ODD

Question 1

<p>Which type of psychotherapy shows the most potential for treating kleptomania?</p>

Answer 1

<p>cognitive behavioral therapy</p>

<p></p>

<p>Case studies suggest that forms of cognitive-behavioral therapy (CBT) may be a potentially promising treatment for kleptomania. Behavioral models conceptualize kleptomania as a learned pattern of reinforcement within a functional framework. Psychotherapeutic interventions included CBT and insight-oriented therapy, and were administered to the patient at each visit. The patient was asked to chart compulsive behaviors in a diary. The patient also engaged in desensitization by imagining situations in which she might steal and utilizing relaxation techniques to reduce the tension she experienced in these settings. Conditioning was also employed—the patient was instructed to imagine the negative consequences of shoplifting (e.g., embarrassment, legal ramifications) and couple the negative emotions with the compulsion to steal. Other behavioral techniques included the avoidance of shopping alone or shopping in large chain retailers. Psychoeducation was utilized to enable the patient to better understand the condition in the context of depression, anxiety, past trauma, and addictive behaviors. The patient was followed by the treatment team for approximately 12 months, with zero instances of shoplifting reported by termination date.</p>

Question 2

What is the most widely studied pharmacotherapy in treating kleptomania?

Answer 2

naltrexone

The benefit of naltrexone, the most widely studied pharmacotherapy in treating this disorder, was first confirmed in case reports of use of naltrexone 150 mg/day in an adolescent with co-occurring kleptomania and compulsive sexual behavior (Grant and Kim 2001) and an adolescent with kleptomania (Grant and Kim 2002a).
A reasonable paradigm for psychopharmacology in kleptomania can consist of the following: start with a SSRI or SNRI and titrate to the recommended dosage and duration. If the response is inadequate, a trial of naltrexone or topiramate should be considered.

Question 3

How are oppositional defiant disorder (ODD) and disruptive mood dysregulation disorder (DMDD) different from a diagnostic standpoint?

Answer 3

DMDD requires a chronic state of anger and irritability, whereas ODD does not.

IT IS IN BOTH

Oppositional defiant disorder (ODD) will be frequently, if not invariably, found in children with disruptive mood dysregulation disorder (DMDD). Oppositional defiant disorder may be diagnosed before age 6, after which there may be debate as to which diagnostic category is most applicable to the clinical course. The primary phenomenology of explosive irritability on a background of a chronic state of anger and irritability warrants application of DMDD as a primary diagnosis. The absence of the chronic unhappy irritability criteria (including time duration) would support oppositional defiant disorder as the sole diagnosis.
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts in persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of the three settings (i.e., at home, at school, with peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
H. By history or observation, the age of onset of Criteria A-E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.
J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Question 4

Which triad of behaviors in children is predictive of future violence? (3 correct answers)

Answer 4

U F C

Urine/Enuresis (subconscious destructive act), 
Fire setting (destruction of inanimate objects), and 
Cruelty to animals (Practicing on small animals before violence on larger ones – humans)

Question 5

Children with ODD are worst with who?

Answer 5

People they know best.

Children with ODD are at their worst around those people that they know the best. So it is not surprising for these kids to exhibit no symptoms when seen for a clinical interview.

Question 6

Hormones levels in I.E.D.?

