Oppositional Defiant Disorder 

Oppositional defiant disorder (ODD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - Text Revision (DSMIV-TR) as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months and is not due to a mood or psychotic disorder. To fulfill the diagnosis, an individual must have 4 of the following:

• Often loses temper
• Often argues with adults
• Often actively defies or refuses to comply with adult requests
• Often deliberately annoys others
• Often blames others for his or her mistakes or poor behavior
• Often touchy or easily annoyed
• Often angry or resentful
• Often spiteful or vindictive

Symptoms are almost always present at home and may or may not be present in the community and at school.

Surveys estimate the prevalence rate to be 2-16% in the general population. Before puberty, the condition is more common in boys; however, after puberty, it is equally common in boys and girls. The disorder usually manifests by age 8 years.

Roughly half the children with attention-deficit/hyperactivity disorder (ADHD) have oppositional defiant disorder (ODD).

Oppositional defiant disorder (ODD) is most likely to arise when a strong-willed child with a reactive and high-energy temperament has a parent who is authoritarian rather than authoritative. An authoritarian parent who expects obedience will be frustrated with a child who does not listen as a result of being strong willed or having a high energy level.

Children with ADHD are particularly vulnerable. The child will react to the excessive control of the parent by becoming angry and wanting to assert himself or herself even more. The child will see the parent as inappropriately domineering and bossy, rather than helpful. The parent sees the child as unreasonable and disrespectful and is likely to try doubly hard to enforce his or her authority.

A downward spiral occurs, with the parent trying to control the child and the child feeling he or she must refuse to give in and must defend his or her autonomy. Both parties become angry and increasingly rigid in their stances as they try to defend their self-esteem. The child's negative behaviors may be inadvertently rewarded by attention, which, even though may be negative, is still desired.

If a child with a difficult temperament or ADHD grows up in a family with parents who respond to the child's behavior with harsh, punitive, or inconsistent parenting, there is a high risk of the child will develop oppositional defiant disorder (ODD). While the parents may have been adequate for a child with an easy temperament, faced with a child with a difficult temperament who often fails to do what he or she is told, perhaps due to ADHD, the parents become angry, punitive, and inconsistent. The child, in response, becomes angry and oppositional.

While problems initially appear at home, in time they may affect relationships with teachers and peers. Problems with teachers and peers lead to depression, anxiety, and additional problematic behavior. Children with ODD and poor social skills often do not recognize their role in peer conflicts, and they tend to not take responsibility for their own actions.

Symptoms frequently remit, especially if the child receives treatment (including treatment for the underlying ADHD), and the parents receive parent guidance. At times, ODD may give way to conduct disorder.

Children with oppositional defiant disorder (ODD) need to be assessed for the presence of ADHD and learning disorders, given the high comorbidity.^[1] If ADHD is present, guanfacine or stimulants may be very useful in helping the child contain his or her behavior and reversing the vicious cycle the child and parents have gotten into. Parent guidance, as well as therapy for the child, is needed.^[2] Parent management training (PMT) consists of procedures in which parents are trained to change their own behaviors and thereby alter their child's problem behavior in the home.^[3]

These patterns develop when parents inadvertently reinforce disruptive and deviant behaviors in a child by giving those behaviors a significant amount of negative attention. At the same time, the parents, who are often exhausted by the struggle to obtain compliance with simple requests, usually fail to provide positive attention; often, the parents have infrequent positive interactions with their children. The pattern of negative interactions evolves quickly as the result of repeated, ineffective, emotionally expressed commands and comments; ineffective harsh punishments; and insufficient attention and modeling of appropriate behaviors.

PMT alters the pattern by encouraging the parent to pay attention to prosocial behavior and to use effective, brief, nonaversive punishments. Treatment is conducted primarily with the parents; the therapist demonstrates specific procedures to modify parental interactions with their child. Parents are first trained to simply have periods of positive play interaction with their child. They then receive further training to identify the child's positive behaviors and to reinforce these behaviors. At that point, parents are trained in the use of brief negative consequences for misbehavior. Treatment sessions provide the parents with opportunities to practice and refine the techniques.

Follow-up studies of operational PMT techniques in which parents successfully modified their behavior showed continued improvements for years after the treatment was finished. Treatment effects have been stronger with younger children, especially in those with less severe problems. Recent research suggests that less severe problems, rather than a younger patient age, is predictive of treatment success. Approximately 65% of families show significant clinical benefit from well-designed parent management programs.

Regardless of the child's age, intervention early in the developing pattern of oppositional behavior is likely to be more effective than waiting for the child to grow out of it. These children can benefit from group treatment. The process of modeling behaviors and reactions within group settings creates a real-life adaptation process. In younger children, combined treatment in which parents attend a PMT group while the children go to a social skills group has consistently resulted in the best outcome. The efficacy of group treatment of adolescents with oppositional behaviors has been debated.^[4] Group therapy for adolescents with ODD is most beneficial when it is structured and focused on developing the skills of listening, empathy, and effective problem solving.

The authors of one study developed a novel prediagnosis intervention, Strongest Families, which includes trained nonprofessionals supervised by mental health professionals for children with disruptive behavior and/or anxiety disorders. The intervention provides care using a handbook, instructional videos, and weekly telephone contacts. The study results noted that these telephone-based treatments resulted in a significant decrease in the proportion of children diagnosed with disruptive behavior or anxiety disorders; this treatment may be an option for those patients who are unable to attend face-to-face sessions.^[5]

Learning more effective parenting skills is crucial for the child to improve. When parents are unable or unwilling to change, because of their own emotional or other issues, treatment may be impossible.