Frolli A1,2, Cavallaro A2, Bosco A3, Caruso G2, Vignola R2, Lombardi A3, Rega A4, Operto FF5 and Ricci M C3
1University of International Studies of Rome, Italy
2Serapide SPEE - Specialization School in Cognitive Behavioral Psychotherapy for Developmental Age Disorders, Italy
3FINDS - Italian Neuroscience and Developmental Disorders Foundation, Caserta, Italy
4University of Naples Federico II, Italy 5 University of Salerno, Italy
Submission: March 8, 2020; Published: March 19, 2020
*Corresponding author: Frolli Alessandro, Disability Research Centre of University of International Studies of Rome Via Cristoforo Colombo, 200, Rome – Italy
How to cite this article: Frolli A, Cavallaro A, Bosco A, Caruso G, Vignola R, et al. Reflective Functions and Parent Training in ODD. Psychol Behav Sci Int J .2020; 14(3): 555895. DOI:10.19080/PBSIJ.2019.10.555896.
Background Oppositional Defiant Disorder falls into the category of Disruptive Behaviour Disorder, Pulse Control and Conduct Control characterized by hostile, negative and provocative behaviour towards authoritative individuals, and conditions that involve problems of self-control of one’s emotions.
Aim: This study aims to demonstrate how improving self-perception and fostering informed parenthood can foster more competent emotional development in children.
Sample: The sample therefore includes 30 children divided into two 15 test groups who had been diagnosed with Oppositional Defiant Disorder (ODD) age range 4-6 years.
Methods: After having validated the diagnosis, we started parent training: it is an intervention aimed to improving the relationship between parents and children, increasing the ability to analyze educational problems that may arise, increase knowledge of psychological development of children and principles that govern them, disseminate effective educational methods and make family life and educational problems that can arise more easily manageable. showed an improvement of reflective functions to subscale certainty and uncertainty on perception of one’s own and others’ mental states of RFQ test after development of parent training in both groups, and this can lead to behavioural improvements.
Oppositional Defiant Disorder falls within the category of Disruptive Behaviour Disorder, Pulse Control and Conduct Control , which is generally characterized by hostile, negative and provocative behaviour towards authoritative individuals and all those conditions involving self-control issues of own emotions. Negativism has proved to be physiological in the early years of life and intensifies at the age of two to the extent that, according to some researchers such as Brazelton , this stage of life is often referred to as the “terrible two”, in which a child begins to perceive himself as an autonomous subject, separated from the mother, committed to asserting himself even through recurrent denials. Therefore, it might be difficult to tell a healthy separation-detection process apart from a pathological behaviour. This distinction can be made through an evaluation of the child
and the contexts in which he lives, as well as by assessing the severity and persistence of his opposition. The disorder begins to manifest itself clearly around the age of 3, at the time of entering nursery school, which is normally a stressful time for the child, as it requires an effort of adaptation, regulation of his behaviour and continuous interaction with peers: children with this disorder often fail to adapt and integrate. The onset of first symptoms occurs mainly at a preschool age and hardly ever beyond the early stages of adolescence; an onset after the age of sixteen is very rare in both sexes . These children have frequent outbursts of anger, do not respect rules, are irritated by the presence of others, causing tiredness, discouragement and frustration in those who seek to interact with them. Assumption of such behaviour may be due to a number of causes, including social learning: these children have often been exposed to antisocial behavioural patterns, were
urged to adopt aggressive attitudes to defend themselves or were
reinforced when showing aggressive manners in solving social
conflicts. Usually, as newborns, they used to display a very high
temperament and intense motor activity. Several hypotheses have
been put forward to explain the aetiology of Oppositional Defiant
Disorder: some of them refer to the risk factors of a temperamental
nature, such as a high emotional reactivity, a low level of
frustration tolerance or hyperactivity traits . Other hypotheses,
however, would give greater importance to environmental
aspects, such as too rigid and inconsistent educational practices
, family instability or exposure to particularly stressful changes
 and neglect or abuse. In particular, a strict education is thought
to create a vicious circle in which more attention is given to the
problematic behavioural aspects of the child; in such upbringings,