Dopamine
Serotonin
Testosterone

Answer 6

Dopamine - down
Serotonin - down
Testosterone - up

They have a high incidence of soft neurological signs. They also have nonspecific EEG abnormalities, indicating prefrontal cortex abnormalities. They also have decreased serotonin levels and possibly increased testosterone levels.
DSM-5 diagnosis The current DSM-5 criteria for Intermittent Explosive Disorder include:
Recurrent outbursts that demonstrate an inability to control impulses, including either of the following:
Verbal aggression (tantrums, verbal arguments or fights) or physical aggression that occurs twice in a week-long period for at least three months and does not lead to destruction of property or physical injury (Criterion A1)
Three outbursts that involve injury or destruction within a year-long period (Criterion A2) Aggressive behavior is grossly disproportionate to the magnitude of the psychosocial stressors (Criterion B)
The outbursts are not premeditated and serve no premeditated purpose (Criterion C)
The outbursts cause distress or impairment of functioning, or lead to financial or legal consequences (Criterion D)
The individual must be at least six years old (Criterion E)
The recurrent outbursts cannot be explained by another mental disorder and are not the result of another medical disorder or substance use (Criterion F)
It is important to note that DSM-5 now includes two separate criteria for types of aggressive outbursts (A1 and A2) which have empirical support:
Criterion A1: Episodes of verbal and/or non damaging, nondestructive, or non injurious physical assault that occur, on average, twice weekly for three months. These could include temper tantrums, tirades, verbal arguments/fights, or assault without damage. This criterion includes high frequency/low intensity outbursts.
Criterion A2: More severe destructive/assaultive episodes which are more infrequent and occur, on average, three times within a twelve-month period. These could be destroying an object without regard to value, assaulting an animal or individual. This criterion includes high-intensity/low-frequency outbursts.

Question 7

EEG abnormalities in I.E.D?

Answer 7

nonspecific

They have a high incidence of soft neurological signs. They also have nonspecific EEG abnormalities, indicating prefrontal cortex abnormalities. They also have decreased serotonin levels and possibly increased testosterone levels.

Question 8

Type of neurological signs in I.E.D?

Answer 8

soft

They have a high incidence of soft neurological signs. They also have nonspecific EEG abnormalities, indicating prefrontal cortex abnormalities. They also have decreased serotonin levels and possibly increased testosterone levels.

Question 9

What about stealing, makes it kleptomania?

Answer 9

the item stolen is not needed for personal use

pleasure may be felt at the time of committing the theft

relief may be felt at the time of committing the theft

there is an increasing sense of tension immediately before committing the theft

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
B. Increasing sense of tension immediately before committing the theft.
C. Pleasure, gratification, or relief at the time of committing the theft.
D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.
Kleptomania is characterized by recurrent episodes of compulsive stealing. Stealing commonly occurs in the form of shoplifting. The items involved are usually of trivial value and are not needed by the individual stealing them. The compulsions to steal are ego dystonic and upsetting to the patient.
Kleptomania and other impulse control disorders seem to be more prevalent among those with psychiatric disorders. In a study of 204 psychiatric patients admitted for inpatient treatment, 31 percent of the patients were identified with a current impulse control disorder and 7.8 percent with kleptomania. A report that identified 11 patients with kleptomania compared them to a group of patients with alcoholism and to a group of non-psychotic psychiatric patients. The patients with kleptomania had significantly higher levels of impulsivity that distinguished them from both comparison groups. The patients with kleptomania were also found to have high rates of substance abuse and mood disorders.
The pathophysiology of kleptomania is unknown. Psychoanalytic theories link compulsive stealing to childhood trauma and neglectful or abusive parents, and stealing may symbolize repossessing the losses of childhood. Kleptomania has also been linked to psychosexual issues such as sexual repression and suppression. Neuropsychiatric factors are also thought to play a role in kleptomania. The disorder appears to be highly associated with mood disorders and anxiety spectrum disorders.. Reports of kleptomania responding to selective serotonin reuptake inhibitors (SSRIs) suggests a common pathophysiology with mood and anxiety disorders.
Kleptomania may also be regarded as a form of addictive behavior and has been shown to be associated with other substance use disorders (e.g., alcohol and nicotine). Naltrexone, an opiate antagonist used to treat addictive behaviors, has been shown to reduce kleptomania symptoms. A double-blind, placebo-controlled study of 25 patients who were administered naltrexone showed significant improvement in kleptomania. Topiramate, an anticonvulsant drug, has been shown to be effective in impulse control disorders, and recently topiramate demonstrated efficacy in treating binge eating. Again, this has been extrapolated to kleptomania with encouraging results in small case series. Additionally, there are case reports in the literature documenting kleptomania responding to lithium, valproate, trazodone, and electroconvulsive therapy.

Question 10

Which of the following principles is emphasized in parent management training programs for treatment of oppositional defiant disorder?

