Oppositional Defiant Disorder
Oppositional defiant disorder (ODD) is a disruptive behavior disorder that emerges during childhood or adolescence and is characterized by persistent angry or irritable mood, unruly and argumentative behavior, and vindictiveness. It frequently manifests in hostility toward authority figures.
All children display defiant behavior at some point, especially when tired or stressed. Oppositional behavior is in fact normal in toddlers and in early adolescents. The behavior of a child with ODD is much more extreme and disruptive than normal, however, and occurs much more frequently than the type of childhood stubbornness and rebellion that children may display over the course of development. The oppositional behavior of ODD is not only persistent but occurs across a wide array of situations and interferes with children’s social, family, and educational life.
The condition affects about 3 percent of children and occurs more frequently in boys than girls before adolescence, but not after, according to the DSM-5. It often co-occurs with attention deficit hyperactivity disorder (ADHD), conduct disorder, and with anxiety and mood disorders.
ODD is diagnosed when, on some to most days for a period lasting at least six months, a child or teenager behaves in extremely negative, hostile, and defiant ways that disrupt their home, school, and social lives. Symptoms can appear as early as three years of age. Children with ODD usually display an angry or irritable mood. Children often lose their temper, become easily annoyed, angry and resentful, and the behavior is directed at a person or persons who are not a sibling. They engage in argumentative behavior with parents, teachers, or other authority figures; deliberately annoy others; and often blame others for their misbehavior. They are spiteful and vindictive.
Children with ODD may also have problems with their peers, although, in relatively mild cases, symptoms may be confined to only one setting, typically the home. In more severe cases, the uncooperative, vindictive, and disruptive behavior occurs in multiple settings across multiple relationships. Children with the disorder often do not see themselves as angry and defiant but consider their behavior justified by the unreasonable demands of others. The irritability that ODD children display may also be associated with anxiety.
Oppositional defiant disorder is the most frequent behavioral disorder in preschoolers. The prevalence of ODD is reported to be between 1 percent and 11 percent in community samples. Some studies report 10 percent occurrence rate in the United States and 7 percent in other countries, such as Spain.
There is no one test for ODD and because the disorder often occurs with other conditions, a definitive diagnosis can be difficult to establish. The diagnosis of ODD is made after a comprehensive psychological evaluation that probes many facets of a child’s behavior to identify patterns typical of the disorder as well as to gauge the presence or absence of related conditions such as ADHD and anxiety.
Typically, clinicians use a variety of well-validated screening tools in addition to their own experienced observations of a child’s behavior and interaction patterns. Screening tools include child behavior checklists to identify behavioral, cognitive, and emotional problems and parental questionnaires and observations of a child’s behavior. Important factors include the frequency and intensity of problem behaviors, the types of settings problem behaviors occur in, the nature of family interactions, and the co-existence of other difficulties.
ODD is a serious diagnosis and is not rendered lightly. Some experts believe that diagnosis is itself harmful in that it implies that the problem resides in the child and doesn’t tell parents more than they already know—that dealing with their child is difficult. Further, it doesn’t direct attention to why a child is behaving in a disruptive manner. “Defiant” is not merely a stigmatizing label but also carries implications of willfulness that affect parental attitudes toward a child, their willingness to focus on the problems underlying disruptive behavior, and their own receptivity to change.
The cause of ODD is unclear but a mix of biological, social, and psychological factors appears to put children at risk. These factors can include poverty (although ODD can occur in families of any economic status), experiencing a traumatic transition, having a parent with a mood, addictive, or behavioral disorder, having a bad relationship with a parent, having a neglectful or abusive parent, or a parent who is an overly harsh disciplinarian, or other family instabilities. At least one study has reported that ODD symptoms are worse in children who struggle with peer acceptance in addition to family issues. Several studies link ODD to harsh, inconsistent, or neglectful parenting practices.
