Oppositional Defiant Disorder

Oppositional defiant disorder

Definition

Oppositional defiant disorder (ODD) is a childhood mental disorder characterized by a pattern of angry, antagonistic, hostile, negative, irritable, and/or vindictive behavior lasting at least six months and occurring more frequently than is typically observed for the child's age and developmental stage. Children diagnosed with ODD do not meet the clinical diagnostic criteria for conduct disorder .

Description

Oppositional defiant disorder (ODD), a relatively new clinical classification, involves an ongoing pattern of antagonistic, defiant, and hostile behavior toward parents and other authority figures. Children and adolescents with ODD often have frequent temper tantrums , blame others for their misbehavior, argue excessively with adults, actively refuse to comply with adult rules and requests, deliberately defy adults and attempt to annoy or upset them, and are easily annoyed by others.

Demographics

Before puberty , ODD is more common in boys than girls; however, after puberty ODD occurrence rates are about equal in boys and girls. The disorder typically begins by the age of eight. According to the American Academy of Child and Adolescent Psychiatry, approximately 5 to 15 percent of all school-aged children have ODD.

Causes and symptoms

Although the specific causes of ODD are unknown, genetics and environment are thought to play a role in its development. As of 2004 several theories about the causes of oppositional defiant disorder are being investigated. ODD may be related to the following:

• the child's temperament and the family's response to that temperament
• an inherited predisposition to the disorder in certain families
• a neurological cause, such as a head injury
• a chemical imbalance in the brain (especially with the brain chemical serotonin)

ODD appears to be more common in families in which at least one parent has a history of a mood disorder, conduct disorder, attention deficit hyperactivity disorder (ADHD), antisocial personality disorder , or a substance abuse-related disorder. Children with one parent who is alcoholic or who has been in trouble with the law are almost three times more likely to have ODD. Additionally, some studies suggest that mothers with a depressive disorder are more likely to have children that develop ODD. ODD can also occur in conjunction with other conditions such as ADHD, learning disabilities, anxiety disorders, and mood disorders . About 50 percent to 65 percent of children with ADHD also have ODD.

Symptoms of ODD include a pattern of negative, hostile, and defiant behavior lasting at least six months. During this time four or more of the following must be present for a child to be diagnosed with ODD:

• often loses his/her temper
• often argues with adults
• often actively defies or refuses to comply with adults' requests or rules
• often deliberately annoys people
• often blames others for his/her mistakes or misbehavior
• is often touchy or easily annoyed by others
• is often angry and resentful
• is often spiteful or vindictive
• misbehaves frequently
• swears or uses obscene language
• has a low opinion of him/herself

Additional problems may be present, including the following:

• learning problems
• a depressed mood
• hyperactivity (although ADHD must be ruled out)
• substance abuse or dependence
• dramatic and erratic behavior

When to call the doctor

Parents of children and adolescents who exhibit symptoms of ODD should see a physician as soon as possible. Usually, a referral to a psychologist, psychiatrist, or therapist will be given.

Diagnosis

ODD is diagnosed by psychological and psychiatric evaluations; interviews with family members, teachers, and caregivers; and observation and interviews with the child or adolescent. Diagnosis is based on clinical criteria defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision C (DSM-IV-TR).

ODD often has characteristics in common with other psychological disorders and often occurs in conjunction with other conditions, such as ADHD or mood disorders. Therefore, diagnosis of ODD usually depends on exclusion of other disorders. A diagnosis of ODD is not made if the symptoms occur exclusively in psychotic or mood disorders, or if the child meets clinical criteria for conduct disorder, or, if the adolescent is 18 years old or older and meets clinical criteria for antisocial personality disorder. Children and adolescents with ODD do not exhibit the more serious aggressive behaviors or physical cruelty that is common in other disorders.

Treatment

Treatment of ODD usually involves medication, and group, individual, and/or family therapy . Of these, individual therapy is the most common. The goal of therapy is to help provide a consistent daily schedule, support, rules, discipline , and limits, as well as to help train patients to get along with others by modifying behaviors. Therapy can occur in residential or day treatment facilities, in a medical setting, or on an outpatient basis. Therapy can instruct patients on how to effectively deal with ODD and help them learn how to do the following:

• use self time-outs
• identify what increases anxiety
• talk about feelings instead of acting on them
• find and use ways to calm themselves
• frequently remind themselves of their goals
• get involved in tasks and physical activities that provide a healthy outlet for energy
• learn how to talk with others
• develop a predictable, consistent, daily schedule of activity
• develop ways to obtain pleasure and feel good
• learn how to get along with other people
• find ways to limit stimulation
• learn to admit mistakes in a matter-of-fact way

Therapy can also involve the parents. Parent management training focuses on teaching parents specific and more effective techniques for handling the child's opposition and defiance. Research has shown that parent management training is more effective than family therapy.