Answer 10

P,arental attention for prosocial behavior

Parental attention for prosocial behavior - Interestingly enough the child doesn’t necessarily have to be involved in PMT. The main focus in PMT is helping the parents come up with a consistent parenting approach that rewards positive behaviors and ignores (or at least doesn’t ‘negatively’ reward) misbehavior.

Question 11

Which personality disorder has been found to be common in arsonists?

Answer 11

Antisocial personality disorder

The likelihood that arson offenders have a diagnosis of schizophrenia has been estimated to be more than 20 times greater than that in the general population.6 Yesavage et al. found that 10 percent of all convicted arsonists had schizophrenia. In another study, the authors reported that arson offenders referred for pretrial psychiatric evaluation were four times more likely to have a psychotic illness than were homicide offenders.32 Of those arsonists referred for psychiatric assessment, between 8 and 76 percent have a diagnosis of schizophrenia or other psychotic disorders.
Mental retardation and low intellectual functioning have also received considerable attention in the arson and firesetting literature. In one study, arson was the most common offense committed by Finnish intellectually disabled criminal offenders.
Personality disorders, in particular antisocial and borderline personality disorders, have also been commonly observed in populations of arsonists in correctional and forensic hospital settings.

Question 12

Which of the following occurs most frequently with conduct disorder?

Answer 12

ODD

Conduct disorder is commonly comorbid with other psychiatric disorders, further contributing to the ambiguity of the epidemiological data for CD. Males demonstrate higher rates of comorbidity than females (Maughan et al. 2004), and comorbidity with oppositional defiant disorder and ADHD is extremely common.

Question 13

Which of the following is true about pyromania?

Answer 13

the fire setting is done due to fascination with fire

Question 14

Which of the following is not a neurochemical abnormality in aggressive children?

Answer 14

Low CSF 5HIAA levels,
low plasma dopamine beta-hydroxylase levels,
and abnormal prolactin response to fenfluramine are seen in aggressive children.

Question 15

Which of the following has been shown to work no better than placebo in decreasing aggression in children?

Answer 15

Carbamazepine – atypical antipsychotics (risperidone, olanzapine), clonidine, and SSRIs have all been used with varying degrees of success. I think the majority of clinicians favor the atypical antipsychotics.

Question 16

Which disorder is commonly seen prior to the childhood-onset subtype of conduct disorder?

Answer 16

Oppositional defiant disorder is commonly seen prior to the childhood-onset subtype of conduct disorder (i.e., before age 10 years).

Question 17

Which behavior has been shown to correlate highly with fire-setting behaviors in children and adolescents?

Answer 17

smoking

Question 18

What type of intervention is most effective for children with conduct disorder?

Answer 18

parent management training

Question 19

What percent of adolescence with conduct disorder go on to develop Antisocial personality disorder?

Answer 19

The essential features of antisocial personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose antisocial personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
b.Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
b. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion;

Question 20

What is the strongest predictor of poor outcome in Conduct Disorder?

Answer 20

Early onset – this relates to the correlation between early onset of antisocial behavior and the persistence of it in adulthood (makes sense since it probably indicates a more genetic bias). These early onset kids also seem to have more comorbid ADHD and learning disabilities. Probably the 2nd strongest predictor of poor outcome is the number of comorbid conditions.

Question 21

What is the most common comorbid disorder in children with ADHD?

Answer 21

Oppositional defiant disorder (40-60% prevalence)

Question 22

What is the best type of therapy for treating oppositional and aggressive disorders in children?