Many children with ODD have coexisting conditions, most notably mood or anxiety disorders and ADHD, but also learning disorders or language disorders. Such conditions, if present, require specific treatment in addition to treating the behavioral disorder. It is necessary to determine whether a child’s poor behavior is occurring in response to a temporary situation or, as in ADHD, is limited to situations that demand sustained effort, attention, or sitting still.
Disruptive disorders of childhood are not well understood. Children do not set out to be difficult. Childhood misbehavior is a nonspecific response to many internal and external disturbances, and defiance is even appropriate at some stages of development. No single cause of ODD has been identified, and while the condition tends to run in families, no genetic patterns have been identified. Biological, social, and childrearing factors all seem to play a role in ODD.
Some research identifies two different types of ODD that may have different roots. One, more reactive, is marked by irritability, associated with internalizing conditions such as anxiety, and fueled by poor frustration tolerance and problems of emotion regulation. The other, more proactive, is most marked by argumentativeness and vindictiveness, associated with externalizing conditions such as conduct disorder, and is linked to neurobiological makeup including low heart rate and low stress reactivity, both signs of underarousal of the autonomic nervous system.
It may be most accurate to think of ODD as a consequence of the interaction of several factors. In this view, individual characteristics such as a high emotional reactivity, low emotion regulation, or difficulties in social learning collide with environmental adversities such as dysfunctional parenting style, parental psychopathology, socioeconomic difficulties, or high levels of family conflict.
Several studies identify complex behavioral patterns in which coercive interactions between young children and their caregivers amplify children’s noncompliance. Patterns of relating within the family are thought to carry over into other settings.
There’s no invariable outcome for ODD, but when tackled early, conduct problems that develop early in childhood can be mitigated. ODD is a largely treatable condition. According to the American Academy of Child and Adolescent Psychiatry, the signs and symptoms of ODD resolve within three years in approximately 67 percent of children diagnosed with the disorder.
In the absence of treatment, the disruptive behavior of ODD is linked to later behavior problems in school and adjustment difficulties in adulthood. ODD carries a risk for the development of anxiety and depression in adulthood. A small portion of children with ODD, notably those who display defiance, argumentativeness, and vindictiveness, may go on to develop frank Conduct Disorder, a more serious condition marked by aggression toward people and animals, property destruction, and deceitfulness or theft.
It is generally up to the parent to seek treatment, since the child is unlikely to understand that there is a problem. Referrals for psychological evaluation and treatment often come from a medical doctor who has performed an examination and ruled out a physical cause.
Once the diagnosis of ODD is established, a combination of therapies is generally prescribed. It typically includes behavioral and family therapies, parental training. sometimes medication. One goal of therapy is to rebuild the parent-child relationship. Another is to teach parents new techniques for dealing with the child’s behavior. The earlier treatment begins, the greater the chances of preventing ODD from developing into a more serious conduct disorder, mental health disorder, or criminal behavior.
There is no medication for treatment of ODD, and medication is not recommended as an approach to treating the behavioral disorder. However, medication may be warranted for treating co-existing problems such as ADHD, anxiety, and depression, and drug treatment of those disorders, such as stimulants for ADHD or antidepressants for mood disorders, can improve symptoms of ODD. The most important treatment for ODD is psychotherapy involving parents as well as children.
The first-line treatments for ODD are psychosocial, and, while they take time, they can be highly effective. Therapy is aimed at both children and their parents. Children of school age engage in individual therapy to learn and practice skills and strategies of emotion and behavior regulation and impulse control. Therapy for parents of both preschoolers and school-age children includes learning effective parental management strategies.
In addition, family therapy is often helpful in undoing the damage done by repeated negative interactions and in supporting the establishment of new, more rewarding behavioral dynamics. Peer group therapy may be needed to address deficits in social skills. Teachers may be enlisted in some therapeutic settings.
A form of Cognitive and Behavioral Therapy (CBT) has been specifically developed for treating children with disruptive behavior. Called Collaborative and Proactive Solutions (CPS), it helps both parents and teachers engage with children in nonpunitive ways to identify and solve the problems that give rise to difficult behavior.