Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD)

ODD is one of the most commonly diagnosed mental health conditions in childhood. It is defined as a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient and hostile behavior toward authority figures. ODD is diagnosed if these behaviors are present for at least 6 months and they negatively impact the child’s social, academic, and/or occupational functioning (DSM-V). The prevalence rate for ODD is estimated to be around 3% in the US. Children with ODD have significantly impaired relationships with parents, teachers and peers. They are not only impaired compared to their peers with no ODD, but show greater impairment than those with bipolar disorder, depression or anxiety.

ODD is characterized by persistent stubbornness and refusal to comply with instructions, unwillingness to compromise with adults or peers, persistently and deliberately testing limits, failing to accept responsibility for one’s own actions and blaming others for one’s own mistakes, deliberately annoying others, and frequently losing one’s temper (APA, 2013). Oppositional defiant disorder is more common in boys than girls, but it is not clear by how much. Girls also differ in the behaviors they exhibit as part of ODD. They may use more verbal and covert types of aggression (i.e. relational aggression – spreading rumors about others) and less physical aggression.

ODD is more common in children who live in low-income and single-parent households. Obese children are also at greater risk for developing ODD. It is typically diagnosed in late preschool and early elementary school, although there is a second wave of new onset of ODD in early adolescence.

Risk factors for ODD

There is no single cause or risk factor for ODD. The transactional conceptualization of ODD posits that ODD children may possess deficits in their executive cognitive skills (i.e. working memory, organized problem solving, ability to change tasks, etc.) and/or affective modulation (i.e. calming down, not exploding) and this undermines their ability to comply with parental demands. This model emphasizes the role of the interaction between parents and children and the context in which the behavior occurs.

Neurobiologic theories focus on the role of neurotransmitters (i.e. serotonin, dopamine, norepinephrine) that can contribute to aggression. However, no single neurotransmitter has been identified as the root cause of ODD.

Co-Existing Conditions

Unfortunately, most children diagnosed with ODD in childhood will later develop an affective disorder (anxiety, depression, bipolar disorder) and/or ADHD (attention-deficit hyperactivity disorder). Co-existing conditions are very common. As many of 40% of children with ADHD also meet criteria for ODD. Those who have both disorders tend to be more aggressive, have more persistent behavioral problems, experience more rejection from peers, and underachieve academically. Children with ODD are also twice as likely to develop bipolar disorder or major depression when compared to a reference group. Learning disabilities and language disorders are also common co-existing conditions. Approximately 30% of children with ODD will later develop conduct disorder (CD), and 40% of those people will develop antisocial personality disorder in adulthood. Those who have both ODD and ADHD are at particularly high risk for developing conduct disorder. Conduct disorder is characterized by aggression toward other people and animals, disregard for the rights of others and destruction of property (DSM-V). Conduct disorder is a more serious disorder than ODD and leads to more serious social, occupational and even legal consequences. 

Diagnosis and Treatment

The diagnosis is often made during elementary school years, although most children have symptoms in preschool as well. Before making a diagnosis, it is important to determine whether the behaviors are abnormal. A certain amount of oppositional behavior is normal both in childhood and adolescence. The assessment should always include information from several sources including parents, teachers, and from the child directly. A psychologist or mental health professional is best equipped to provide an accurate diagnosis.

Research studies have demonstrated that outpatient therapy can be beneficial for the treatment of ODD, specifically parent training. Parents often see their child’s behavior as deliberate, under the child’s control, and intentionally hurtful toward the parent. The behavioral and social disruptions caused by children with ODD also have negative effects on the parents. Therefore, parent training can empower parents through teaching them to be more positive and less harsh in their discipline style. Moreover, involving the child as well as the parents in parent training results in even better outcomes.

Multisystemic therapy is a community-based intervention that aims to intervene in multiple life settings, such as in the home and at school.

Collaborative problem-solving interventions facilitate joint problem-solving, rather than motivate children to just comply with parental demands. Parents and children are encouraged to identify their issues together and use skills to resolve their conflict in a mutually beneficial way.

Pharmacological treatment can also be effective. According to research, medications used to treat ADHD are also effective in the treatment of ADHD with co-existing ODD.

Of course, prevention is the best and least expensive way to reduce ODD. In elementary school-age children parent management strategies are the best form of prevention. Two well-researched programs are the Triple P-Positive Parenting Program and the Incredible Years parenting series. These use self-directed, multimedia parenting and family strategies to prevent behavioral problems in children by enhancing the confidence, knowledge and skills of parents. These programs work best for those parents whose children appear to be at risk for developing emotional and behavioral problems. In addition, some school-based programs on anti-bullying, antisocial behavior and peer groups can also be effective prevention approaches.

ODD References

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Diagnostic and Statistical Manual of Mentai Disorders. 4th ed. rev. Washington, DC: American Psychiatric Association; 1994.

Maughan B, Rowe R, Messer J, Goodman R, Meltzer H. Conduct disorder and oppositional defiant disorder in a national sample: developmental epidemiology. J Chiid Psycho! Psychiatry. 2004;45(3):609-621

Costello EJ, Mustilio S, Erkanii A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003:60(8):837-844.

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Angold A, Costello EJ. Toward establishing an empirical basis for the diagnosis of oppositional defiant disorder. J Am Acad Chiid Adoiesc Psychiatry 1996:35(9):1205-1212.

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Loeber R, Burke JD, Lahey BB, Winters A, Zera M. Oppositional defiant and conduct disorder: a review of the past 10 years, part I. J Am Acad Chiid Adoiesc Psychiatry. 2000;39(12):1468-148

National Iniatitive for Children’s Healthcare Quality. Caring for children with ADHD: a resource toolkit for clinicians, http://www.nichq.org/ NICHQ/Topics/ChronicConditions/ADHD/Tools/ADHD.htm. (password required). Accessed November 29, 2007.

Farmer EM, Compton SN, BumsBJ, Robertson E. Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. J Consuit din Psychoi. 2002;70(6):1267-1302.

Dadds MR, Hawes D. Integrated Family intervention for Child Conduct Problems: A Behaviour-Attachment-Systems intervention for Parents. Bowen Hills, Queensland, Australia: Australian Academic Press; 2006:1-10.

Kashdan TB, Jacob RG, Pelham WE, etal. Depression and anxiety in parents of children with ADHD and varying levels of oppositional defiant behaviors: modeling relationships with family functioning. J Clin Chiid Adoiesc Psychoi. 2004•,33(^):•i69-^8^.

Montgomery P, Bjornstad G, Dennis J. Media-based behavioural treatments for behavioural problems in children. Cochrane Database Syst Rev. 2006;(1):CD002206.

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Greene RW, Ablon JS, Goring JC, et al. Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional- defiant disorder: initial findings. J Consult Clin Psychoi. 2004;72(6):1157-1164.

Swanson JM, Kraemer HC, Hinshaw SP, et al. Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment. J Am Acad Chiid Adoiesc Psychiatry. 2001;40(2):168-179.

Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. J Am Acad Chiid Adoiesc Psychiatry 2002•,A^{^^):^27S-^293.

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