Randomized controlled trial of individualized arousal-biofeedback for children and adolescents with disruptive behavior disorders (DBD)

Disruptive behavior disorders [including conduct disorder (CD) and oppositional defiant disorder (ODD)] are common childhood and adolescent psychiatric conditions often linked to altered arousal. The recommended first-line treatment is multi-modal therapy and includes psychosocial and behavioral interventions. Their modest effect sizes along with clinically and biologically heterogeneous phenotypes emphasize the need for innovative personalized treatment targeting impaired functions such as arousal dysregulation. A total of 37 children aged 8-14 years diagnosed with ODD/CD were randomized to 20 sessions of individualized arousal biofeedback using skin conductance levels (SCL-BF) or active treatment as usual (TAU) including psychoeducation and cognitive-behavioral elements. The primary outcome was the change in parents´ ratings of aggressive behavior measured by the Modified Overt Aggression Scale. Secondary outcome measures were subscales from the Child Behavior Checklist, the Inventory of Callous-Unemotional traits, and the Reactive-Proactive Aggression Questionnaire. The SCL-BF treatment was neither superior nor inferior to the active TAU. Both groups showed reduced aggression after treatment with small effects for the primary outcome and large effects for some secondary outcomes. Importantly, successful learning of SCL self-regulation was related to reduced aggression at post-assessment. Individualized SCL-BF was not inferior to active TAU for any treatment outcome with improvements in aggression. Further, participants were on average able to self-regulate their SCL, and those who best learned self-regulation showed the highest clinical improvement, pointing to specificity of SCL-BF regulation for improving aggression. Further studies with larger samples and improved methods, for example by developing BF for mobile use in ecologically more valid settings are warranted.

Long-term cortisol secretion in attention deficit hyperactivity disorder: roles of sex, comorbidity, and symptom presentation

Low activity of the hypothalamic-pituitary-adrenal axis (HPAA) has been found in children with attention deficit hyperactivity disorder (ADHD). The condition may be related to the reduced attention regulation capacity and/or to comorbid oppositional defiant or conduct disorder (ODD/CD). Sex differences are probable but not sufficiently studied. We analyzed the HPAA activity and sympathetic nervous system reactivity (SR) in children with ADHD while accounting for ADHD symptom presentation, comorbidity, and sex differences. The sample comprised 205 children, 98 (61 boys, 37 girls) with ADHD and 107 (48 boys, 59 girls) healthy controls. DSM-5 phenotypic symptom presentation and comorbid ODD/CD were assessed using clinical interviews. Hair cortisol concentration (HCC) was used to assess the long-term, cumulative activity of the HPAA. SR was assessed via skin conductance response (SCR). For control purposes, comorbid internalizing symptoms and indicators of adverse childhood experiences (ACE) were assessed. Children were medication naive. Boys presenting with predominantly inattentive symptoms (ADHD-I) showed lower HCC than healthy boys. Girls presenting with combined symptoms (ADHD-C) showed higher HCC than did healthy girls (p's < 0.05, sex-by-group interaction, F (2,194) = 4.09, p = 0.018). Boys with ADHD plus ODD/CD showed a blunted SR (p < 0.001, sex-by-group interaction, F (2,172) = 3.08, p = 0.048). Adjustment for ACE indicators led to non-significant differences in HCC but did not affect differences in SR. HCC constitutes an easily assessable, reliable, and valid marker of phenotypic ADHD-related features (i.e. symptom presentation and comorbidity). It indicates more homogenous subgroups of ADHD and might point to specifically involved pathophysiological processes.

Recognition and management of children and adolescents with conduct disorder: a real-world data study from four western countries

BACKGROUND

Conduct disorders (CD) are among the most frequent psychiatric disorders in children and adolescents, with an estimated worldwide prevalence in the community of 2-4%. Evidence-based psychological outpatient treatment leads to significant improvement in about two-thirds of cases. However, there seems to be considerable variation in rates of CD diagnoses and implementation of evidence-based interventions between nations. The aim of this study was to compare administrative prevalence and treatment patterns for CD in children and adolescents seen in health care systems across four Western countries (Denmark, Germany, Norway, and the USA).

METHODS

Cross-sectional observational study using healthcare data to identify children and adolescents (aged 0-19 years) with an ICD-10 code for CD within the calendar year 2018. Within each country's study population, the prevalence of CD, psychiatric comorbidity, psychopharmacological treatment, and psychiatric hospitalisation was calculated.

RESULTS

The prevalence of diagnosed CD differed 31-fold between countries: 0.1% (Denmark), 0.3% (Norway), 1.1% (USA) and 3.1% (Germany), with a male/female ratio of 2.0-2.5:1. The rate of psychiatric comorbidity ranged from 69.7 to 86.1%, with attention-deficit/hyperactivity disorder being most common. Between 4.0% (Germany) and 12.2% (USA) of youths with a CD diagnosis were prescribed antipsychotic medication, and 1.2% (Norway) to 12.5% (Germany) underwent psychiatric hospitalisation.

CONCLUSION

Recognition and characteristics of youths diagnosed with CD varied greatly by country. In some countries, the administrative prevalence of diagnosed CD was markedly lower than the average estimated worldwide prevalence. This variation might reflect country-specific differences in CD prevalence, referral thresholds for mental health care, diagnostic tradition, and international variation in service organisation, CD recognition, and availability of treatment offers for youths with CD. The rather high rates of antipsychotic prescription and hospitalisation in some countries are remarkable, due to the lack of evidence for these therapeutic approaches. These findings stress the need of prioritising evidence-based treatment options in CD. Future research should focus on possible reasons for inter-country variation in recognition and management of CD, and also address possible differences in patient-level outcomes.

Executive function in children with disruptive mood dysregulation disorder compared to attention-deficit/hyperactivity disorder and oppositional defiant disorder, and in children with different irritability levels

Addressing current challenges in research on disruptive mood dysregulation disorder (DMDD), this study aims to compare executive function in children with DMDD, children with attention-deficit/hyperactivity disorder (ADHD), and children with oppositional defiant disorder (ODD). We also explore associations between irritability, a key DMDD characteristic, and executive function in a clinical sample regardless of diagnosis. Our sample include children (6-12 years) referred to child psychiatric clinics. Measures of daily-life (parent-reported questionnaire) and performance-based (neuropsychological tasks) executive function were applied. Identifying diagnoses, clinicians administered a standardized semi-structured diagnostic interview with parents. Irritability was assessed by parent-report. First, we compared executive function in DMDD (without ADHD/ODD), ADHD (without DMDD/ODD), ODD (without DMDD/ADHD) and DMDD + ADHD (without ODD). Second, we analyzed associations between executive function and irritability using the total sample. In daily life, children with DMDD showed clinically elevated and significantly worse emotion control scores compared to children with ADHD, and clinically elevated scores on cognitive flexibility compared to norm scores. Children with DMDD had significantly less working memory problems than those with ADHD. No differences were found between DMDD and ODD. Increased irritability was positively associated with emotional dyscontrol and cognitive inflexibility. For performance-based executive function, no diagnostic differences or associations with irritability were observed. We discuss how, in daily life, children with high irritability-levels get overwhelmed by feelings without accompanying regulatory capacities.

Longitudinal relationship between oppositional defiant disorder symptoms and attention-deficit/hyperactivity disorder symptoms in Chinese children: insights from cross-lagged panel network analyses

Oppositional defiant disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD) are two of the most common childhood mental disorders, and they have substantial comorbidity. The developmental precursor model has long been widely used to explain the mechanisms of comorbidity between ODD and ADHD, however whether it is equally effective at the symptomatic level is unclear. Therefore, this study aimed to (a) examine the stability of the ODD and ADHD comorbidity network in a longitudinal sample of high-risk children in China; and (b) examine the longitudinal relationship between the ODD and ADHD symptom networks based on a developmental precursor model. Two hundred sixty-three Chinese children aged 6 to 13 years with ODD and/or ADHD were assessed for symptoms of ODD and ADHD in two surveys conducted 1 year apart. We used data from these two time points to construct two cross-sectional networks and a cross-lagged panel network (CLPN) to explore the symptom network for comorbidity of ODD and ADHD. The analysis shows that: (1) the two cross-sectional networks are highly similar in terms of structure, existence of edges, centrality estimates, and the invariance test shows that there is no significant difference between them. The symptoms "follow through", "interrupts/intrudes", "difficulty playing quietly" and "concentration" had the highest expected influence centrality at both time points. (2) Combined with the results of the cross-sectional and cross-lagged networks, we found that "annoy" and "blame" are potential bridge symptoms between the ODD and ADHD symptom networks. The symptom "annoy" forms a reciprocal predictive relationship with "interrupts/intrudes", while "blame" unidirectionally predicts "close attention". In addition, we found that "vindictive" predicted numerous ADHD symptoms, whereas "angry" was predicted by numerous ADHD symptoms. The findings emphasize the broad predictive relationship between ODD and ADHD symptoms with each other, and that ODD symptoms may lead to activation of the ADHD symptom network and vice versa. These findings suggest that the developmental precursor model at the symptom level may partially explain the comorbidity mechanisms of ODD and ADHD, and future studies should further investigate the underlying multiple mechanisms.