Answer 22

Psychosocial management
Available psychosocial therapies can be subclassified into parental management training (PMT), parenting/school-based training, functional family therapy, brief strategic family therapy, cognitive behavior therapy (CBT) imparted in individual and group formats, multisystemic therapy, and multidimensional therapy in the foster-care setting. While multicomponent treatment approaches including parent-group programs are the treatment of choice in aggression with young children >8 years of age, older children benefit more from family-based and multicomponent approaches like brief strategic family therapy and multisystemic therapy, according to Center for Education and Research on Mental Health Therapeutics.
PMT includes quality time with the child and differential reinforcement strategies to give proper direction to the child’s motivation. It focuses on parenting skills. Though more effective with smaller children, components of positive parenting practices like the Triple P model can be effective with adolescence as well. Classic PMT models like the Oregon model or others like Kazdin or Berkley are effective. Parent–child interaction therapy includes video-based monitoring and feedback that can make the training of parents easier. Some models also include school-based interventions that help to extend gains in good behavior to the school setting, eg, Good Behavior Game or Incredible Years. All these techniques are effective in changing behavior, but programs can vary in effectiveness and in different areas of improvements.
Functional family therapy postulates that problem behavior plays some functional role in family equilibrium, and modification in family functioning can change the behavior problem. Brief strategic family therapy also resorts to a similar principle, but the process of intervention is different. When the child is slightly older, CBT in different formats is a very useful component of the treatment of DBD. First on this list is an anger-coping program. The Coping Power program has an additional parent component to the anger-coping program. Problem-solving skills training and perspective-taking are other components of an effective CBT model for aggressive children.

Question 23

What factor (considering both biological and social ones) is most robustly associated with violent behavior?

Answer 23

Age – people between ages 15-25 are overwhelmingly most often associated with violence. Male gender, low IQ, low birth weight, and alcohol abuse are also very much associated with violent behavior.

Question 24

The single most reliable predictor of future violence is:

Answer 24

A history of violence (naturally); excessive alcohol intake and a history of child abuse are also risk factors.

Question 25

The age at onset of kleptomania is generally during which developmental period?

Answer 25

The age at onset of kleptomania is generally during adolescence (ages 16–20 years), although symptoms could occur in early childhood or late adulthood (Grant and Kim 2002b). The average age for treatment presentation, however, is about 35 years for females and 50 years for males (Goldman 1991).

Question 26

Studies suggest that the percent of sons born to a mentally ill mother and criminal father who will become violent is estimated to be:

Answer 26

27% – note that genetic factors play a role in that monozygotic twins have a higher concordance rate for aggression than dizygotic twins.

Question 27

Significant symptoms of conduct disorder emerge between which to phases of human development?

Answer 27

Generally, significant symptoms of conduct disorder emerge between middle childhood and middle adolescence.

Question 28

Patients with intermittent explosive disorder tend to be ________ men.

Answer 28

They are usually large, dependent men with a poor sense of masculine identity who lose control when they feel impotent.

Question 29

Patients with intermittent explosive disorder show ________ after an episode.

Answer 29

genuine regret They have discrete episodes of losing control of their aggressive impulses that last for a brief amount of time and remit spontaneously, after which they tend to show genuine regret.

Question 30

Patients with intermittent explosive disorder may have CSF characterized by:

Answer 30

Decreased serotonin levels Remember that serotonin is inversely correlated with impulsivity. There are not too many studies, but it does appear that SSRIs can be helpful in IED. The more bipolar a patient looks, the more a mood stabilizer may be helpful. Criteria for Intermittent explosive disorder A. Recurrent behavioral outburst representing a failure to control aggressive impulses as manifested by either of the following: Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period. B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).

Question 31

Oppositional defiant disorder most commonly emerges at about age ________ while the average age at onset for conduct disorder is ________ for boys and ________ for girls.

Answer 31

8 years of age (although oppositional behavior is common between 18-24 months), 10-12 for boys and 14-16 for girls. The key to ODD is that the natural oppositionality that characterizes the increased autonomy of the 2 year-old continues well past that age. This may be a disorder that is a clear example of failure to negotiate the autonomy vs. shame or anal stage. Often these toddlers were locked in battle with overly controlling and punitive parents. On the behavioral side, don’t forget that any form of attention is better than none (i.e., these kids seek to have their negative behaviors reinforced because it at least gets them some attention.) The end result is a temperamental, argumentative, annoying, irresponsible child. Note that the ODD kid blames others but rarely initiates a fight; the conduct d/o kid initiates fights and blames others; the ADHD kid generally interrupts others but (unless comorbid with conduct) doesn’t initiate fights.

Question 32

Kleptomania is more often comorbid with which of the following disorders?

