Is oppositional behavior linked to impaired neurocognitive functioning?

If you are parenting a child who has been diagnosed with Oppositional Defiant Disorder or Conduct Disorder, you probably spend a lot of your time exhausted, frustrated, and even depressed.  And you’ve probably spent a lot of time trying behavioral interventions, often without experiencing any tremendous success.

Assessment and understanding of behavior drives the treatment or intervention.  If you view oppositional behavior as a willful behavior problem, you’re likely to approach it behaviorally and by trying to motivate your child to cooperate.

But what if the problem really isn’t motivational? What if it is related to impaired higher-order brain functions?  Although I cannot prove it via research because the research has never really been conducted, I have often hypothesized that “Oppositional Defiant Disorder” (ODD)  is a meaningless diagnosis because there are no brain tests or other tests that really discriminate ODD from ADHD.  And I’ve often argued that many children diagnosed with ODD may really have OCD or Executive Dysfunction that interferes with their ability to shift flexibility and cooperate when the world is not going according to their plan.  If your child is “stuck” and cannot cooperate, they will say, “No.” And if they are lucky, you will understand that what their “no” really means is “Mom, I can’t do what you’re asking me to do right now“ as opposed to, “No, I don’t want to cooperate with you and I’m choosing not to cooperate with you because I don’t care about you and I just want to do what I want to do.”  Whew!

Now Matthys, Vanderschuren,  Schutter, and Lochman have published a study in the September issue of Clinical Child and Family Psychology Review that looks at whether other impaired neurocognitive functions affect social learning processes in children with ODD and CD. Here’s the abstract:

In this review, a conceptualization of oppositional defiant (ODD) and conduct disorder (CD) is presented according to which social learning processes in these disorders are affected by neurocognitive dysfunctions. Neurobiological studies in ODD and CD suggest that the ability to make associations between behaviors and negative and positive consequences is compromised in children and adolescents with these disorders due to reduced sensitivity to punishment and to reward. As a result, both learning of appropriate behavior and learning to refrain from inappropriate behavior may be affected. Likewise, problem solving is impaired due to deficiencies in inhibition, attention, cognitive flexibility, and decision making. Consequently, children and adolescents with ODD and CD may have difficulty learning to optimize their behavior in changeable environments. This conceptualization of ODD and CD is relevant for the improvement of the effect of psychological treatments. Behavioral and cognitive-behavioral interventions that have been shown to be modestly effective in ODD and CD are based on social learning. Limited effectiveness of these interventions may be caused by difficulties in social learning in children and adolescents with ODD and CD. However, although these impairments have been observed at a group level, the deficits in reward processing, punishment processing, and cognitive control mentioned above may not be present to the same extent in each individual with ODD and CD. Therefore, the neurocognitive characteristics in children and adolescents with ODD and CD should be assessed individually. Thus, instead of delivering interventions in a standardized way, these programs may benefit from an individualized approach that depends on the weaknesses and strengths of the neurocognitive characteristics of the child and the adolescent.

What does that mean, you ask with glazed eyes? It means that what I said before is important: your assessment drives your treatment, and you shouldn’t assume that you know the cause of your child’s oppositional behavior but should have your child assessed for neurocognitive functions that impact their ability to form connections between their behavior and outcomes and for their ability to shift flexibly and use feedback.

A more neurobiologically oriented version of the article was published in July in Developmental Psychopathology (abstract)

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DSM-V: Additions to childhood-onset disorders

Among the many changes proposed for the DSM-V are the inclusion of disorders not currently listed in the DSM-IV-TR. Clicking on the links below will take you the related sections of the DSM-V web site where you can read the proposed diagnostic criteria for these new diagnoses as well as the rationale for proposing each one:

• Posttraumatic Stress Disorder in Preschool Children
• Temper Dysregulation Disorder with Dysphoria
• Callous and Unemotional Specifier for Conduct Disorder
• Learning Disabilities
• Non-Suicidal Self Injury
• Non-Suicidal Self Injury Not Otherwise Specified

The Temper Dysregulation Disorder with Dysphoria proposal is particularly controversial and will be discussed in a separate post when we consider changes affecting children with mood disorders.