Interpersonal Competence: A Mediator Between ODD Problems and Parent-Child Relationship Discord

A central requirement of Oppositional Defiant Disorder (ODD) consists of difficulties with interpersonal relationships. As emerging adults' transition into adulthood and seek more autonomy from parents, it is important to examine how ODD problems and parent-child discord are indirectly associated through interpersonal competencies. The current study examined the indirect effects between ODD problems in emerging adults and parent-child discord through multiple interpersonal competencies as well as the additional differences among parent-child gender dyads. Emerging adults (N = 599 individuals aged 18 to 25 years; M = 19.60, SD = 1.40; 68% females) were recruited via an online research platform and completed online survey measures of ODD problems, parent-child relationship discord, and interpersonal competence. Indirect effects were significant for the mother-daughter dyad only. Additional results, limitations, and implications are discussed.

Is internet-based parent training for everyone? Predictors and moderators of outcomes in group vs. internet-based parent training for children with disruptive behavior problems

Parent training is an effective treatment for disruptive behavior problems in children. However, as there is limited access to traditional face-to-face treatment, other delivery formats have been evaluated. This study aims to evaluate possible predictors and moderators of outcome, completion and engagement in parent training when delivered in group or through the internet. A recent randomized controlled non-inferiority trial (N = 161) demonstrated equal effectiveness of the parent training program Comet when delivered in group (gComet) and through the internet (iComet). Demographic, clinical and theory-driven variables were studied to find predictors and moderators of treatment effect, completion and engagement. Linear mixed effects models were used to determine predictors and moderators of change in disruptive behavior from baseline to the 3- and 12-month follow-up. Most variables did not have significant predictive or moderating effects. However, there were some variables that predicted or moderated outcomes that may have implications for practice (e.g., comorbid emotional problems, preferred treatment format, and ADHD). This trial can contribute to guiding clinical work with children with disruptive behavior and results indicate that parent training in both treatment formats can be offered regardless of a range of demographic and clinical factors. Taking patients' treatment preferences into account can increase treatment completion.

Pragmatic language and associations with externalizing behaviors in autistic individuals and those who have lost the autism diagnosis

Background

Pragmatic language weaknesses, a core feature of autism spectrum disorder (ASD), are implicated in externalizing behavior disorders (Gremillion & Martel, 2014). Particularly in a clinical setting, these co-occurring externalizing disorders are very common in autism; rates of Attentional Deficit-Hyperactive Disorder (ADHD) and Oppositional Defiant Disorder (ODD) are as high as 83% (ADHD) and 73% (ODD; Joshi et al., 2010). It is possible that pragmatic language weaknesses impact the ability to effectively communicate one's needs, which may lead autistic children to utilize externalizing behaviors in order to achieve a desired outcome (Ketelaars et al., 2010; Rodas et al., 2017).

Methods

The aim of the current study is to investigate the relationship between pragmatic language, assessed via multiple modalities, and externalizing behaviors, assessed by parent interview, in youth with autistic (n=33) or neurotypical (NT; n=34) developmental histories, along with youth diagnosed with autism, who lost the diagnosis (LAD) by adolescence (n=31).

Results

The autism group had significantly more pragmatic language difficulties, and more externalizing behaviors and disorders; ADHD symptoms were particularly more prevalent, while LAD and NT groups did not differ. Challenges in pragmatic language abilities were associated with more externalizing symptoms when controlling for other facts that typically influence such symptoms, including nonverbal cognition, structural language, executive functioning, and autistic characteristics, but did not remain when age was included in the model.

Conclusions

We discuss the mechanisms underlying difficult-to-manage externalizing behaviors and implications for interventions and long-term outcomes for youth with and without a history of autism.

Impact of Comorbid Oppositional Defiant Disorder on the Clinical and Neuropsychological Characteristics of Korean Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

The aim of the present study was to investigate the influence of comorbid oppositional defiant disorder (ODD) on clinical features and neuropsychological profiles of children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

We divided the participants into three groups: the ADHD with ODD (ADHD/ODD) (n=36), ADHD without ODD (ADHD/noODD) (n=307), and control groups (n=128). Parents of the participants completed the ADHD Rating Scale, Social Responsiveness Scale (SRS), Korean Personality Rating Scale for Children (K-PRC), and 10-item mania scale from the Parent General Behavior Inventory (P-GBI-10M). Neuropsychological profiles were assessed using the Advanced Test of Attention (ATA), Children's Color Trails Test, and Stroop Color and Word Test.

RESULTS

The ADHD/ODD group had more ADHD symptoms and functional impairments in relationships with teachers and peers, and self-esteem than the ADHD/noODD group. The ADHD/ODD group scored higher in Social Communication (p<0.001) and Autistic Mannerisms (p<0.001) subscales of SRS, P-GBI-10M (p<0.001), and Delinquency (p<0.001) and Psychosis (p<0.001) subscales of K-PRC than the ADHD/noODD group. Commission Errors (p<0.001) and Response-Time Variability (p<0.001) in Visual ATA and Commission Errors (p<0.001) in Auditory ATA were significantly higher in the ADHD/ODD group than in the ADHD/noODD group.

CONCLUSION

The present study suggests that patients with ADHD with ODD experience more ADHD symptoms and neuropsychological deficits than those with ADHD without ODD. These results also imply that comorbid ODD is associated with greater social impairment and emotional dysregulation.

Stability of the effects of a social competence training program for children with oppositional defiant disorder/conduct disorder: a 10-month follow-up

The stability and effectiveness of the Treatment Program for Children with Aggressive Behavior (THAV) in terms of reducing behavioral problems in children with oppositional defiant disorder (ODD) and conduct disorder (CD) were examined at a 10-month follow-up (FU). A total of 76 families and their children (boys aged 6-12 years), who previously participated in a randomized controlled trial comparing THAV with an active control group, took part in the 10-month FU assessment. Outcome measures were rated by parents and included the evaluation of child aggressive behavior, prosocial behavior, problem-maintaining and problem-moderating factors, and comorbid symptoms. Linear mixed models for repeated measures (MMRM) were conducted. The results revealed that THAV effects remained stable (problem-maintaining and problem-moderating factors; comorbid symptoms) and even partially improved (aggressive behavior; ADHD symptoms) over the FU period. Additionally, the differences between the THAV intervention group and the control group, which were apparent at the end of the treatment (post), mainly also remained at the FU assessment. It can be concluded that THAV is an effective and stable intervention for boys aged 6-12 years with ODD/CD.

Negative Parenting Mediates the Longitudinal Association between Parental Internalizing Symptoms and Child Oppositional Symptoms

Research has pointed to both cross-sectional and longitudinal associations between parental internalizing symptoms and child externalizing symptoms. This study analyzed whether the association is mediated by negative parenting behavior in view of previous reports that both parental internalizing symptoms and child externalizing symptoms are related to parenting behaviors. Longitudinal data for the current analyses were derived from a randomized controlled trial on the efficacy of a web-assisted self-help intervention for parents of children with elevated levels of externalizing symptoms. Two different mediation models were analyzed, one using attention-deficit/hyperactivity disorder (ADHD) symptoms as the dependent variable and the other using oppositional defiant disorder (ODD) symptoms. Both models included parental internalizing symptoms as the independent variable, negative parenting behavior as a mediator, and study condition as a confounder. The longitudinal analyses support the mediating role of negative parenting behavior in the association between early parental internalizing symptoms and later child ODD symptoms.

Comorbid Psychiatric Symptom Associated With Oppositional Defiant Symptom in Community School-Age Children

Objectives

Oppositional defiant disorder (ODD) is often comorbid with other psychiatric disorders in childhood. This study aimed to investigate comorbid psychiatric symptoms and associated factors in elementary school children with symptoms of ODD.

Methods

The participants consisted of 205 mother-offspring pairs. Psychiatric symptoms were measured using the Diagnostic Predictive Scales and Korean Child Behavior Checklist. Psychiatric comorbid symptoms were compared between children with ODD symptom and those without ODD symptom. Multivariate logistic regression analysis was used to estimate the odds ratio of psychiatric symptom on ODD.

Results

ODD group had a significant association with internalizing and externalizing problem (p=0.001, p<0.001, respectively). ODD group were more comorbid with anxiety disorder, depressive disorder, attention-deficit/hyperactivity disorder, and conduct disorder. Among psychiatric disorder, generalized anxiety disorder (GAD) (adjusted odds ratio [AOR]=18.620, p<0.001) and conduct disorder (AOR=9.529, p=0.014) were associated with ODD symptom.

Conclusion

These findings suggest that children with ODD symptom had significantly higher rates of comorbid psychiatric symptoms. And GAD and conduct disorder are related to ODD symptom.

