Oppositional Defiant Disorder Guide (ODD)

Have you ever wondered if your child’s misbehavior, defiance, or argumentative personality are normal?

Have you ever been concerned that your child’s aggression or temper tantrums are becoming a more concerning issue that may need to be addressed by a mental health specialist?

Every child disobeys and defies authority at times, but if your child is easily angered or annoyed, hostile, or excessively defiant, he or she may need to be evaluated for ODD.

What is ODD?

ODD, or Oppositional Defiant Disorder, is one of the most common behavioral disorders in children and adolescents.

ODD involves a pattern of aggressive, disobedient, rebellious, and overtly defiant behavior lasting at least 6 months, with the negative behavior directed towards people of authority^[1].

Children with ODD tend to have uncontrollable emotional outbursts that are explosive and unpredictable. These children also have a hard time controlling their temper.

Although most normal children demonstrate moments of opposition or disobedience at times, children with ODD show a more consistent pattern of belligerent and antagonistic behavior towards authority figures.

Children with ODD tend to consistently demonstrate the following attributes^[1]

• Hostility
• Verbally aggressive behavior
• Anger and emotional outbursts
• Defiance
• Meanness or vindictiveness

It is very important to seek evaluation by a mental health specialist if you are concerned that your child may have ODD. Treatment is important because it may equip children with the skills to become socially and professionally successful later in life.

Further, children with ODD can oftentimes have other serious mental health concerns that should be promptly addressed. Also, untreated ODD can eventually turn into a more serious mental health disorder called conduct disorder (discussed more below), and professional intervention can help mitigate or prevent this progression.

How Common is ODD?

ODD is likely more prevalent than previously thought.

Although it is difficult to know with certainty exactly how many children have ODD, it may be underreported and under-diagnosed. This is because some parents may have difficulty accepting that their children’s defiance, disobedience, hostility, and angry outbursts may be due to an emotional/mental disorder.

Recent research suggests that up to 16% of children and adolescents have ODD^[3]. Some other estimates say that only 1% of children have ODD. This is a wide range. In the preschool age group, it is more common in boys. In the school age children, the rates equalize between boys and girls.

What Are the Symptoms?

As discussed previously, most children will demonstrate some rebellion or defiance at some point.

These can be due to changes in routine, trauma, or stress. It may also be a way for children to express their frustration if presented with a scenario that they can’t tackle confidently.

Children who have difficulty with verbal expression also tend to demonstrate symptoms of defiance. However, sometimes parents will notice these symptoms that occur more frequently:

• Hostility
• Defiance
• Refusing to obey or comply with rules
• Constant arguing
• Losing their temper easily
• Extreme negativity
• Spiteful in their interactions with others
• Seeks revenge for perceived slights
• Frequent temper tantrums in the younger aged children
• Challenging rules and authority
• Intentionally try to annoy or upset others
• Easily annoyed by others
• Refuses to take accountability for their actions

There may also be differences in symptoms based on the gender of the patient:

Girls tend to:

• Be more verbally aggressive
• Not tell the truth
• Refuse to be cooperative

Boys tend to:

• Lose temper
• Be argumentative

What Are the Risk factors and Causes of ODD?

Although there are no definitive causes of ODD, there are certain risk factors that are felt to increase an individual’s chances for developing ODD.

Mental health specialists and professionals believe that there are three main categories of risk factors which play a role: biological, psychological, and environmental/social.

Having these risk factors makes children more susceptible to developing ODD, and the risk is cumulative:

Biological risk factors^[4]:

• A parents with a mental health disorder, most notably:
  • ADHD
  • ODD
  • Conduct disorder
  • Mood disorder like depression
  • Substance abuse issues including alcohol
• Developmental delays
• Nicotine exposure in utero
• Exposure to toxins in utero
• Poor nutrition both in utero and in early childhood

Psychological factors^[6]:

• Insecure attachment to one or both parents
• Abusive parenting
• Harsh punishments
• Difficulty processing social cues

Environmental factors^[6]:

• Low socioeconomic status
• Exposure to abuse
• Lack of stability in home environment
• Inconsistent discipline
• Distracted/uninvolved parents
• Maternal aggression
• Peer rejection
• Violence in the community
• Repeated episodes of stress in the family, like moves, divorce, death of loved ones

When Should I Seek Professional Help?

It is important to note that some of the behaviors classically associated with ODD can present in normal children when they are going through a particularly stressful time in life.

Sometimes, children undergoing a major life transition, change, or crisis can demonstrate some of these behaviors. These events may include the birth of a sibling, the death of a loved one, changing schools, moving, etc.

However, these behaviors do not traditionally last for the length of time seen in ODD (6 months) and they are not as severe in frequency or intensity.

If you are concerned that your child is exhibiting hostile, aggressive, or frequently defiant behavior, please talk to your child’s pediatrician or mental health specialist for an evaluation.

How is ODD Diagnosed?

There are currently no questionaries’ that are designed for the diagnosis of ODD. However, other tools can be helpful in making the diagnosis while screening for other mental health conditions.

For example, the Vanderbilt questionnaire used to diagnose ADHD asks other cursory questions about aggression, hostility, and outbursts of anger that are seen in ODD. If there is concern based on the answers to those questions, a more thorough evaluation should be performed.

In order for your child to meet the criteria for ODD, a mental health specialist must make a clinical diagnosis by taking a thorough history of his or her symptoms. Then, it is determined if your child meets the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

In order to be diagnosed with ODD, your child must demonstrate at least 4 symptoms of anger/hostility, defiance, or maliciousness/spitefulness that negatively impact social functioning.

If the child is under 5 years old, the symptoms need to occur on most days of the week for at least 6 months. If the child is over 5 years old, the symptoms should occur at least once a week for 6 months^[1].