Answer 32

affective disorders Kleptomania is more often comorbid with affective disorders than with any other psychiatric disorders, with lifetime comorbidity rates varying from 59% to 100%. Some studies suggest that bipolar disorder is the most common co-occurring disorder, whereas other studies demonstrate that unipolar depression has the highest rate of comorbidity. Research has also shown high rates of comorbid impulse-control disorders (20%–46%), anxiety disorders (60%–80%), eating disorders (60%), and substance use disorders (23%–50%) over the lifetime. Individuals with kleptomania also have high rates of comorbid personality disorders, ranging from 43% to 55%, with paranoid (17.9%), schizoid (10.7%), borderline (10.7%), and histrionic (18%) personality disorders identified as the most common (Grant 2004; Grant and Kim 2002b; McElroy et al. 1991).

Question 33

It is hypothesized that children with conduct disorder and __________ IQs were found to have greater substance abuse during adolescence according to a recent study in CNS spectrum (2004).

Answer 33

higher Higher IQs – high verbal IQs interacted with conduct d/o to produce a greater likelihood of substance abuse. It is hypothesized that the higher IQs enable the adolescents to negotiate and obtain the substances.

Question 34

In the presence of familial adversity (e.g., abuse), low gene activity for _______ significantly increases the risk conduct disorder in children.

Answer 34

MAO-A – this has been confirmed in two independent studies now. ,

Question 35

In pyromania, the peak incidence of fire setting occurs at age:

Answer 35

17 years old is the peak incidence of fire setting. Pyromania is a psychiatric diagnosis rather than a legal term. Individuals with pyromania engage in intentional and pathological firesetting, but do not always commit the crime of arson. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) currently includes firesetting as a symptom in pyromania and conduct disorder. Although firesetting behavior accounts for only 1 of 15 potential symptoms of conduct disorder, it is central to the diagnosis of pyromania

Question 36

How does oppositional defiant disorder differ from conduct disorder?

Answer 36

children with conduct disorder are physically aggressive toward people or animals, whereas those with oppositional defiant disorder are not Although both are considered “disruptive disorders,” oppositional defiant disorder differs from conduct disorder in that children with conduct disorder fail to recognize societal rules and personal rights, are physically aggressive toward people or animals, may destroy property, and/or may steal. The criteria for conduct disorder include a descriptive features specifier for individuals who meet full criteria for the disorder but also present with limited prosocial emotions. The criteria for oppositional defiant disorder are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child's behavior caused the parents to act in a more hostile manner toward the child, if the parents' hostility led to the child's problematic behavior, or if there was some combination of both. Whether or not the clinician can separate the relative contributions of potential causal factors should not influence whether or not the diagnosis is made. In the event that the child may be living in particularly poor conditions where neglect or mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful. w

Question 37

From 1984 to 1994, the number of murders committed by children under 18 increased by:

Answer 37

Increased by 300%

Question 38

Fire-setters diagnosed with pyromania tend to exhibit which of the following test results:

Answer 38

hypoglycemia Fire-setters exhibit hypoglycemia, in addition to the typical decreases in 5HIAA and MHPG.

Question 39

Conduct disorder has a lifetime prevalence in the U.S. of approximately what percent?

Answer 39

10% Conduct disorder has a lifetime prevalence of 9.5%

Question 40

Aside from genetic factors and parental treatment factors, what is a significant factor in the development of disruptive behavior in children and adolescents?

Answer 40

Malnutrition – A recent longitudinal study assessed children aged 3 for malnutrition and cognitive function, then reassessed their cognitive function and behavior at ages 8, 11, and 17. The degree of malnutrition at age 3 correlated with the degree of behavioral disturbances in adolescence and this appeared to be mediated by cognitive deficits

Question 41

Approximately 20% of patients with Kleptomania have a first-degree relative with:

Answer 41

Approximately 20% of patients with Kleptomania have a first-degree relative with substance use disorder. The prevalence of kleptomania in the general population is approximated at 0.6 percent. In those arrested for shoplifting, the prevalence of kleptomania is 3.8 to 24 percent. The female to male ratio is estimated at 3:1. The onset is usually in adolescence, and the average age for presentation for treatment is 35 years for women and 50 years for men. Kleptomania is rarely brought to medical attention voluntarily. Patients usually present for treatment by legal mandate due to repeated shoplifting. Men are more likely to be sent to prison instead of being referred to treatment. A study involving 20 kleptomania patients found a high association with major depression and, to a lesser extent, anxiety and eating disorders. All of the patients in the study had a lifetime diagnosis of depression; 16 had a lifetime diagnosis of an anxiety disorder; and 12 had a lifetime diagnosis of an eating disorder.

