, G. R., (1982), Coercive Family Process, Eugen, OR: Castalia. Patterson, G. R., & Guillion, M. E. (1968). Living with children: New methods for parents and children. Research Press: Champaign, IL. Patterson, G., Chamberlain, P., & Reid, J. B. (1982). A comparative evaluation of a parenttraining program. Behavior Therapy, 13, Paul, G. (1967). Outcome research in psychotherapy. Journal of Consulting Psychology, 31, Sanders, M. R. (1999). Triple P -positive parenting program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child & Family Psychology Review, 2, Sanders, M. R., Markie-Dadds, C., Tully, L. A., & Bor, W. (2000). The Triple-P positive parenting program: A comparison of enhanced, standard, and self-directed behavioral family intervention for parents of children with early onset conduct problems. Journal of Consulting & Clinical Psychology, 68, Shaffer, D., Fisher, P., Dulcan, M., & Davies, M. (1996). The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA study. Journal of the American Academy of Child & Adolescent Psychiatry, 35, Schuhmann, E. M., Foote, R. C., Eyberg, S. M., Boggs, S. R., & Algina, J. (1998). Efficacy of parent-child interaction therapy: Interim report of a randomized trial with short-term maintenance. Journal of Clinical Child Psychology, 27,

8 468 C HAPTER F ORTY-SIX Southam-Gerow, M. A. (2003). Child-focused cognitive-behavioral therapies. In C. A. Essau (Ed.), Conduct and oppositional defiant disorders: Epidemiology, risk factors, and treatment (pp ). Mahwah, NJ: Lawrence Erlbaum Associates. Waslick, B, Werry, J. S., & Greenhill, L. L. (1999). Pharmacotherapy and toxicology of oppositional defiant disorder and conduct disorder. In H. C. Quay & A. E. Hogan (Eds.). Handbook of Disruptive Behavior Disorders (pp ). New York: Kluwer Academic/Plenum. Webster-Stratton, C. (1994). Advancing videotape parent training: A comparison study. Journal of Consulting and Clinical Psychology, 66, Webster-Stratton, C., Reid, M. J., & Hammond, M. (2001). Preventing conduct problems, promoting social competence: A parent and teacher training partnership in head start. Journal of Clinical Child Psychology, 30,