The patient must exhibit at least four symptoms from any of the following categories^[1]:

• Angry/Irritable Mood
  • Has frequent temper tantrums/frequently loses temper.
  • Is often sensitive or easily annoyed.
  • Is often irritated and resentful.
• Argumentative/Defiant Behavior
  • Often argues with authority figures or adults in general.
  • Often intentionally defies or refuses to comply with rules.
  • Attempts deliberately to annoy others.
  • Refuses to take responsibility for his or her actions. Tries to place blame on others for misbehavior.
• Vindictiveness
  • Has been spiteful or vindictive at least twice within the past 6 months.

It is important to note that the symptoms cannot occur in the setting of, or be due to, another mental health issue, substance abuse, or a mood disorder. If the child fits these requirements, the severity of his ODD will then be assessed:

• Mild ODD- symptoms only occur in one setting, like at home only or at school only
• Moderate ODD- symptoms occur in at least two settings
• Severe ODD- symptoms are present in three or more settings

What Coexisting Disorders Should I Know About?

There are several mental health issues that commonly present with ODD. These comorbid problems include:

• ADHD
• Substance use and abuse
• Anxiety
• Depression
• Subsequent or comorbid conduct disorder

Anywhere from 14-40% of patients with ODD also have ADHD^[5]. This is seen in more defiant and willful children with ODD. These children are also at higher risk for substance abuse.

One study showed that up to 14% of ODD patients have anxiety and up to 7% have depression^[2]. Another study showed that up to 50% of ODD patients have either one or the other mental health problems^[5]. These are both common, and can even occur in the preschool age range.

What is the Treatment for ODD?

Research has suggested that pharmacotherapy is not beneficial in the treatment of ODD. However, medications can be helpful in treating other co-existing conditions like ADHD, depression, or anxiety⁴.

If these other conditions are adequately treated, this maximizes your child’s chances of success at understanding and resolving his ODD symptoms, because remaining therapy can target the child’s problematic behavior. At the same time, your mental health specialist will formulate a specialized plan specific to your child’s pathological behavior.

The cornerstones of treatment for ODD include parent training, parent-child interaction therapy (PCIT), social skills training, family therapy, child therapy, and problem solving^4.7:

Parent Training

Here, a mental health specialist helps the parent or authority figure identify and adopt more positive parenting skills that are more conducive to building positive interactions between the child and adult. The importance of positive reinforcement is usually discussed here.

Rather than punishing bad behavior, it is oftentimes more beneficial to “catch” the child doing well, and then to lavish him with praise. This is usually more successful in producing long-term results. Sometimes, the child will participate with you, so that the family goals are formulated together, and everyone can feel like they are working towards a common goal.

PCIT

Here, the mental health specialist watches and corrects the parents while they interact with the child during a session. The specialist may sit behind a mirror, for example, and coach the parent through an interaction with the child via an “ear bug” audio device.

They attempt to show the parents strategies that are more likely to encourage cooperation from the child. Parents can then utilize these strategies at home.

Social skills training

This therapy teaches the child social skills necessary to function in his school/family/social settings in a more constructive way. It may help him recognize triggers and teach self-soothing skills to maintain positive relationships with other people.

Parent/child therapy

Here, each person goes through individual therapy that can help identify personal goals and track progress throughout therapy. Family therapy can bring both parties together so that open and constructive conversations can occur under the guidance of a mental health specialist.

Problem solving

This therapy can either be taught to the child alone, or with the parent. It resembles cognitive behavioral therapy used in other mood or anxiety disorders, and helps the child identify dangerous thought patterns when faced with triggers which ultimately lead to problematic behavior.

It then encourages the child to change his/her mindset approaching that problem in order to come up with a more constructive, less inflammatory solution.

What Can I Expect in the Future?

With prompt and early treatment, children with ODD can have a good prognosis. Although the symptoms associated with ODD can be difficult to change, studies have shown that about 65% of children with ODD improve after 3 years^[5].

Chances for improvement are highest when the behavioral symptoms start later in childhood, as compared to in preschool. Younger children in the preschool age group seem to have lower chances for complete improvement^[5].

Unfortunately, up to 30% of children with ODD eventually develop conduct disorder, which can be seen as the precursor to adult-type antisocial personality disorder^[7]. Conduct disorder differs from ODD in that the behavior involves more serious infarctions and there are usually negative legal ramifications.

The delinquencies include physical or sexual aggression/violence, destruction of property, deceitfulness involving stealing, and truancy from school. Up to 10% of children with ODD develop a personality disorder like antisocial personality disorder later on in adulthood^[7].

Thus, it is imperative that children with ODD receive prompt treatment in order to maximize the chances of preventing these more serious mental health disorders.

It is important to remember that most children who receive early intervention and consistent therapy will eventually lead socially, personally, and professionally successful lives. If you are concerned about your child’s behavior, they should be evaluated and treated by an experienced mental health team.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
2. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40(1):57-87.
3. Canino G, Polanczyk G, Bauermeister JJ, Rohde LA, Frick PJ. Does the prevalence of CD and ODD vary across cultures? Soc Psychiatry Psychiatr Epidemiol. 2010;45(7):695-704.
4. Nock MK, Kazdin AE, Hiripi E, Kessler RC. Lifetime prevalence, cor- relates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication. J Child Psychol Psychiatry. 2007;48(7):703-713.
5. Raine A. Annotation: the role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. J Child Psychol Psychiatry. 2002;43(4): 417-434
6. Rowe R, Costello EJ, Angold A, Copeland WE, Maughan B. Develop- mental pathways in oppositional defiant disorder and conduct disorder. J Abnorm Psychol. 2010;119(4):726-738.
7. Steiner H, Remsing L; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 20 07; 4 6 (1) :126 -141.