Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD) is a behavioral condition, usually diagnosed in childhood, which consists of strongly embedded patterns of negative reactions to authority, willful noncompliance, irritable mood, and negative attention-seeking behaviors.¹ There are 2 primary symptom categories used to diagnose ODD, externalizing behavior problems and negative emotions.²

ODD symptoms can be extremely disruptive in nature and they often coincide with other childhood problems such as Attention-Deficit/Hyperactivity Disorder (ADHD) and Anxiety and Mood related conditions. ODD-related problems not only negatively affect the child’s daily functioning, but also interfere with relationships with peers, family members, teachers and other caregivers. Further, the primary problems associated with ODD are distinct from other conditions in that they frequently violate the rights of others.

What causes oppositional defiant disorder?

ODD is widely believed to be influenced by individual child temperament. But there are no known biological or genetic predictors specific to the disorder.³

Environmental factors known to contribute to the emergence of ODD include higher family conflict and parenting stress as well as multiple socioeconomic variables. Current research findings suggest that ODD symptoms are most directly accounted for by families’ reports of parenting stress and poorer family functioning overall.¹ The relation between these contextual factors and the development of ODD has also been described in terms of “coercive family processes” in which symptoms are brought about by an interaction between a difficult child temperament and reactive, authoritarian and inconsistent parenting.⁵

Who is affected by oppositional defiant disorder?

Disruptive behavior disorders such as ODD are considered to be the most prevalent childhood psychiatric conditions in need of psychological services.⁶ The prevalence of ODD reported across clinical studies varies widely (1% to 11%), even reaching as high as 15.6% in some community samples.⁷ There are also notable differences in the presentation of ODD based upon age, gender, and environmental factors.

With regard to age, ODD symptoms typically arise during preschool years and seldom present later than adolescence.  Although ODD symptoms often present early, the nature and severity of these symptoms often change in adolescence and early adulthood. The developmental course of ODD symptoms often reveals a consistent increase in severity over time that frequently progresses to diagnoses of Conduct Disorder (CD), depression or other major mental health concerns.

Reported gender differences suggest that boys are diagnosed with ODD more frequently than girls (1.4: 1) in pre- and elementary school, but these gender differences dissipate in adolescence and beyond. Girls appear to be more at risk for later developing depression after experiencing ODD and boys show a greater proclivity for developing a more severe Conduct Disorder.⁴

What are the symptoms of oppositional defiant disorder?

Most symptoms seen in children and adolescents with ODD also occur at times in children without this disorder, especially around the ages or 2 or 3, or during the teenage years. Many children, especially when they are tired, hungry, or upset, tend to disobey, argue with parents, or defy authority. However, in children and adolescents with ODD, these symptoms occur more frequently and interfere with learning, school adjustment, and, sometimes, with the child's relationships with others.

Symptoms of oppositional defiant disorder may include:

Externalizing Problems

• argumentative with authority figures/adults
• defiant or refusing to comply with rules or request from authority figures
• seeking to deliberately annoy others
• blaming others for own mistakes or misbehaviors

Negative Emotions

• touchy, irritable, or easily annoyed
• prone to losing his/her temper
• angry and resentful
• spiteful or vindictive (at least twice within the past 6 months)

How is oppositional defiant disorder diagnosed?

For a diagnosis of ODD, 4 or more of the symptoms above must be present for a period of at least 6 months, with a frequency and persistence that exceed similar behaviors in peers (i.e., causing distress and impaired social, educational, and/or occupational functioning). Symptoms do not have to be present in more than 1 setting; however, there is now a diagnostic specifier that is used to indicate the cross-situational nature of impairments. Thus, the severity of ODD is further qualified as mild (limited to 1 primary setting), moderate (present across at least 2 settings), and severe (presenting in 3 or more settings).¹

Parents, teachers, and other authority figures in child and adolescent settings often identify the child or adolescent with ODD. However, a child psychologist, child psychiatrist or a qualified mental health professional usually diagnoses ODD in children and adolescents. A detailed history of the child's behavior is gathered along with clinical observations of the child's behavior, and parent and teacher forms of standardized rating scales. Parents who note symptoms of ODD in their child or teen can help by seeking an evaluation and treatment early. Early treatment can often prevent future problems.

Further, oppositional defiant disorder often coexists with other mental health disorders, including Mood Disorders, Anxiety Disorders, Conduct Disorder, and ADHD, increasing the need for early diagnosis and treatment. Consult your child's health care provider for more information.