Stimulant medication is used only when ODD cooccurs with ADHD. Occasionally, children and adolescents with ODD may also have depression or anxiety disorders, and treatment with antidepressants and anti-anxiety medications can help alleviate some symptoms of ODD.

Prognosis

The prognosis for ODD varies. In some children, ODD evolves into a conduct disorder or a mood disorder. ODD, if left untreated, has approximately an 80 percent chance of turning into conduct disorder as a child ages. Later in life, ODD can develop into passive-aggressive personality disorder or antisocial personality disorder. ODD can cause significant social, academic, and/or occupational impairment. Generally, with treatment and long-term participation in therapy, adjustment in social settings and in the workplace can be made in adulthood.

Prevention

As of 2004, ODD could not be prevented.

Parental concerns

Children and adolescents with ODD usually have difficulties in school and at home. In some cases, ODD can result in expulsion from school. Parents should investigate alternative school settings that may be able to provide counseling and group therapy integrated with academics. Assistance is available through county social or mental health services, educational consultants, and local school counselors. Family therapy may help alleviate stressful family situations and help other family members understand the disorder.

Television viewing and video/computer games can contribute to ODD behaviors. For children with ADHD or ODD, the American Academy of Pediatrics recommends limiting use of television and video/computer games to no more than two hours per day, monitoring children's use of television and computers, and viewing family-oriented television programs with their children.

Parents may find it helpful to track their child's moods and behaviors and to help children learn to track their own moods and behaviors to help identify possible stresses and causative factors.

Parents should actively participate in their child's therapy and learn positive parenting techniques that can help ODD behaviors. When parents are too restrictive, children and adolescents with ODD can rebel, and power struggles can frequently occur. Therapists specializing in ODD can help families become more effective in handling ODD behaviors in order to avoid such rebellion. The American Academy of Child and Adolescent Psychiatry recommends the following for parents with children who have ODD:

• Choose battles by setting priorities regarding child's behavior.
• Set reasonable, age-appropriate limits with consistently enforceable consequences.
• Work with teachers, coaches, and other family members for support in dealing with the child with ODD.
• Use positive reinforcement praise when the child displays desired behaviors.
• Take time to manage stress by exercising and/or relaxing away from the child.

KEY TERMS

Alternative school —An educational setting designed to accommodate educational, behavioral, and/or medical needs of children and adolescents that cannot be adequately addressed in a traditional school environment.

Antisocial personality disorder —A disorder characterized by a behavior pattern that disregards for the rights of others. People with this disorder often deceive and manipulate, or their behavior might include aggression to people or animals or property destruction, for example. This disorder has also been called sociopathy.

Attention deficit hyperactivity disorder (ADHD) —A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems.

Conduct disorder —A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate societal norms.

Resources

BOOKS

Sutton, James D. What Parents Need to Know about ODD: Upto-Date Insights and Ideas for Managing Oppositional Defiant Disorder and Other Defiant Behavior. Pleasanton, TX: Friendly Oaks Publications, 2003.

PERIODICALS

Barrickman, L. "Disruptive Behavioral Disorders." Pediatric Clinics of North America 50 (2003):1005–17.

Greene R. W., et al. "Psychiatric Comorbidity, Family Dysfunction, and Social Impairment in Referred Youth with Oppositional Defiant Disorder." American Journal of Psychiatry 159 (July 2002): 1214–24.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. Web site: <www.aacap.org>.

American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209–3901. Web site: <www.psych.org/>.

WEB SITES

Tynan, W. Douglas. "Oppositional Defiant Disorder." eMedicine, November 2, 2003. Available online at <www.emedicine.com/ped/topic2791.htm> (accessed November 21, 2004).

Wood, D. "What is Oppositional Defiant Disorder (ODD)?" Available online at <www.mental-health-matters.com/disorders/dis_details.php?disID=67> (accessed November 21, 2004).

Jennifer E. Sisk, M.A.