a child would make his own image of the “bad” child, reiterating
unwanted behaviors. Seemingly, a lack of reinforcement of positive
actions might make a child feel less encouraged to implement
them . Children who have not shown aggressive behaviour in
early childhood are unlikely to develop high levels of aggression
in later years . About the influence of biological factors, lower
levels of cortisol  a.k.a. stress hormone, have been found in
children with Oppositional Defiant Disorder, which may suggest
hypoactivity of central nervous system in the area of impulse
control and in the prediction of negative consequences of a given
action. There is also a lack of physiological activation, which is
expressed through lower levels of sensitivity to danger . In
cognitive-behavioural model of anger and aggressive behaviors in
evolutionary age, a child’s aggressive emotions and behaviors are
regulated by the way the child perceives, processes and mediates
environmental events, rather than by the events themselves
. Anger therefore arises as a subjective reaction to everyday
problems and frustrating events. In these children, in fact, there
is little control, little reflexivity, difficulty in taking a different
perspective from their own, absence of problem-solving skills
and overall, a cognitive deficit that prevents activation of thought
processes that functionally guide behavior . For subjects with
a predominance of symptoms related to anger and irritability,
emergence of an emotional dysregulation disorder is more likely.
Jenkins et al.  state that a lack of awareness of their emotions
could be at the root of the emotional dysregulation trait, which
in turn is held responsible for bad behavior aimed at moderating
subjective suffering, such as self-injurious gestures . Various
research shows that poor regulation of emotions, both positive
and negative, might result in an exteriorization of the child’s
behavioural issues, in school as well as family contexts, while an
excessive inhibition in regulation of emotions is associated with a
tendency to internalize problems and to develop social anxiety [15-
17]. Parental fitness is also assessed by the criterion of reflexivity
of Fonagy , which refers to that set of psychological processes
underlying the ability to mentalize  also understood as the
capacity for abstraction and reflective awareness, which plays a
central role in cognitive and developmental psychology. Fonagy, et
al.  have validated the first self-report that measures RF, the
reflective functioning questionnaire (RFQ) and that investigates
precisely the parental reflective functions. The present study aims
to compare two parents’ training models throughout a period of
six months: one of which is based on rational emotional education
, opposed to the other based on the Circle of Security , an
attack- based model focused on parental regulation and reflex. The
aim of our study is to ultimately demonstrate that by improving
self-perception as a parent and embracing conscious parenthood,
one can foster a more competent emotional development in the
child and reduce externalizing behaviors typical of the ODD.
It is not enough to improve behavioural strategies and reduce
irrational thoughts through a standard cognitive intervention, but
we must broaden parental reflexive function by promoting more
stable and mature mentalization processes: a competent parent
can structure accurate emotional reflection processes.
In this study we initially considered a sample of 72 subjects.
From this sample we excluded 12 children who had parents
with a positive perception as caregiver, resulting from the
administration of the PSI/SF  and valuable reflexive functions
derivative from the administration of the RFQ questionnaire.
The total sample therefore includes 60 children who had been
diagnosed with Oppositional Defiant Disorder (ODD)  following
the administration of K-SADS-PL DSM 5  to their parents,
and whose parents had a low self-perception, of the mental
states of their child, and absent reflective functions on parental
awareness arising from the administration of the RFQ and PSI/
SF questionnaire. The presence of an externalizing disorder was
confirmed by the administration of CBCL to parents and teachers;
the administration of K-SADS-PL 5 also allowed the exclusion
of other neuropsychiatric childhood disorders, while Raven’s
Matrices confirmed an intelligence in the normal range. Data
was collected from FINDS Neuropsychiatry Clinics by qualified
psychologists. The sample included preschool children age range
4-6 years and was divided into two subgroups according to the
type of parent training disposed for parents, as discussed in the
next paragraph. The first group included 30 children (23 males
and 7 females) Mage =5.2; the second group included 30 children
(22 males and 8 females) Mage =5.4. (Figure 1)
The Protocol used consists of the following tests: K-SADS-PL
, PSI/SF , RFQ , CBCL .