Oppositional Defiant Disorder Symptoms and Multi-level Family Factors in Chinese Migrant Children: A Network Perspective

Based on the network theory of mental disorders, this study used network analysis to examine the network of ODD symptoms and multilevel family factors and identify the most crucial family factors influencing ODD symptoms in children. A total of 718 Chinese migrant children aged 7-14 years participated in this study. This study measured ODD symptoms, family system-level variables (3 factors), family dyadic-level variables (6 factors), and family individual-level variables (6 factors) with factors selected based on the multilevel family factors theory of ODD symptoms. The results indicated that (1) "annoy" was the center symptom of ODD, (2) "annoy" and "vindictive" was the main bridge connecting the multilevel family factors, and (3) family cohesion at the family system level, parent-child conflict at the family dyadic level, and parental depression at the family individual level were critical central and bridging influencing factors. The findings of this study highlight the critical role of "annoy" and "vindictive" symptoms in the activation of ODD symptom networks in children and provide a basis for future improvements in diagnostic criteria. These potential core and bridge factors might become key intervention targets for childhood ODD.

The Post-intervention Impact of Amaka Amasanyufu on Behavioral and Mental Health Functioning of Children and Adolescents in Low-Resource Communities in Uganda: Analysis of a Cluster-Randomized Trial From the SMART Africa-Uganda Study (2016-2022)

PURPOSE

Disruptive behavioral disorders (DBDs) are common among children/adolescents in sub-Saharan Africa. A 16-week manualized multiple family group (MFG) intervention called Amaka Amasanyufu designed to reduce DBDs among school-going children/adolescents in low-resource communities in Uganda was efficacious in reducing symptoms of poor mental health relative to usual care in the short-term (4 months post-intervention-initiation). We examined whether intervention effects are sustained 6 months postintervention.

METHODS

We used longitudinal data from 636 children positive for DBDs: (1) Control condition, 10 schools, n = 243; (2) MFG delivered via parent peers (MFG-PP), eight schools, n = 194 and; (3) MFG delivered via community healthcare workers (MFG-CHW), eight schools, n = 199 from the SMART Africa-Uganda study (2016-2022). All participants were blinded. We estimated three-level linear mixed-effects models and pairwise comparisons at 6 months postintervention and time-within-group effects to evaluate the impact on Oppositional Defiant Disorder (ODD), impaired functioning, depressive symptoms, and self-concept.

RESULTS

At 6 months postintervention, children in MFG-PP and MFG-CHW groups had significantly lower means for ODD (mean difference [MD] = -1.08 and -1.35) impaired functioning (MD = -1.19 and -1.16), and depressive symptoms (MD = -1.06 and -0.83), than controls and higher means for self-concept (MD = 3.81 and 5.14). Most outcomes improved at 6 months compared to baseline. There were no differences between the two intervention groups.

DISCUSSION

The Amaka Amasanyufu intervention had sustained effects in reducing ODD, impaired functioning, and depressive symptoms and improving self-concept relative to usual care at 6 months postintervention. Our findings strengthen the evidence that the intervention effectively reduces DBDs and impaired functioning among young people in resource-limited settings and was sustained over time.

Unidirectional or Bidirectional? Relation between Parental Responsiveness and Emotion Regulation in Children with and without Oppositional Defiant Disorder

Parenting is crucial for emotion regulation in children. Much less is known, however, concerning the association between parenting and emotion regulation in children with oppositional defiant disorder (ODD), who are known to have poor emotion regulation. The current study aimed to examine how parental responsiveness and child emotion regulation related either unidirectionally or bidirectionally to one another over time and to investigate whether the associations were different in ODD and non-ODD groups. Data were collected each year for three consecutive years from a sample of 256 parents of children with ODD and 265 parents of children without ODD in China. The results from the random intercepts cross-lagged panel model (RI-CLPM) suggested that the directionality of the link between parental responsiveness and child emotion regulation differs according to ODD status. The non-ODD group demonstrated a unidirectional link between early emotion regulation and subsequent parental responsiveness, consistent with the "child effect". However, in the ODD group, the link between parental responsiveness and emotion regulation was transactional, in line with social coercion theory. Multiple-group comparisons found that increased parental responsiveness was more strongly associated with improved child emotion regulation in the ODD group only. The research established a dynamic and longitudinal relationship between parental responsiveness and emotion regulation and suggested that intensive interventions should aim to improve parental responsiveness to children with ODD.

Vicious cycle of emotion regulation and ODD symptoms among Chinese school-age children with ODD: a random intercept cross-lagged panel model

A strong link between children's emotion regulation and oppositional defiant disorder (ODD) symptoms has been documented; however, the within-person mechanisms remain unclear. Based on the self-control theory and self-regulation theory, our study investigated the longitudinal, bidirectional relationship between emotion regulation and ODD symptoms in school-age children with ODD using parent- and teacher-reported data, respectively. A total of 256 Chinese elementary school students participated in a three-wave longitudinal study spanning two years. We used the random intercept cross-lagged panel model (RI-CLPM) to investigate the concurrent and longitudinal associations between emotion regulation and ODD symptoms. Results from the RI-CLPMs revealed that ODD symptoms were negatively correlated with emotion regulation and positively correlated with emotion lability/negativity at both the between-person and within-person levels across settings. Additionally, in the school setting, emotion regulation negatively predicted subsequent ODD symptoms but not vice versa, whereas emotion lability/negativity was bidirectionally associated with ODD symptoms over time. The longitudinal associations of ODD symptoms with emotion regulation and lability/negativity were not observed in the home setting. These findings suggest a circular mechanism between children's emotion regulation and ODD symptoms and support the view that emotion regulation, particularly emotion lability/negativity, plays an important role in the development of ODD symptoms.

Behavioural and nondirective parent training for children with externalising disorders: First steps towards personalised treatment recommendations

For children with externalising disorders, parent training programmes with different theoretical foundations are available. Currently, there is little knowledge concerning which programme should be recommended to a family based on their individual needs (e.g., single parenthood). The personalised advantage index (PAI) indicates the predicted treatment advantage of one treatment over another. The aim of the present study was to examine the usefulness of this score in providing individualised treatment recommendations. The analysis considered 110 parents (per-protocol sample) of children (4-11 years) with attention-deficit/hyperactivity (ADHD) or oppositional defiant disorder (ODD), randomised to either a behavioural or a nondirective telephone-assisted self-help parent training. In multiple moderator analyses with four different regression algorithms (linear, ridge, k-nearest neighbors, and tree), the linear model was preferred for computing the PAI. For ODD, families randomised to their PAI-predicted optimal intervention showed a treatment advantage of d = 0.54, 95% CI [0.17, 0.97]; for ADHD, the advantage was negligible at d = 0.35, 95% CI [-0.01, 0.78]. For children with conduct problems, it may be helpful if the PAI includes the treatment moderators single parent status and ODD baseline symptoms when providing personalised treatment recommendations for the selection of behavioural versus nondirective parent training. TRIAL REGISTRATION: The study was registered prospectively with ClinicalTrials.gov (Identifier NCT01350986).

The computational psychiatry of antisocial behaviour and psychopathy

Antisocial behaviours such as disobedience, lying, stealing, destruction of property, and aggression towards others are common to multiple disorders of childhood and adulthood, including conduct disorder, oppositional defiant disorder, psychopathy, and antisocial personality disorder. These disorders have a significant negative impact for individuals and for society, but whether they represent clinically different phenomena, or simply different approaches to diagnosing the same underlying psychopathology is highly debated. Computational psychiatry, with its dual focus on identifying different classes of disorder and health (data-driven) and latent cognitive and neurobiological mechanisms (theory-driven), is well placed to address these questions. The elucidation of mechanisms that might characterise latent processes across different disorders of antisocial behaviour can also provide important advances. In this review, we critically discuss the contribution of computational research to our understanding of various antisocial behaviour disorders, and highlight suggestions for how computational psychiatry can address important clinical and scientific questions about these disorders in the future.

Systematic Review of Environmental and Psychosocial Risk Factors associated with Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder in Children and Adolescents

Background

In the majority of cases, attention deficit hyperactivity disorder (ADHD) is accompanied by one or more comorbid disorders, with the oppositional defiant disorder (ODD) being one of the most frequently diagnosed comorbid disorders. There is a lack of systematic reviews addressing the evidence for an association between the independent environmental and psychosocial risk factors associated with ADHD, ODD, and Conduct Disorder (CD).

Objective

This study aims to determine the link between ADHD and ODD/CD, specifically in terms of the most up-to-date environmental and psychosocial risk factors in the development of these illnesses.

Results

Eleven studies were included in this systematic review. Among these, ten studies involved environmental risk factors, and only one involved socioeconomic risk factors as exposure. Of the ten studies highlighting the environmental risk factors, six studies reported perinatal risk factors, three reported Atopic diseases as exposure measures, and one involved exposure to energy and coffee drinks. We have found that the most common risk factors associated with ADHD, ODD and CD in Europe and North America were Perinatal risk factors. In contrast, the risk factors of Atopic diseases were more common in Asia.

Conclusions

Most of the studies included in our systematic review fall within the scope of environmental risk factors were perinatal risk factors and atopic diseases are the most common risk factors. However, only one article highlighted the association of socioeconomic risk factors as an exposure. Our review results suggest the need for more research focused on psychosocial risk factors for ADHD and comorbid ODD/CD. Further research is required with the primary objective of investigating this association in greater depth and examining the possible mechanisms at varying levels is needed.