Question 42

Among the following choices, fire setting is least commonly seen in adolescents in:

Answer 42

Borderline Personality disorder Fire setting is most commonly seen in the following disorders in adolescents: ADHD, conduct disorder, and adjustment disorder (pyromania is much rarer than these disorders). People with pyromania also have a high incidence of MR and alcohol abuse. Note the association between fire-setting, enuresis, and cruelty to animals, although it seems that enuresis may not be as related as originally thought.

Question 43

A 9-year-old child presents with sudden outbursts at home when asked to complete chores or when told “no.” These behaviors are not present while playing with siblings. Which of the following treatments has the largest body of evidence to treat this condition?

Answer 43

Parent management training – The kid most likely has oppositional defiant disorder (ODD). Oppositionality in these kids most often manifests at home with their parents, so therapy has to be targeted at this dyad: parents and child. As K&S put it, “the underlying rationale for all programs [for Parent Management Training] is based on the general view that child oppositional problem behaviors are inadvertently learned, developed, and sustained in the home by chronic and maladaptive parent-child interactions.” Bottom-line, Parent management training has the most evidence supporting its effectiveness in the treatment of oppositional defiant disorder. In some older kids and adolescents, problem-solving skills training can be helpful. The diagnosis of oppositional defiant disorder (ODD) is broadly based on frequent and persistent angry or irritable mood, argumentativeness/defiance, and vindictiveness. It is “qualitatively” different from conduct disorder (CD), which talks about impingement of others’ rights and violation of age-appropriate social norms. Both of these together are known as disruptive behavior disorders (DBDs), the concept of which was conceived almost 50 years ago. Over the years, there have been changes in the clinical, psychosocial, and biological understanding of ODD. There have been noteworthy changes in diagnostic schemes. Numerous psychosocial risk factors have been identified. Biological factors, especially with the help of newer neuroimaging techniques, and brain substrates for oppositional behaviors have been explored. Studies have been conducted to find the best possible preventions and interventions. Psychosocial management Available psychosocial therapies can be subclassified into parental management training (PMT), parenting/school-based training, functional family therapy, brief strategic family therapy, cognitive behavior therapy (CBT) imparted in individual and group formats, multisystemic therapy, and multidimensional therapy in the foster-care setting. While multicomponent treatment approaches including parent-group programs are the treatment of choice in aggression with young children >8 years of age, older children benefit more from family-based and multicomponent approaches like brief strategic family therapy and multisystemic therapy, according to Center for Education and Research on Mental Health Therapeutics. PMT includes quality time with the child and differential reinforcement strategies to give proper direction to the child’s motivation. It focuses on parenting skills. Though more effective with smaller children, components of positive parenting practices like the Triple P model can be effective with adolescence as well. Classic PMT models like the Oregon model or others like Kazdin or Berkley are effective. Parent–child interaction therapy includes video-based monitoring and feedback that can make the training of parents easier. Some models also include school-based interventions that help to extend gains in good behavior to the school setting, eg, Good Behavior Game or Incredible Years. All these techniques are effective in changing behavior, but programs can vary in effectiveness and in different areas of improvements. Functional family therapy postulates that problem behavior plays some functional role in family equilibrium, and modification in family functioning can change the behavior problem. Brief strategic family therapy also resorts to a similar principle, but the process of intervention is different. When the child is slightly older, CBT in different formats is a very useful component of the treatment of DBD. First on this list is an anger-coping program. The Coping Power program has an additional parent component to the anger-coping program. Problem-solving skills training and perspective-taking are other components of an effective CBT model for aggressive children.