K-SADS-PL DSM 5 is a diagnostic interview for the evaluation
of psychopathological disorders (past and present) in children
and adolescents according to the criteria of DSM-5. In particular,
it allows to detect the presence of: mood disorders, psychotic
disorders, anxiety disorders, disturbances of attention deficit and
disruptive behaviour, substance abuse.
RFQ. It evaluates the level of mentalization possessed through
two subscales, which evaluate the certainty (RFQ_C) and the
uncertainty (RFQ_U) of self and others on mental states. Higher
scores at these subscales indicate two distinct RF disturbances,
respectively, hypomentalization and hypermentalization: the
hypomentalization reflects actual thought and poor understanding
of mental states of self and others, while hypermentalization
describes that attitude directed toward the identification of
overly certain and detailed patterns of mind and mental states not
supported by evidence.
PSI/SF. A self-assessment questionnaire used for the
identification of parental stress and for the early identification of
factors that can compromise a child’s normal development. The
instrument is based on the hypothesis that the stress experienced
by a parent is the joint result of certain characteristics of the child,
characteristics of the parent himself and a series of situations
closely related to parenthood. In the short form it is composed of
36 items, divided into three subscale: Parental Distress (PD), which
analyzes the level of stress that a parent experiences, resulting
from an altered perception of his parenthood, Parent–Child
Dysfunctional Interaction (P-CDI), focusing on the fact that the
parent perceives the child as not meeting their expectations and
the interactions therefore don’t reinforce their parental perception,
and Child Difficult (DC), which analyzes some characteristics of the
behaviour of the child that originate in his temperament making it
manageable or not. Finally, a defensive responding score (DR) and
the global stress index can be calculated.
CBCL. structured interview around 8 syndromic scales:
anxiety/depression, withdrawal/depression, somatic complaints,
social disorders, disturbances of thought, disturbances of
attention, behaviour of transgression of rules, aggressive behavior,
which are grouped in other two general dimensions: internalizing
and externalizing disturbances. The 2001 version enables
therefore to rate the behavior through scales, that partially
replicate the diagnostic criteria of the DSM 5, and that in the
Italian standardization used are structured in: affective disorders,
anxiety disorders, somatic disorders, attention and hyperactivity
disorders, oppositional disorders - provokers and disturbances of
After confirming the diagnosis (K- SADS- PL DSM 5 and
CBCL) and collecting information on reflexive functions and
parental stress (PSI/SF and RFQ), we started the parent training
for parents: it is intended to improve the relationship between
parents and children, to increase the capacity to analyse
educational problems that may arise, to increase knowledge of
the psychological development of children and the principles that
govern it, disseminate effective educational methods and make
family life and educational problems that can arise more easily
manageable . Parent training demands to change relational
styles and attitudes that have been adversely affecting children’s
behaviour: parents learn to deal effectively with many common
problems that, in the long run, can compromise not only the wellbeing
of the whole family but the psychological development of
the child . The intervention lasted six months, four times a
month for a total of 24 meetings. The sample of 60 families has
been divided into two sub-groups of 30 according to the model
of parent training used to support parental couples. In particular,
group 1 performed a parent training based on the Circle of Security,
an experiential psychological intervention to support parenthood,
where parents are instructed directly by a therapist on how to
improve their relationship with their child: increasing degrees of
relational safety of children with their parental figures, will affect
their self-esteem and will eventually result in a better regulation
of their emotional states in various contexts of life. Group 2 has
carried out parent training based on the REBT protocol, which
is aimed at stimulating cognitive functions, especially those of
understanding, interpretation and recognition of emotions. This
work makes it possible to model bias and cognitive distortions by
eliminating irrational thoughts and promoting better decoding
of emotional experience . At the end of the six months of
treatment, we reviewed the PSI/SF and RFQ questionnaires to
the mothers and the CBCL questionnaire to the only teachers of
children of both groups individually, to detect any improvement
after treatment, because the enhancement of the parental RF
could alter the results of the CBCL when administered to them.