Online Parent Training for The Initial Management of ADHD referrals (OPTIMA): the protocol for a randomised controlled trial of a digital parenting intervention implemented to support parents and children on a treatment waitlist

BACKGROUND

Children referred for attention-deficit/hyperactivity disorder (ADHD) often present with a broader pattern of conduct problems including oppositionality and defiance. This combination can be extremely stressful to parents, lower parents' self-esteem and negatively impact family life. The National Institute for Health and Care Excellence (NICE) recommends that families receive support as soon as possible after their referral. However, as clinical services are overstretched, and traditional in-person parenting intervention programmes are expensive, families often must wait times a long time prior to receiving this vital input. To address this, we have created a digital parenting programme called STEPS. It is delivered as a mobile phone app providing a set of tools and resources that can be easily accessed at parents' convenience. This study aims to evaluate the clinical and cost-effectiveness of STEPS in supporting parents of children with high levels of hyperactivity/impulsivity, inattention and conduct problems, who are waiting to be assessed by specialist children's clinical services.

METHODS

Online Parent Training for The Initial Management of ADHD referrals (OPTIMA) is a two-arm superiority parallel randomised controlled trial with an internal pilot study. We aim to recruit 352 parents and their children, who have been accepted onto a waitlist in Child and Adolescent Mental Health Services or similar child health services. Parents who consent will be randomised 1:1 to either the STEPS or wait-as-usual (WAU) group. The trial will be conducted remotely (online and telephone) with measures taken at baseline and 3, 6, 9 and 12 months post-randomisation. The primary objective is to evaluate whether STEPS reduces the severity of children's oppositional and defiant behaviour, as rated by parents, measured at 3 months post-randomisation compared to WAU.

DISCUSSION

Digital solutions, such as mobile phone apps, have potential for delivering psychological support for parents of children with clinical-level needs in a timely and inexpensive manner. This trial will provide data on the clinical and cost-effectiveness of the STEPS app, which could support the implementation of this scalable parenting intervention programme into standard clinical care and, ultimately, improve the outcomes for families of children referred to specialist child and adolescent health services.

TRIAL REGISTRATION

ISRCTN 16523503. Prospectively registered on 18 November 2021. https://www.isrctn.com/ISRCTN16523503.

Dimensionality of Oppositional Defiant Disorder Symptoms Across Elementary-School Grades

Various models of the dimensionality of behaviors associated with Oppositional Defiant Disorder (ODD) have been proposed or reported. Many of these models describe ODD-related behaviors in either two- or three-factor models. The purpose of the study was to determine which of the models of ODD-related behaviors demonstrated the best fit using teacher report of 15,521 children across eight grade levels and to examine measurement invariance of the model across grades. Confirmatory factor analyses were conducted to determine which of the models demonstrated best fit of teacher-reported ODD-related behaviors across eight grades. A two-factor model from a preliminary analysis of a subset of the current data demonstrated a better model fit than any of the existing six models examined and demonstrated measurement invariance across all grades. Across all of the models, affective and behavioral symptoms loaded onto separate factors, which may be an important consideration to inform future clinical and empirical work.

The importance of familial risk factors in children with ADHD: direct and indirect effects of family adversity, parental psychopathology and parenting practices on externalizing symptoms

BACKGROUND

Children experiencing unfavorable family circumstances have an increased risk of developing externalizing symptoms. The present study examines the direct, indirect and total effects of family adversity, parental psychopathology, and positive and negative parenting practices on symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in children with ADHD.

METHODS

Data from 555 children (M = 8.9 years old, 80.5% boys) who participated in a multicenter study on the treatment of ADHD (ESCAschool) were analyzed using structural equation modeling (SEM).

RESULTS

The SEM analyses revealed that (a) family adversity and parental psychopathology are associated with both child ADHD and ODD symptoms while negative parenting practices are only related to child ODD symptoms; (b) family adversity is only indirectly associated with child ADHD and ODD symptoms, via parental psychopathology and negative parenting practices; (c) the detrimental effect of negative parenting practices on child ADHD and ODD symptoms is stronger in girls than in boys (multi-sample SEM); (d) there are no significant associations between positive parenting practices and child ADHD or ODD symptoms.

CONCLUSIONS

Family adversity, parental psychopathology, and negative parenting practices should be routinely assessed by clinicians and considered in treatment planning. Trial registration (18th December 2015): German Clinical Trials Register (DRKS) DRKS00008973.

Low serum allopregnanolone levels in children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) has increasing evidence for the role of neurohormones in its etiopathogenesis. It has been suggested that the effects of neurosteroids on the brain in the early developmental period may predispose to neurodevelopmental pathologies. In our study, we examined serum dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), and allopregnanolone levels in children with ADHD and whether these neurosteroids differ in the presence of specific learning disorder (SLD) and oppositional defiant disorder (ODD) comorbidities (ADHD+SLD and ADHD+ODD). We also investigated the relationship between neurosteroid levels and the severity of ADHD symptoms. Thirty-five prepubertal children with ADHD and 33 prepubertal healthy children, all aged 6-10 years, were included in this study. The severity of ADHD symptoms was assessed with the parent-rated and teacher-rated Turgay DSM-IV Disruptive Behavior Disorders Rating Scale (T-DSM-IV-S). Serum allopregnanolone levels were significantly lower in the ADHD group compared to healthy controls. When analyzed according to comorbidity status, serum allopregnanolone levels were lower in ADHD+SLD and ADHD+ODD groups compared to healthy controls. However, when compared to healthy children, serum DHEA and DHEA-S levels in children with ADHD were not significantly different. Serum allopregnanolone levels were negatively associated with teacher-rated T-DSM-IV-S hyperactivity/impulsivity scores for all participants only. These findings suggest that allopregnanolone may play a role in the pathophysiology of ADHD, especially in the presence of ODD and SLD comorbidities.

Longitudinal Associations between Parental Warmth, Harsh Discipline, Child Emotion Regulation, and ODD Dimensions

Research has yet to investigate the mediating role of emotion regulation in the relation between parental warmth and harsh discipline with oppositional defiant disorder (ODD). Further, few studies have investigated ODD as both a unitary construct and as three distinct dimensions (anger, defiance, spitefulness). Thus, the present study aimed to investigate child emotion regulation (grade 2) as a mediator of the relation between parental warmth and harsh discipline (kindergarten, grade 1, grade 2) and ODD and its dimensions (grade 3). Participants included the high-risk and normative samples from the Fast Track project (N = 753, male = 58 %, Black = 46 %). Constructs were assessed using observation and parent and teacher reports. Although results demonstrated an absence of indirect effects, emotion regulation was negatively associated with overall ODD and anger and defiance, but not spitefulness. Findings illustrate how increased attention toward the study of ODD as distinct dimensions contributes to our ability to parse out heterogeneity among children with the disorder.

The conduct and oppositional defiant disorder scales (CODDS) for disruptive behaviour disorders

This study evaluates the clinical validity of a five-minute instrument, the Conduct and Oppositional Defiant Disorder Scales (CODDS), for assessing oppositional defiant disorder (ODD) and conduct disorder (CD). Children (N = 428) aged 11-12 years and their caregiver were administered the NIMH DISC-IV (Diagnostic Interview Schedule for Children), the CODDS, and validity measures. A second sample (N = 671) was utilized to develop a brief measure of limited prosocial emotions based on DSM 5. Receiver operating characteristic (ROC) curves documented good sensitivity and specificity for CODDS scales in predicting DISC-IV clinical diagnoses of ODD (85%, 72% respectively) and CD (85%, 88%) diagnoses. Baseline CODDS provided added value over and above baseline clinical DISC- diagnoses in predicting future DISC ODD and CD diagnoses 12 months later, as well as in predicting social and school functioning. Study 2 further established psychometric properties of the CODDS, with brief measures of CODDS limited prosocial emotions (LPE) having a good fit to the hypothesized DSM 5 four-factor structure of LPE. Findings indicates that the CODDS has utility as a five-minute proxy for diagnoses of ODD and CD in clinical research and potentially practice where time and resources are limited.

Debate: Oppositional defiant disorder is a real disorder

Oppositional defiant disorder (ODD) is a valid mental health disorder, characterized by negativistic defiant behavior and angry, irritable mood. The very low and stable prevalence rate over development from early childhood into adulthood suggests that ODD does not erroneously medicalize normative childhood behavior. ODD is associated with significant impairments across multiple contexts and raises risks for other future psychopathology. Although simplistic tropes often suggest that ODD is merely the product of bad parenting, substantial evidence shows that it is instead influenced by a variety of factors, including genetic and neurobiological factors. Individuals with ODD evoke negative interactions with peers, teachers, coworkers, romantic partners, and parents. ODD is often misunderstood as being a mild form of conduct disorder (CD). Rather, in stark contrast to ODD, CD reflects a pattern of aggressive behaviors, violations of laws or status offenses, and psychopathic features. Mounting evidence for their distinction led to diagnostic changes distinguishing ODD and CD nearly a decade ago. Empirically supported treatments are available and help caregivers to develop specific parenting practices to meet the needs of children with ODD. Minimizing and mischaracterizing ODD increases the likelihood that families who are suffering may not seek the treatment that they need.

