Oppositional Defiant Disorder
- Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD more...
Defining Oppositional Defiant Disorder
Oppositional defiant disorder (ODD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a recurrent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months. To fulfill the diagnosis, an individual must have at least 4 symptoms from the following categories:
Often loses temper
Often touchy or easily annoyed
Often angry and resentful
Often argues with authority figures or with adults (if a child or adolescent)
Often actively defies or refuses to comply with requests from authority figures
Often deliberately annoys others
Often blames others for his or her mistakes or poor behavior
Has been spiteful or vindictive at least twice within the past 6 months
Symptoms are distinguished from behaviors that are developmentally normative for children of different ages: for children younger than 5 years, the behavior should occur on most days; for children 5 years or older, the behavior should occur at least once per week. Symptoms may be present at home, in the community, at school, or in all three settings.
Prevalence and Comorbidity
Estimated prevalence ranges from 1-11% in the general population, with an average of 3.3%. Before puberty, the condition is more common in boys (1.4:1); 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).
Risk Factors and Etiology
Oppositional defiant disorder (ODD) is associated with temperamental contributions including poor emotion regulation, high levels of emotional reactivity, and poor frustration tolerance. Environmental risk factors include harsh or neglectful parenting, and highly authoritarian parenting.
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.
Interactional patterns betwen parents and children may develop that inadvertently promote and maintain the behaviors. For example, the child's negative behaviors may be rewarded by attention, which albeit negative, tends to maintain or even increase the undesired behaviors. Both children and parents may become angry and increasingly rigid in their stances as they try to defend their self-esteem.
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 higher risk that the child will develop oppositional defiant disorder (ODD). While the parents may have been well matched for a child with an easy temperament, faced with an emotionally reactive child who often fails to do what he or she is asked, perhaps due to ADHD, the parents may have difficulty regulating their own emotions and become angry, punitive, and inconsistent. The child, in response, may become angry and oppositional.
While problems often initially appear at home, in time they may affect relationships with teachers and peers. Problems with teachers and peers may 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 therefore tend not to take responsibility for their own actions.
Symptoms may remit spontaneously over time, especially if the child receives treatment for comorbid conditions such as ADHD, and the parents receive parent training. At times, ODD may give way to conduct disorder.
Treatment & Management
Children with oppositional defiant disorder (ODD) need to be assessed for the presence of ADHD and learning disorders, given the high comorbidity. 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. 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.
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. 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.
Obstacles to Treatment
Learning more effective parenting skills is a critical component of treatment for ODD. When parents are unable or unwilling to engage in treatment, due to their own emotional or other issues, treatment for their child will be compromised.
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