Data analysis has been performed using SPSS 25.0 statistical
survey software. Significance has been accepted at a level of
5% (α<0.05). Comparison of groups averages has been made by
means of a variance analysis test (Analysis of variance - ANOVA),
a parametric test that allows to examine two or more data
groups by comparing the variability within these groups with the variability between groups. This analys normally applies
distributed test variables suchas Fisher’s random variable F.
In this study, we performed an ANOVA to compare scores to
individual tests before and after treatment within the same group.
Specifically, for Group 1 we compared the RFQ scores before and
after the parent training, and significant results were found both
in the subscale Certainty [F (1.59) = 321.14; p<0.05] and in the
subscale Uncertainty [F (1,59) = 460,74; p<0.05] after treatment,
demonstrating that the intervention improves the perception of
self that parents have, and that will influence the child’s behaviour
in a positive way; we compared the scores from the PSI/SF test
before and after the intervention of PT, and significant results
were found at subscale PD (parental distress) [F (1.59) = 456.93;
p<0.05], at the P- CDI (Parent-Child Dysfunctional Interaction) [F
(1,59) = 535,47; p<0.05] and DC (Difficult Child) [F (1,59)= 985,75;
p<0.05] after treatment, demonstrating that PT reduces parental
stress perception, improves relationship with the child, which
becomes more responsive and improves behavioural aspects.
These results have significantly influenced parental responses
in reporting a more favorable self-image, made evident by the
increased significance to the DR value [F(1.59)=662.52; p<0.05]
after treatment; finally we compared the scores of the CBCL before
and after the intervention of PT, and meaningful results were
found for the externalizing disorders [F(1.59)=313.51; p<0.05]
after PT treatment, demonstrating that externalizing symptoms
in children with this disorder are reduced compared to the start
of treatment (test results fall below clinical relevance). As far as
group 2 is concerned, we compared the RFQ scores before and
after the parent training, and the scores in the subscale Certainty
are not significant, while those in the subscale Uncertainty
are slightly below the accepted significance [F(1,59) = 4,791;
p<0.05] showing that parental reflexive function while having a
slight change after treatment, does not improve significantly; we
compared the scores from the PSI/SF test before and after the
intervention of PT, and meaningful results were found at subscale
PD (parental distress) [F( 1.59) = 651.406; p<0.05], at the
P- CDI (parent-Child Dysfunctional Interaction) [F(1,59)=40,265;
p<0.05] and DC (difficult Child) [F(1,59) = 91,799; p<0.05] after
treatment, demonstrating that behavioural cognitive PT however
improves the sense of educational effectiveness but not parental
reflexive function; finally we compared the scores emerged from
the CBCL before and after the intervention of PT and no significant
results emerged: this shows that only the improvement of the
educational perception does not produce significant results on
the change of the child. We then performed an ANOVA in order to
compare the scores to the individual tests between the two groups
before and after the intervention of PT and to understand which
of the two interventions could better improve the perception of
parenthood and have a positive effect on the reduction of external
symptoms typical of the ODD. We compared the RFQ scores after
the parent training intervention in the two groups and found
significant results in the uncertainty and certainty subscales that
showed a significantly greater improvement in Group 1. We then
compared the scores of the PSI/SF test after the intervention of
PT in the two groups, and significant results were found at subset
PD (parental distress) [F (1.59) = 405.840; p<0.05], PCDI (Parent
Child Dysfunctional Interaction) [F (1.59) = 580.968; p<0.05] and
DC (difficult Child) [F (1.59) = 599.271; p<0.05] and we found a
more meaningful enhancement in group 1 after treatment. Finally,
as regards the comparison of CBCL scores, the results show a
significant reduction in symptomatology to children in group 1
families (Tables 1-3).
This study aims to demonstrate how by improving selfperception
and promoting informed parenthood a more
competent emotional development in children can be installed.