Family-level correlates of disruptive behavior challenges among children in Southwestern Uganda

Introduction

This exploratory study sought to examine the extent to which family-level factors are associated with disruptive behavioral disorder (DBD) symptoms, including oppositional defiant disorder (ODD) and conduct disorder (CD) among school children in Uganda, a low-resource country in SSA. The examination of key influences within the SSA context is important to guide needed investments in mental health care and family-level support. Importantly, identifying families at higher risk can inform the development of contextualized family interventions that reinforce positive parenting practices.

Method

We analyzed baseline data (N = 2110) from the NIH-funded Strengthening Mental health And Research Training in Africa (SMART Africa) scale-up study in Southwestern Uganda. Children aged 8-13 and their caregivers were recruited from 30 public primary schools. DBDs were examined using the DBD rating scale, Iowa Conners, and Impairment scales. Logistic regression analysis using cluster adjusted robust standard errors to adjust for within-school clustering was conducted to assess the association between DBD symptoms and family-level factors, including parenting practices, marital status, and family size.

Results

Results indicate that poor parental supervision (OR = 1.17; CI: 1.13, 1.21; P <.001), divorced families (OR = 1.33; CI: 1.03, 1.72; P <.05), and widowed families (OR = 1.48; CI: 1.10, 2.00; P <.01) were associated with higher DBD symptoms among children. On the other hand, caregiver age (OR = 0.99; CI: 0.98, 0.99; P <.01) was associated with lower DBD symptoms among children. Moreover, caregiver employment and parental education were not statistically significant in the model.

Conclusion

Findings from the study reveal an association between family-level factors and behavioral difficulties among children in Uganda suggesting that divorced and widowed families may benefit from additional support in caring for children. Moreover, caregivers may also benefit from programs that provide tools for effective parental supervision.

Association between oppositional defiant disorder and parenting style in children with attention deficit hyperactivity disorder

OBJECTIVES

To study the association between oppositional defiant disorder (ODD) and parenting style in children with attention deficit hyperactivity disorder (ADHD).

METHODS

A case-control study was performed on 482 children with ADHD, among whom 322 did not have ODD (simple ADHD group) and 160 had ODD (ADHD+ODD group). General demographic data and the Parenting Style Scale assessment scores were collected from the two groups. A multivariate logistic regression analysis was used to identify the association between parenting style and ODD in children with ADHD.

RESULTS

There was no significant difference in parenting style scores (including rejection factor, emotional warmth factor, overprotection factor, and preference factor) and general demographic data between the simple ADHD and ADHD+ODD groups (P>0.05). Among the children with the predominantly inattentive type of ADHD, the older the child or the lower the father's educational level, the higher the risk of ODD (P<0.05), while there was no significant association between parenting style and the development of ODD (P>0.05).

CONCLUSIONS

Parenting style is not significantly associated with the development of ODD in children with ADHD. In clinical practice, it is necessary to eliminate the stereotype that the parents of children with ADHD and comorbid ODD have a poor parenting style and look for the causes of development of ODD from multiple perspectives, so as to provide reasonable intervention recommendations.

Generalized structural equation modeling: Symptom heterogeneity in attention-deficit/hyperactivity disorder leading to poor treatment efficacy

BACKGROUND

Treatment efficacy for attention-deficit/hyperactivity disorder (ADHD) is reported to be poor, possibly due to heterogeneity of ADHD symptoms. Little is known about poor treatment efficacy owing to ADHD heterogeneity.

AIM

To use generalized structural equation modeling (GSEM) to show how the heterogeneous nature of hyperactivity/impulsivity (H/I) symptoms in ADHD, irritable oppositional defiant disorder (ODD), and the presentation of aggression in children interferes with treatment responses in ADHD.

METHODS

A total of 231 children and adolescents completed ADHD inattention and H/I tests. ODD scores from the Swanson, Nolan, and Pelham, version IV scale were obtained. The child behavior checklist (CBCL) and parent’s satisfaction questionnaire were completed. The relationships were analyzed by GSEM.

RESULTS

GSEM revealed that the chance of ADHD remission was lower in children with a combination of H/I symptoms of ADHD, ODD symptoms, and childhood aggressive behavior. ODD directly mediated ADHD symptom severity. The chance of reaching remission based on H/I symptoms of ADHD was reduced by 13.494% [= exp (2.602)] in children with comorbid ADHD and ODD [odds ratio (OR) = 2.602, 95% confidence interval (CI): 1.832-3.373, P = 0.000] after adjusting for the effects of other factors. Childhood aggression mediated ODD symptom severity. The chance of reaching remission based on ODD symptoms was lowered by 11.000% [= 1 - exp (-0.117)] in children with more severe baseline symptoms of aggression based on the CBCL score at study entry [OR = -0.117, 95%CI: (-0.190)-(-0.044), P = 0.002].

CONCLUSION

Mediation through ODD symptoms and aggression may influence treatment effects in ADHD after adjusting for the effects of baseline ADHD symptom severity. More attention could be directed to the early recognition of risks leading to ineffective ADHD treatment, e.g., symptoms of ODD and the presentation of aggressive or delinquent behaviors and thought problems in children with ADHD.

Where Should Psychopathic Traits Be Placed in a Diagnostic Framework? Evidence for a Grandiose-Manipulative Specifier for ODD

Youth exhibiting psychopathic traits are at increased risk for a more severe, persisting, and treatment-resistant course of antisocial behavior. To reflect this diagnostically, the specifier with limited prosocial emotions (LPE) was added to the criteria for conduct disorder (CD). Yet, psychopathic traits often show an earlier onset than CD symptoms and LPE may exclude important dimensions of psychopathy. This study examines grandiose-manipulative (GM) traits both dimensionally and as a diagnostic specifier for behavioral disorders.Data come from a clinic sample of 177 boys aged 7-12 followed up annually through age 17. Annual parent reports of children's GM, and symptoms of CD, oppositional defiant disorder (ODD), and attention-deficit/hyperactivity disorder (ADHD) were tested, controlling for other psychopathology and demographics. A categorical GM specifier for ODD or ADHD was also tested as a predictor of CD or ODD diagnosis.GM and ODD were significantly predictive of increases in CD. Reciprocal associations were observed between GM and ODD symptoms. The GM specifier was most commonly associated with ODD (91.9%), compared to CD (44.1%) or ADHD (67.1%), and was significantly predictive of future CD when applied to ODD. GM as a specifier for ADHD enhanced the prediction from ADHD to ODD, but not to CD. Including GM as a specifier for disorders beyond CD improves the prediction of future behavioral disorders, distinguishing youth with ODD at risk for CD, and youth with ADHD at risk for ODD. Failing to do so may miss a substantial portion of elevated GM.

Parenting practices moderate the link between attention to the eyes and callous unemotional traits in children with Disruptive Behavior Disorder: An eye-tracking study

Callous-unemotional (CU) traits are associated with gaze pattern deficits in youths, though it has not yet been explored if environmental factors could influence this relationship. Since parenting can influence both CU traits and children's emotion processing, the current study sought to test whether parenting moderated the relation between gaze pattern deficits and CU traits in a sample of children with Disruptive Behavior Disorder. The sample included 92 boys (aged 7-12 years) with Conduct Disorder (N = 12) and Oppositional Defiant Disorder (N = 80). All children completed a task, during which they were presented with 24 images depicting happy, sad, fearful, disgusted, angry, and neutral facial expressions. Gaze pattern has been recorded throughout the task with an eye-tracker. Positive parenting moderated the association between CU traits and first fixation duration to the eyes of facial expressions depicting negative emotions. Negative parenting moderated the association between CU traits and fixation count and fixation duration to the eyes of negative emotions. Negative parenting along with reduced attention to emotional cues (i.e., eyes) may identify a group of youths with Disruptive Behavior Disorder diagnosis at risk for severe outcomes.

Parent Management Training Combined with Group-CBT Compared to Parent Management Training Only for Oppositional Defiant Disorder Symptoms: 2-Year Follow-Up of a Randomized Controlled Trial

Parent management training (PMT) is recommended treatment for children with oppositional defiant disorder (ODD) and child-directed cognitive behavior therapy (CBT) is also recommended for school-aged children. The current study examined 2-year follow-up effects of parent management training (PMT) combined with the CBT based group intervention Coping Power Program (CPP) compared to PMT only. Results showed long-term effectiveness of both PMT and PMT combined with CPP in reduced disruptive behavior problems and harsh parenting strategies, and increased emotion regulation- and social communication skills. The earlier reported increase in emotion regulation- and social communication skills in the PMT with CPP condition during treatment remained stable while the PMT condition showed continued improvement during the follow-up period. To conclude, PMT with CPP did generally not provide significant benefits at the 2-year follow-up compared to PMT, apart from an improvement earlier in time regarding emotion regulation- and social communication skills.Trial registration number ISRCTN10834473, date of registration: 23/12/2015.

