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Oppositional Defiant Disorder 

  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
 
Updated: Oct 07, 2015
 

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.[1]  To fulfill the diagnosis, an individual must have at least 4 symptoms from the following categories:

Angry/Irritable Mood

  • Often loses temper
  • Often touchy or easily annoyed
  • Often angry and resentful

Argumentative/Defiant Behavior

  • 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

Vindictiveness

  • 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.

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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.[1]

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

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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.[2]   Both children and parents may become angry and increasingly rigid in their stances as they try to defend their self-esteem. 

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Clinical Course

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.

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Treatment & Management

Children with oppositional defiant disorder (ODD) need to be assessed for the presence of ADHD and learning disorders, given the high comorbidity.[3] 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.[4] 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.[5]

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.[6] 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.[7]

Hobbel and Drugli report success in reducing ODD symptoms in children with the Incredible Years Program.[8] Marco et al report success in treating adolescents with dialectical behavioral therapy.[9]

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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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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD Private Practice

Roy H Lubit, MD, PhD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author W Douglas Tynan, PhD, to the development and writing of this article.

References
  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, DC: American Psychiatric Association; 462-466.

  2. Bornovalova MA, Cummings JR, Hunt E, Blazei R, Malone S, Iacono WG. Understanding the relative contributions of direct environmental effects and passive genotype-environment correlations in the association between familial risk factors and child disruptive behavior disorders. Psychol Med. 2013 May 29. 1-14. [Medline].

  3. Kadesjo C, Hagglof B, Kadesjo B, Gillberg C. Attention-deficit-hyperactivity disorder with and without oppositional defiant disorder in 3- to 7-year-old children. Dev Med Child Neurol. 2003 Oct. 45(10):693-9. [Medline].

  4. Kazdin AE. Parent Management Training: Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents. New York, NY: Oxford University Press; 2005.

  5. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol. 1998 Jun. 27(2):180-9. [Medline].

  6. Barlow J, Stewart-Brown S. Behavior problems and group-based parent education programs. J Dev Behav Pediatr. 2000 Oct. 21(5):356-70. [Medline].

  7. McGrath PJ, Lingley-Pottie P, Thurston C, et al. Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: randomized trials and overall analysis. J Am Acad Child Adolesc Psychiatry. 2011 Nov. 50(11):1162-72. [Medline].

  8. Hobbel S, Drugli MB. Symptom changes of oppositional defiant disorder after treatment with the Incredible Years Program. Nord J Psychiatry. 2013 Apr. 67(2):97-103. [Medline].

  9. Marco JH, García-Palacios A, Botella C. Dialectical behavioural therapy for oppositional defiant disorder in adolescents: A case series. Psicothema. 2013 May. 25(2):158-63. [Medline].

  10. Brammer WA, Lee SS. Impairment in Children With and Without ADHD: Contributions From Oppositional Defiant Disorder and Callous-Unemotional Traits. J Atten Disord. 2011 Apr 13. [Medline].

  11. Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry. 2002 Nov. 41(11):1275-93. [Medline].

  12. Connor DF, Steeber J, McBurnett K. A review of attention-deficit/hyperactivity disorder complicated by symptoms of oppositional defiant disorder or conduct disorder. J Dev Behav Pediatr. 2010 Jun. 31(5):427-40. [Medline].

  13. Connor, DF. Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York, NY: The Guilford Press; 2002.

  14. Cunningham CE. COPE: Large-Group, Community-Based, Family-Centered Parent Training. Barkley RA, ed. Attention-Deficit Hyperactivity Disorder. 3rd ed. 2005.

  15. Da Fonseca D, Cury F, Santos A, Sarrazin P, Poinso F, Deruelle C. How to increase academic performance in children with oppositional defiant disorder? An implicit theory effect. J Behav Ther Exp Psychiatry. 2010 Sep. 41(3):234-7. [Medline].

  16. Diamantopoulou S, Verhulst FC, van der Ende J. The parallel development of ODD and CD symptoms from early childhood to adolescence. Eur Child Adolesc Psychiatry. 2011 Jun. 20(6):301-9. [Medline].

  17. Dickstein DP. Oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2010 May. 49(5):435-6. [Medline].

  18. Drabick DA, Ollendick TH, Bubier JL. Co-occurrence of ODD and Anxiety: Shared Risk Processes and Evidence for a Dual-Pathway Model. Clin Psychol (New York). 2010 Dec 1. 17(4):307-318. [Medline]. [Full Text].

  19. Forehand R, Long N. Parenting the Strong Willed Child. Chicago, IL: Contemporary Press; 1997.

  20. Forehand R, McMahon RJ. Helping the Non-Compliant Child: Family Based Treatment for Oppositional Behavior. 2nd ed. New York, NY: Guilford Press; 2003.

  21. Raine A. Annotation: the role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. J Child Psychol Psychiatry. 2002 May. 43(4):417-34. [Medline].

  22. Rowe R, Costello EJ, Angold A, Copeland WE, Maughan B. Developmental pathways in oppositional defiant disorder and conduct disorder. J Abnorm Psychol. 2010 Nov. 119(4):726-38. [Medline].

  23. Steiner H, Remsing L. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jan. 46(1):126-41. [Medline].

  24. Webster-Stratton C. Preventing conduct problems in Head Start children: strengthening parenting competencies. J Consult Clin Psychol. 1998 Oct. 66(5):715-30. [Medline].

 
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