From our analysis an enhancement of reflective functions to
subscales of certainty and uncertainty on perception of mental
states of self and of others of RFQ test has emerged, after
development of parent training in group 1, that is the one in which
an intervention focused on the safety circle has been performed,
the purpose of which has been reflected in the improvement of the
parental regulative and reflective function. High levels of RF in fact
can ensure progresses in regulation of affections, development
and maintenance of a strong sense of self, as well as constructive
social interactions in children, as stated by Fonagy . In group
2, that is, the one in which an intervention focused on emotional
rational education was performed, there was no improvement in
the reflexive function of the parenthood. With regard to scores
from administration of the PSI/SF to mothers of children, there
is a significant reduction in the PD (parental distress) and PCDI
(parent–Child Dysfunctional Interaction) subset after parent
training, which shows a major impact in reduction of the child’s
difficulties in DC subset, particularly in Group 1. All these
findings highlight how maternal containment capacity is indeed
a metacognitive competence, which makes the mother capable of
perceiving her child as a mental subject and restoring, through
functional interactions, an image of self as a mind-endowed
subject. The systematic lack of such ability by the caregiver, along
with situations of uneasiness and evolutionary risk, would lead
to failure in the child’s development of mentalization [27,28].
The detection of the reduction of these indices allows us to say
that both types of parent training promote an enhancement in
the ability of parents to reflect comprehensively on the inner
experience of children, But more relevant results are obtained
with the intervention based on the safety circle, working on
parental reflexive functions. If the parents are not able to respond
adequately, they deny the child a central psychological structure
essential to build a stable sense of self . The reflective function
(RF) is an evolutionary acquisition that allows the child to respond
not only to other people’ behavior, but also to his conception of
their feelings, beliefs and expectations. By attributing mental
states, a child is able to make all the aforementioned expressions
meaningful and predictable, to exhibit a more appropriate
behaviour and consequently to respond adaptively to the various
interpersonal exchanges. A reason for that also relies in the various
self-other representational models, built on the basis of previous
relational experiences . In addition, Fonagy  defines the
capacity of maternal containment as a meta-cognitive competence,
which makes a mother able to conceive her child as a mental
subject, and to restore through interactions, an image of self as a
mind-endowed subject. The systematic lack of such ability by the
caregiver, along with conditions of uneasiness and evolutionary
risk, might prevent a child from strengthening his mentalization
skills [27,28]. Parents who fail to reflect comprehensively on
the inner experience of their children, not managing to provide
an adequate response, won’t grant them a central psychological
structure, which is essential to build an authentic sense of self.
According to Fonagy, the determining factor is the ability of a
mother to mentally contain and reciprocate her child . Fonagy
 considers first relational environment as fundamental; he
argues that security of attachment to the mother is a competitive
predictive index of child’s reflexive capacity. The absence of a
reflective function seems to be strongly linked to failure of parental
reflex function and to a dysfunction of the family relational
system . In this scenario, the child won’t be allowed to create
a reflective self and might, as a consequence, display behaviors
of avoidance and aggression . Finally, we analyzed the scores
on the CBCL test, given to teachers: from the statistical analysis,
we have found a significant reduction in scores of the CBCL in the
subscale externalizing in group 1, that is the one which had carried
out the parent training, according to the Circle of Safety, aimed
at increasing the degree of relational safety of children with their
parental figures and claims to act also on their self-esteem. In
group 2 instead, the scores have not evidenced meaningful results
noting therefore that the externalizing symptomatology persists
without obvious improvements. From the results of this study one
can assert that the lack of reflective function in children seems to
be strongly linked to failure of the parental reflexive function and
dysfunction of the family relational system .
In these cases, the child won’t be able to create a reflexive Self
and, as a consequence, could display behaviors of avoidance and
aggressiveness  typical of the external symptoms of the ODD.
Mentalization and good emotional regulation are evolutionary acquisitions that allow the child to respond not only to behavior
of others, but also to his own conception of feelings, beliefs and
expectations. By attributing mental states, a child can make
behaviour of others meaningful and predictable and adjust his
own behaviour, so as to be able to respond adaptively to the
various interpersonal exchanges. In conclusion, the treatment of
behavioural parent training with parents of preschool children,
can improve regulative and reflexive child function, providing
functional support to the young generations and ensuring adaptive
functioning in various life contexts.
All procedures performed in studies involving human
participants were in accordance with the ethical standards of
the institutional and/or national research committee and with
the 1964 Helsinki Declaration and its later amendments or
comparable ethical standards.
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