The feasibility of a strategy for the remote recruitment, consenting and assessment of recent referrals: a protocol for phase 1 of the On-Line Parent Training for the Initial Management of ADHD referrals (OPTIMA)

BACKGROUND

In the UK, children with high levels of hyperactivity, impulsivity and inattention referred to clinical services with possible attention-deficit/hyperactivity disorder (ADHD) often wait a long time for specialist diagnostic assessment. Parent training (PT) has the potential to support parents during this difficult period, especially regarding the management of challenging and disruptive behaviours that often accompany ADHD. However, traditional face-to-face PT is costly and difficult to organise in a timely way. We have created a low-cost, easily accessible PT programme delivered via a phone app, Structured E-Parenting Support (STEPS), to address this problem. The overall OPTIMA programme will evaluate the efficacy and cost-effectiveness of STEPS as a way of helping parents manage their children behaviour while on the waitlist. To ensure the timely and efficient evaluation of STEPS in OPTIMA, we have worked with children's health services to implement a remote strategy for recruitment, screening and assessment of recently referred families. Part of this strategy is incorporated into routine clinical practice and part is OPTIMA specific. Here, we present the protocol for Phase 1 of OPTIMA-a study of the feasibility of this remote strategy, as a basis for a large-scale STEPS randomised controlled trial (RCT).

METHODS

This is a single arm observational feasibility study. Participants will be parents of up to 100 children aged 5-11 years with high levels of hyperactivity/impulsivity, inattention and challenging behaviour who are waiting for assessment in one of five UK child and adolescent mental health or behavioural services. Recruitment, consenting and data collection will occur remotely. The primary outcome will be the rate at which the families, who meet inclusion criteria, agree in principle to take part in a full STEPS RCT. Secondary outcomes include acceptability of remote consenting and online data collection procedures; the feasibility of collecting teacher data remotely within the required timeframe, and technical difficulties with completing online questionnaires. All parents in the study will receive access to STEPS.

DISCUSSION

Establishing the feasibility of our remote recruitment, consenting and assessment strategy is a pre-requisite for the full trial of OPTIMA. It can also provide a model for future trials conducted remotely.

Subgrouping children and adolescents with disruptive behaviors: symptom profiles and the role of callous-unemotional traits

Disruptive behavior during childhood and adolescence is heterogeneous and associated with several psychiatric disorders. The identification of more homogeneous subgroups might help identify different underlying pathways and tailor treatment strategies. Children and adolescents (aged 8-18) with disruptive behaviors (N = 121) and healthy controls (N = 100) were included in a European multi-center cognition and brain imaging study. They were assessed via a battery of standardized semi-structured interviews and questionnaires. K-means cluster-model analysis was carried out to identify subgroups within the group with disruptive behaviors, based on clinical symptom profiles, callous-unemotional (CU) traits, and proactive and reactive aggression. The resulting subgroups were then compared to healthy controls with regard to these clinical variables. Three distinct subgroups were found within the group with disruptive behaviors. The High CU Traits subgroup presented elevated scores for CU traits, proactive aggression and conduct disorder (CD) symptoms, as well as a higher proportion of comorbidities (CD + oppositional defiant disorder + attention deficit hyperactivity disorder (ADHD). The ADHD and Affective Dysregulation subgroup showed elevated scores for internalizing and ADHD symptoms, as well as a higher proportion of females. The Low Severity subgroup had relatively low levels of psychopathology and aggressive behavior compared to the other two subgroups. The High CU Traits subgroup displayed more antisocial behaviors than the Low Severity subgroup, but did not differ when compared to the ADHD and Affective Dysregulation subgroup. All three subgroups differed significantly from the healthy controls in all the variables analyzed. The present study extends previous findings on subgrouping children and adolescents with disruptive behaviors using a multidimensional approach and describes levels of anxiety, affective problems, ADHD, proactive aggression and CU traits as key factors that differentiate conclusively between subgroups.

Incidence and comorbidities of disruptive behavior disorders diagnosed in Finnish specialist psychiatric services

PURPOSE

Disruptive behavior disorders (DBD), including oppositional defiant disorder (ODD) and conduct disorder (CD), are some of the most common psychiatric conditions in childhood. Despite this, there has been limited research on DBDs. We examined the incidence, comorbidity and gender differences of DBDs diagnosed by specialist services.

METHOD

This was a nationwide register study of 570,815 children and adolescents born in 1996-2005. The 7050 individuals diagnosed with DBD by specialist healthcare services were matched to 26,804 controls.

RESULTS

By the age of 15, the cumulative incidence of diagnosed DBDs was 3.5% for boys and 1.4% for girls. The yearly incidence rate increased for girls after 13 years of age, while the incidence for boys was relatively stable between 8 and 15 years of age. When we compared subjects born between 1996-1998 and 1999-2001, we found that by the age of 12, the cumulative incidence per 100 people had increased from 0.56 to 0.68 among girls and from 2.3 to 2.6 among boys. This indicated a minor increase in treated incidence. The parents of children diagnosed with DBDs had lower educational levels than the parents of controls. Children with DBD were also more likely to have been diagnosed with other psychiatric disorders.

CONCLUSION

Although DBDs were 3.5 times more common among boys during the whole follow-up period, the yearly incidence during adolescence was fairly similar between boys and girls. DBD existed alongside various psychiatric disorders at a relatively young age and only a minor increase in treated incidence was found during childhood.

The Mediational Effect of Affect Dysregulation on the Association Between Attachment to Parents and Oppositional Defiant Disorder Symptoms in Adolescents

Oppositional defiant disorder (ODD) is a childhood disorder, commonly occurring in early school aged children with some symptoms becoming normative in adolescence (e.g., irritability, disagreeing). Affect dysregulation is a risk factor in the development of ODD. Affect regulation is nurtured within parent-child relationships, thus disruptions to attachment may derail children's capacity to develop adaptive affect regulation, increasing the risk for ODD. Using a high-risk sample of adolescents, we investigated the association between attachment anxiety and attachment avoidance with ODD through affect dysregulation. Attachment anxiety, but not avoidance, was associated with affect dysregulation and ODD. Affect dysregulation was found to fully mediate the relationship between attachment anxiety and ODD concurrently and prospectively. Similar findings have been demonstrated among children; results show that attachment anxiety, and its effects on affect dysregulation, are associated with ODD symptoms well into adolescence.

Clinical and electrophysiological predictors of behavioral disorders in patients with benign childhood epilepsy with centrotemporal spikes

PURPOSE

Long-term seizure and developmental outcomes of benign childhood epilepsy with centrotemporal spikes (BECTS) are thought to be good. Studies have shown that behavioral disorders may accompany BECTS. We aimed to investigate the frequency of behavioral disorders in patients with BECTS and evaluate their relationship to epilepsy features.

METHODS

Data for 41 patients with BECTS followed up at our clinic between December 2019 and June 2020 were analyzed. Behavioral disorders and intelligence were evaluated by the Turgay Diagnostic and Statistical Manual of Mental Disorders 4th Edition - Disruptive Behaviour Disorders Rating Scale and Wechsler Intelligence Scale for Children Revised, respectively. Patients with a diagnosis of BECTS were divided into 2 groups: children with a behavioral disorder and children without a behavioral disorder. Demographic characteristics, clinical and electroencephalography (EEG) findings, and intelligence level were compared between the two groups.

RESULTS

Twelve of the patients (29%) were classified as having attention-deficit/hyperactivity disorder (ADHD) and 2 (5%) were classified as having oppositional defiant disorder (ODD). The age at seizure onset was earlier in patients with behavioral disorders (p = 0.023). Bilateral interictal epileptic discharges (IEDs) were more common in children with behavioral disorders than children without behavioral disorders (p = 0.039). The most preferred antiseizure medication was carbamazepine, followed by levetiracetam and valproic acid. The intelligence score of the patients with BECTS was in the normal range in both groups. The total, verbal, and performance scores were lower in patients with a behavioral disorder than in patients without a behavioral disorder, but there was no statistically significant difference between the two groups.

CONCLUSION

Behavioral disorders may be present in approximately one-third of patients with BECTS. Early onset of seizures and the presence of bilateral IEDs may be risk factors for behavioral disorders in children with BECTS.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): protocol of a feasibility and pilot study

BACKGROUND

Conduct disorder (CD) is a complex mental disorder characterized by severe rule-breaking and aggressive behavior. While studies have shown that several therapeutic interventions are effective in treating CD symptoms, researchers call for treatments based on etiological knowledge and potential patho-mechanisms. Mentalization-based treatment (MBT) may represent such a treatment approach: Studies have shown that individuals with CD show mentalizing deficits and that mentalizing might represent a protective factor against the development of the disorder. As MBT focuses on the understanding of social behavior in terms of mental states, fostering mentalizing might help CD individuals to (re)gain an adaptive way of coping with negative emotions especially in social interactions and thus reduce aggressive behavior. For this purpose, MBT was adapted for adolescents with CD (MBT-CD). This is a protocol of a feasibility and pilot study to inform the planning of a prospective RCT. The primary aim is to estimate the feasibility of an RCT based on the acceptability of the intervention and the scientific assessments by CD individuals and their families indicated by quantitative and qualitative data, as well as based on necessary organizational resources to conduct an RCT. The secondary aim is to investigate the course of symptom severity and mentalizing skills.