Treatment for oppositional defiant disorder

Psychosocial treatments are considered the “gold standards” and most effective interventions for children with ODD. Parent-training programs, especially those targeting younger children, are among the most extensively studied treatments for children with ODD and are recommended as the first line approach. Interventions for youth in middle-childhood and adolescence generally focus on individual or group sessions with the child and most often incorporate a parent training component. Children in these stages of development present a greater capacity to benefit from cognitive-behavioral approaches in which they are primary agents of change.¹

Studies of medications for treating ODD are so few and unclear in their findings that medication is not even recommended as an option for combined treatment along with psychotherapy. The exception to this is when ODD symptoms are so severe and involve physical aggression and potential safety concerns that a medication is needed for stabilization. There are many behavior therapies available for first line intervention comprised of either parent training or child-focused psychotherapies delivered in individual and group formats.

Recommended treatments include:

• Behavioral Parent Training/Parent Management Training.  Parent training aims to increase desired behaviors and decrease disruptive behaviors using positive reinforcement, to improve parent-child interactions and communication, and to improve family coping and well-being.  The 5 intervention programs with the greatest empirical support are Parent-Child Interaction Therapy, Helping the Noncompliant Child, Positive Parenting Program, The Incredible Years, and the Parent Management Training Oregon Model. These programs typically provide weekly behavior management training to parents, ranging from 8-22 weeks in duration.
• Individual Child-Focused Psychotherapy. Individual psychotherapy for ODD often uses cognitive-behavioral approaches to improve problem solving skills, communication skills, impulse control, and anger management skills.
• Group Child-Focused Psychotherapy. Group therapies are typically provided for adolescents with ODD and often take place within the school setting.  These group interventions apply cognitive-behavioral principles and emphasize more effective problem-solving skills and anger control training. Effective group programs typically provide 12-18 sessions of weekly therapy.
• Medication. While not considered effective in treating ODD, medication may be used if other symptoms such as physical aggression or co-occurring disorders are present (e.g. ADHD) and responsive to medication.

Prevention of oppositional defiant disorder in childhood

Some experts believe that a developmental sequence of experiences occurs in the emergence of ODD.

This sequence may start with the child’s difficult temperament challenging early parenting practices, followed by the child developing more embedded negative beliefs about the intent caregivers, authority figures, and peers. As these experiences compound and continue, oppositional and defiant behaviors may develop into a pattern of maladaptive interactions.

Early detection and intervention for negative family and social experiences may help in disrupting the sequence of experiences that lead to ODD. Early detection and intervention with more effective communication skills, parenting skills, conflict resolution skills, and anger management skills can disrupt the pattern of negative behaviors and decrease the interference of ODD symptoms in interpersonal relationships with adults and peers, and school and social adjustment. The goal of early intervention is to enhance parenting skills in order to improve the child’s relational environment, to improve the child's coping skills, and ultimately improve the quality of life experienced by the individual and family who are directly affected by oppositional defiant disorder.

References:

1. Curtis, D. F., Elkins, S. R., Areizaga, M., Miller, S., Brestan- Knight, E., & Thornberry, T. (2015). Oppositional Defiant Disorder. In Kapalka, G. M., Disruptive Disorders and Behaviors: A Concise Guide to Psychological, Pharmacological and Integrative Treatments (pp. 99-119). New York: Routledge.
2. Frick, P. J. & Nigg, J. T. (2012). Current issues in the diagnosis of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder. Annual Review of Clinical Psychology, 8, 77-107.
3. Loeber, R., Burke, J. D. & Pardini, D. A. (2009). Development and Etiology of Disruptive and Delinquent Behavior. Annual Review of Clinical Psychology, 5, 291–310.
4. Rowe, R., Costello, E. J., Angold, A., Copeland, W. E., & Mauhan, B. (2010). Developmental pathways in oppositional defiant disorder and conduct disorder. Journal of Abnormal Psychology, 119, 726-738.
5. Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia.
6. Olfson, M., Blanco, C., Wang, S., Laje, G., & Correll, C. U. (2014). National Trends in the Mental Health Care of Children, Adolescents, and Adults by Office-Based Physicians. JAMA psychiatry, 71, 81-90.
7. Munkvold, L. H., Lundervold, A. J., & Manger, T. (2011). Oppositional Defiant Disorder –  gender differences in co-occurring symptoms of mental health problems  in a general population of children.  Journal of Abnormal Child Psychology, 39, 577-587.