METHODS

The bi-center study is carried out in two outpatient settings associated with university hospitals (Heidelberg and Mainz) in Germany. Adolescents aged between 11 and 18 years with a CD or oppositional defiant disorder (ODD) diagnosis are included. Participants receive MBT-CD for 6 to 12 months. The primary outcome of the feasibility study (e.g., recruitment and adherence rates) will be descriptively analyzed. Multilevel modeling will be used to investigate secondary outcome data.

DISCUSSION

Fostering the capacity to mentalize social interactions triggering non-mentalized, aggressive behavior might help CD individuals to behave more adaptively. The feasibility trial is essential for gathering information on how to properly conduct MBT-CD including appropriate scientific assessments in this patient group, in order to subsequently investigate the effectiveness of MBT-CD in an RCT.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT02988453 . November 30, 2016 SOURCES OF MONETARY SUPPORT: Dietmar Hopp Stiftung, Heidehof Stiftung RECRUITMENT STATUS: Recruitment complete and intervention complete, follow-up assessments ongoing (Heidelberg). Recruitment and assessments ongoing (Mainz). PRIMARY SPONSOR, PRINCIPAL INVESTIGATOR, AND LEAD INVESTIGATOR IN HEIDELBERG: Svenja Taubner is responsible for the design and conduct of MBT-CD intervention and feasibility and pilot study, preparation of protocol and revisions, and publication of study results.

SECONDARY SPONSOR AND LEAD INVESTIGATOR IN MAINZ

Esther Sobanski is responsible for the recruitment and data collection in the collaborating center Mainz RECRUITMENT COUNTRY: Germany HEALTH CONDITION STUDIED: Conduct disorder, oppositional defiant disorder INTERVENTION: Mentalization-based treatment for conduct disorder (MBT-CD): MBT-CD is an adaptation of MBT for Borderline Personality Disorder. This manualized psychodynamic psychotherapy focuses on increasing mentalizing, i.e., the ability to understand behavior in terms of mental states, in patients. MBT-CD includes weekly individual sessions with the patient and monthly family sessions.

KEY INCLUSION AND EXCLUSION CRITERIA

Included are adolescent individuals with a diagnosis of conduct disorder or oppositional defiant disorder aged between 11 and 18 years.

STUDY TYPE

Feasibility and pilot study (single-group) DATE OF FIRST ENROLLMENT: 19.01.2017 STUDY STATUS: The trial is currently in the follow-up assessment phase in Heidelberg and in the recruitment and treatment phase in Mainz.

PRIMARY OUTCOMES

Acceptability of MBT-CD intervention (as indicated by recruitment rates, completion rates, drop-out rates, treatment duration, oral evaluation), acceptability of scientific assessments (as indicated by adherence, missing data, oral evaluation), and necessary organizational resources (scientific personnel, recruitment networks, MBT-CD training and supervision) to estimate feasibility of an RCT SECONDARY OUTCOMES: Adolescents' symptom severity and mentalizing ability PROTOCOL VERSION: 20.08.2020, version 1.0.

The Irritable and Oppositional Dimensions of Oppositional Defiant Disorder: Integral Factors in the Explanation of Affective and Behavioral Psychopathology

Oppositional defiant disorder includes distinct but inseparable dimensions of chronic irritability and oppositional behavior. The dimensions have been identified in early childhood to adulthood, and show discriminant associations with internalizing and externalizing psychopathology. The introduction of disruptive mood dysregulation disorders and the requirements that it take precedence over oppositional defiant disorder diagnostically are not supported by evidence and introduce confusion about the structure and linkages of irritability and oppositional behavior, and obscure the importance of the behavioral dimension in explaining and predicting poor outcomes. A dimensional framework with irritability, oppositionality, callous-unemotional traits, and aggression may more fully describe antisocial outcomes.

Risk of conduct and oppositional defiant disorder symptoms in offspring of parents with mental health problems: Findings from the Raine Study

BACKGROUND

Epidemiological data indicate that paternal and maternal mental health difficulties are predictors of conduct disorder (CD) and oppositional defiant disorder (ODD) in offspring. We tested the association between maternal anxiety and depressive symptoms and paternal emotional problems with CD and ODD symptoms in adolescent offspring aged 17.

METHODS

Data was from the Raine Study, a birth cohort study based in Western Australia. Offspring CD and ODD symptoms at age 17 years were measured using the DSM-oriented scales of the Child Behavior Checklist (CBCL). Depression, Anxiety, and Stress Scale (DASS) was used to assess maternal depressive and anxiety symptoms, and a self-reported questionnaire measured paternal emotional problems when the offspring was 10 years. Negative binomial regression model was used to explore associations.

RESULTS

Adjusting for potential confounding factors, we found an increased risk of CD symptoms in the offspring of mothers with anxiety [RR = 1.76 (95%CI; 1.08-2.86)], depressive [RR = 1.40 (95%CI; 1.01-1.95)], and comorbid anxiety and depressive symptoms [RR = 2.24 (95%CI 1.35-3.72)]. We also found an increased risk of ODD symptoms in offspring of mothers with depressive [RR = 1.24 (95%CI 1.02-1.52)], but not anxiety symptoms [RR = 1.23 (95%CI 0.92-1.67)]. No associations were seen with paternal emotional problems.

CONCLUSION

Our study showed that adolescents whose mothers reported anxiety, depressive, and comorbid anxiety and depressive symptoms had a higher risk of CD and ODD symptoms at age 17. The findings have implications for preventive strategies.

Helping Clinicians to Detect ODD in Children with ADHD in Clinical Settings

The objectives of this study were to provide a basic tool for pediatricians or other physicians to suspect and detect ODD in children with ADHD and to distinguish the symptomatic profile of ODD from ADHD. 101 subjects with ADHD, 83 with both ADHD and ODD and 342 controls aged 8 to 15 years were included in the study. A semi-structured interview was performed for evaluation of psychiatric diagnoses. Both parents and teachers completed DSM-IV Disruptive Behavior Disorders Rating Scale. We found differences among all three diagnostic subsamples in two-by-two analyses for all dimensions (Inattention, Hyperactivity/Impulsivity and ODD) both according to parent and teacher reports (p < 0.03 for all analyses). Based on parental ODD scores, ROC Curve analyses between 'only ADHD' and 'ADHD+ODD' groups showed that AUC was equal 0.80 (95%CI = 0.73-0.86) and the best cutoff point for ODD diagnosis in the ADHD subjects was 0.68. This study demonstrates the presence of a basic tool for detection and suspicion of ODD in children with ADHD for primary care clinicians or pediatricians in clinical settings. Findings also indicate that patients with ODD and ADHD have more severe inattention, hyperactivity/impulsivity and oppositional symptoms than those with only ADHD have.

The role of tryptophan metabolic pathway in children with attention deficit hyperactivity disorder with and without comorbid oppositional defiant disorder and conduct disorder

Accumulating data presented that tryptophan metabolic pathway (TMP) may play a role in attention-deficit/hyperactivity disorder (ADHD). However, no study have investigated potential role of TMP in disruptive behavior disorders coexisting with ADHD. This study compared serum levels of tryptophan, kynurenine, kynurenic acid, 3-hydroxykynurenine and 3-hydroxyantranilic acid in medication-free children with ADHD combined presentation (ADHD-C), with ADHD-C and oppositional defiant disorder (ODD), and with ADHD-C and conduct disorder (CD) versus healthy controls. The study also compared several ratios that are previously suggested to reflect the activities of the KP enzymes (kynurenine/tryptophan, kynurenic acid/kynurenine, 3-hydroxykynurenine/kynurenine) or neuroprotective activity (kynurenic acid/3-hydroxykynurenine) among groups. A total of 122 patients were enrolled: 46 children with ADHD-C alone, 43 children with ADHD-C+ODD, 33 children with ADHD-C+CD and 50 healthy controls. Targeted biochemical molecules were assessed by liquid chromatography-mass spectrometry/mass spectrometry. Compared to control group, serum kynurenine levels were significantly higher in the ADHD-C group, serum 3-hydroxykynurenine levels were significantly lower in the ADHD-C and ADHD-C+ODD groups, the serum kynurenic acid/kynurenine ratio was significantly higher in the ADHD-C, ADHD-C+ODD and ADHD-C+CD groups, and the serum 3-hydroxykynurenine/kynurenine ratio was significantly lower in the ADHD-C group. These findings suggest that TMP may play a role in the pathophysiology of ADHD-C.

The Phenomenology of Outbursts

Outbursts (severe temper loss) in children are a common reason for treatment referral. However, the diagnostic system has not classified them in a way that expands knowledge. Outbursts are nested in the concept of irritability, which consists of a feeling and a behavioral dimension. Both need to be identified but kept separate. This review summarizes the phenomenology of outbursts normatively and clinically. Severe temper loss needs a consistent label, an operationalized way of classification and measurement, and an assessment approach independent of diagnosis until other data are gathered to more accurately determine what condition provides the most accurate diagnostic home.

Attention-Deficit Hyperactivity Disorder and the Dysregulation of Emotion Generation and Emotional Expression

Individuals with attention-deficit/hyperactivity disorder (ADHD) frequently experience strong reactions to emotionally evocative situations. Difficulties modulating anger and other upsets have clinically significant behavioral consequences. Those with ADHD may have anomalies in emotion generation, emotion expression, or both that predispose to these problems. The association between ADHD and emotion dysregulation raises Important clinical and research issues, including possible heterogeneity in the mechanisms by which they are related. Although first-line treatments for ADHD often help to resolve emotional dysregulation symptoms as well, the evidence base for widespread practice of combination pharmacotherapy remains sparse. Psychosocial treatments that engage processes underlying emotional dysregulation are in development.

Interactive association of maternal education and peer relationship with oppositional defiant disorder: an observational study

BACKGROUND

The objectives of this research were to gain insights on the interactive effects, by measuring familial and peer-related risk factors in youths with oppositional defiant disorder (ODD).

METHODS

Participants were college students recruited nationwide, with age between 18 and 25. Through the consensus of expert meetings, a set of questionnaires were used to evaluate the familial status, participant's peer group conditions, high-risk environment of illicit substance use, and oppositional symptoms. The logistic regression was performed to see the independent and interactive risk factors for ODD.

RESULTS

A total of 981 subjects were enrolled. Six variables significantly associated with ODD at the multivariate logistic regression, including male, night division, poor academic performance, high risk environment, peer with illicit substance use and high maternal education level. High maternal education exerted independent protective effect on the development of ODD (adjusted odds ratio, aOR = 0.65, 95% CI = 0.44-0.99). Peer with illicit substance use was more likely to associate with ODD in the low maternal education group. The 2-way interactive effect of maternal education and peer with substance use on the development of ODD was OR = 4.96 (2.96, 8.31).

CONCLUSION

The present study highlights the influence of maternal education level to ODD and its interaction with peer of illicit substance use. Our findings imply that the familial attachment and peer interaction are essential stages for the development of human behavior.

TRIAL REGISTRATION

The research protocol was reviewed and approved by the ethical review committee of National Taiwan University Hospital (number 201505057RINC ) and registered at clinical trial systems at National Taiwan University. In addition, subjects' information was anonymous and de-identified prior to any analysis.

Parenting styles for children with oppositional defiant disorder: Scope review

Behavioral and emotional problems are the most common form of child psychiatric pathology. Parenting styles are one of the factors affecting the formation of children's personality and the use of inefficient styles can lead to several negative consequences such as behavioral problems. The aim of the present article is to describe a variety of parenting styles and their relationship with children behavioral problems. The present study reviews a variety of parenting styles including Kazdin's Parent Management Education Model, Barclay's Parent Training Program, Adler and Dreikurs Approach, and Positive Parenting Program. Finally, based on reality theory, parenting is neglected to be one of those styles. Therefore, it is imperative to do a research based on reality theory with existential psychotherapy and with the view that everyone chooses to behave, external pressure is always an imposition, the children learn from their mistakes, and everyone is responsible for his own happiness.

Do cognitive interventions for preschoolers improve executive functions and reduce ADHD and externalizing symptoms? A meta-analysis of randomized controlled trials

Many interventions targeting executive function (EF) development in the preschool period, where malleability might be particularly high, have been created and evaluated. We conducted a meta-analysis of randomized controlled trials (RCTs) on the effects of these interventions on (a) EFs in preschool children from the general population as well as preschool children with (symptoms of) attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and (b) ADHD and ODD symptoms in preschool children with ADHD/ODD (symptoms). Literature search yielded 35 RCTs. Risk of bias of the individual studies was assessed. A random-effects model was used. Moderator effects were tested using mixed model analyses. The overall effects on EFs were: d = 0.46 (95% CI 0.30-0.61) for working memory (WM), d = 0.30 (95% CI 0.21-0.38) for inhibitory control (IC), d = 0.33 (95% CI - 0.04 to 0.71) for reward-related IC, and d = 0.47 (95% CI 0.28-0.66) for flexibility. In children with ADHD/ODD, mean effects were d = 0.64 (95% CI 0.31-0.96) for WM and d = 0.46 (95% CI 0.07-0.84) for IC. Studies on reward-related IC and FL were lacking. Effects on ODD and ADHD symptoms were d = 0.40 (95% CI - 0.23 to 1.03) and d = 0.28 (95% CI - 0.08 to 0.64), respectively. Interventions targeting multiple EFs and using interpersonal cognitive scaffolding approaches showed large and statistically significant effects on ADHD and ODD symptoms. In preschool children of the general population and in those with ADHD/ODD (symptoms), interventions led to an improvement of EF performance. In children with ADHD and ODD, cognitive scaffolding interventions were most effective in terms of reducing ADHD and ODD symptoms. However, more well-controlled studies need to be conducted before any firm conclusions can be drawn.

Parenting Stress and Depressive Symptoms Among Chinese Parents of Children With and Without Oppositional Defiant Disorder: A Three-Wave Longitudinal Study

Parents of children with oppositional defiant disorder (ODD) experience greater stress in parenting and more parental depressive symptoms. The study examined the longitudinal and bidirectional associations between three dimensions of parenting stress (i.e., parental distress, parent-child dysfunctional interaction, and difficult child) and parental depressive symptoms from a sample of Chinese parents of children with or without ODD. The sample included 256 parents of children with ODD and 265 parents of children without ODD, along with children's teachers. Using a three wave, cross-lagged design, results showed that parents of children with ODD suffered higher levels of parenting stress across three dimensions. For both groups, the links between parental depressive symptoms and subsequent parental distress and difficult child were unidirectional, whereas the relation between parental depressive symptoms and parent-child dysfunctional interaction was bidirectional. Multi-group analysis found that there was no significant difference in the relations between parenting stress and depressive symptoms between the ODD and non-ODD groups. The findings indicated that children with ODD require comprehensive services to address the stress of their parents. The study also provided support for the dynamic and longitudinal relations between specific dimensions of parenting stress and depressive symptoms among parents of children with or without ODD.

Inhibitory Control Deficits in Children with Oppositional Defiant Disorder and Conduct Disorder Compared to Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis

Inhibitory control deficits are known to be characteristic of Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Attention-Deficit/Hyperactivity Disorder (ADHD); but it is unclear whether children with ODD/CD have inhibitory control problems independent of ADHD comorbidity. Previous reviews of inhibitory control and ODD/CD have only focused on one type of measure of inhibitory control or used non-clinical samples. The current meta-analysis explored inhibitory control problems of children with ODD/CD by systematically reviewing studies where children have a diagnosis of ODD and/or CD. Comparisons were made across 25 studies between children with ODD/CD, ODD/CD + ADHD, ADHD, and healthy controls (HC) on various measures of inhibitory control and ADHD symptomatology to explore impacts of ADHD comorbidity. A small significant effect (g = -0.58, p < .001) suggested children with ODD/CD are likely to have more difficulties with inhibitory control than healthy children. However, comparisons between clinical groups suggested this effect may be due to ADHD symptomatology present in each group. As difficulties with inhibitory control are similar, across clinical groups, a dimensional approach to understanding ODD/CD and ADHD may be more useful to consider in future diagnostic criteria. Similarities across clinical groups highlight that therapeutic approaches that assist children with disruptive behaviours could benefit from teaching children and their families how to cope with inhibitory control deficits.

The Developmental Propensity Model Extends to Oppositional Defiant Disorder: a Twin Study

Previous research has supported the developmental propensity model, which proposes that three socioemotional dispositions (prosociality, negative emotionality, and daring) increase risk for the development of conduct problems through shared genetic and environmental influences. The current study extends this research by examining the model in relation to oppositional defiant disorder (ODD). Based on a confirmatory factor analysis, ODD was examined as three separate dimensions (irritable, headstrong, and hurtful) rather than a unitary construct. Parents of 686 same-sex twins (ages 7-13) provided ratings of their twins' dispositions and ODD symptoms. Results from a path model examining phenotypic relationships showed that all dispositions were significantly related to each ODD dimension, except daring was not predictive of the irritable dimension. Preliminary twin analyses showed nonadditive genetic effects only on daring, which limited the appropriateness of evaluating it with the other dispositions. Results from a series of models used to examine etiological associations showed all ODD dimensions had common additive genetic influences with prosociality and negative emotionality. Only headstrong had common additive genetic influences with daring. Irritable and headstrong had common shared environmental influences with respect for rules (an aspect of prosociality), and common nonshared environmental influences with negative emotionality. Hurtful showed no shared environmental influences, but it had common nonshared environmental influences with prosociality and negative emotionality. These findings support the idea that the socioemotional dispositions in the developmental propensity model have some common etiological influences with ODD dimensions, suggesting this model can provide a novel framework for understanding the development of ODD.