Oppositional Defiant Disorder (ODD)

 

All children are oppositional from time to time, particularly when tired, hungry, stressed, or upset. They may argue, talk back, disobey, and defy parents, teachers, and other adults. Oppositional behavior is a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child's social, family, and academic life.

ODD is a condition in which a child displays an ongoing pattern of an angry or irritable mood, defiant or argumentative behavior, and vindictiveness toward people in authority. The child's behavior often disrupts the child's normal daily activities, including activities within the family and at school.

ODD is typically diagnosed around early elementary school ages and stops being diagnosed around adolescence. Children who have ODD have a well-established pattern of behavior problems. Symptoms can include:

  • Being unusually angry and irritable

  • Frequently anger and resentment

  • Being easily annoyed

  • Arguing with authority figures

  • Refusing to follow rules and questioning the rules

  • Deliberately annoying o upset people

  • Blaming others for mistakes or misbehavior

  • Being vindictive

  • Spiteful attitude and revenge seeking

  • Mean or hateful talking to others

  • Touchy and easily annoyed by others

 

All children can have these symptoms from time to time. What distinguishes ODD from normal oppositional behavior is how severe it is, and how long it has been going on for. A child with ODD will have had extreme behavior issues for at least six months.

Children with ODD are a regular daily frustration with ignored commands, arguments, explosive outbursts (build up over time) and these negative interactions damage the parent-child bond and reinforce hostile patterns of behavior.

The symptoms are usually seen in multiple settings but may be more noticeable at home or at school. One to sixteen percent of all school-age children and adolescents have ODD. The causes of ODD are unknown, but many parents report that their child with ODD was more rigid and demanding than the child's siblings from an early age.

What Causes Oppositional Defiant Disorder?

 

The exact cause of ODD is not known, but it is believed that a combination of biological, genetic, and environmental factors may contribute to the condition.

  • Biological: Some studies suggest that defects in or injuries to certain areas of the brain can lead to serious behavioral problems in children. In addition, ODD has been linked to abnormal functioning of certain types of brain chemicals, or neurotransmitters. Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals are not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses. Further, many children and teens with ODD also have other mental illnesses, such as ADHD, learning disorders, depression, or an anxiety disorder, which may contribute to their behavior problems.

  • Genetics: Many children and teens with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited.

  • Environmental: Factors such as a dysfunctional family life, a family history of mental illnesses and/or substance abuse, and inconsistent discipline by parents may contribute to the development of behavior disorders.

 

How Is Oppositional Defiant Disorder Diagnosed?

 

As with adults, mental illnesses in children are diagnosed based on signs and symptoms that suggest a particular illness like ODD. If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical exam. Although there are no lab tests to specifically diagnose ODD, the doctor may sometimes use tests such as neuroimaging studies or blood tests if they suspect that there may be a medical explanation for the behavior problems that occur. The doctor also will look for signs of other conditions that often occur along with ODD, such as ADHD and depression.

 

If the doctor cannot find a physical cause for the symptoms, he or she will likely refer the child to a child and adolescent psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses in children and teens. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a child for a mental illness. The doctor bases his or her diagnosis on reports of the child's symptoms and his or her observation of the child's attitude and behavior. The doctor often must rely on reports from the child's parents, teachers, and other adults because children often have trouble explaining their problems or understanding their symptoms.

Treatment of ODD may include:
 

  • Parent Management Training to help parents and others manage the child's behavior

  • Individual Psychotherapy to develop more effective anger management

  • Family Psychotherapy to improve communication and mutual understanding

  • Cognitive Problem-Solving Skills Training and Therapies to decrease negativity

  • Social Skills Training to increase flexibility and improve social skills and frustration tolerance with peers

 

Medications may be helpful in controlling some of the more distressing symptoms of ODD as well as the symptoms related to coexistent conditions such as ADHD, anxiety, and mood disorders.

 

A child with ODD can be very difficult for parents. These parents need support and understanding. Parents can help their child with ODD in the following ways:

  • Always build on the positives, give the child praise and positive reinforcement when s/he shows flexibility or cooperation.

  • Take a time-out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if s/he decides to take a time-out to prevent overreacting.

  • Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child a time-out in his room for misbehavior, don't add time for arguing. Say “your time will start when you go to your room."

  • Set reasonable, age appropriate limits with consequences that can be enforced consistently.

  • Maintain interests other than your child with ODD, so that managing your child doesn't take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.

  • Manage your own stress with healthy life choices such as exercise and relaxation. Use respite care and other breaks as needed.

 

Many children with ODD will respond to the positive parenting techniques. Parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist or other qualified mental health professional who can help diagnose and treat ODD and any coexisting psychiatric condition.

 

How Common Is Oppositional Defiant Disorder?

 

Estimates suggest that 2%-16% of children and teens have ODD. In younger children, ODD is more common in boys. In older children, it occurs about equally in boys and in girls. It typically begins by age 8.

What Is the Outlook for Children With Oppositional Defiant Disorder?

 

If your child is showing signs of ODD, it is very important that you seek care from a qualified mental health professional immediately. Without treatment, children with ODD may experience rejection by classmates and other peers because of their poor social skills and aggressive and annoying behavior. In addition, a child with ODD has a greater chance of developing a more serious behavioral disorder called conduct disorder. When started early, treatment is usually very effective.

Can Oppositional Defiant Disorder Be Prevented?

Although it may not be possible to prevent ODD, recognizing and acting on symptoms when they first appear can minimize distress to the child and family, and prevent many of the problems associated with the illness. Family members also can learn steps to take if signs of relapse (return of symptoms) appear. In addition, providing a nurturing, supportive, and consistent home environment with a balance of love and discipline may help reduce symptoms and prevent episodes of defiant behavior.

 

Symptoms

Sometimes it's difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It's normal to exhibit oppositional behavior at certain stages of a child's development.

Signs of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. These behaviors cause significant impairment with family, social activities, school and work. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing ODD. The DSM-5 criteria include emotional and behavioral symptoms that last at least six months.

Angry and irritable mood:
  • Often and easily loses temper

  • Is frequently touchy and easily annoyed by others

  • Is often angry and resentful
     

Argumentative and defiant behavior:
  • Often argues with adults or people in authority

  • Often actively defies or refuses to comply with adults' requests or rules

  • Often deliberately annoys or upsets people

  • Often blames others for his or her mistakes or misbehavior
     

Vindictiveness:
  • Is often spiteful or vindictive

  • Has shown spiteful or vindictive behavior at least twice in the past six months
     

ODD can vary in severity:
  • Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.

  • Moderate. Some symptoms occur in at least two settings.

  • Severe. Some symptoms occur in three or more settings.
     

For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends.

 

When to see a doctor

Your child isn't likely to see his or her behavior as a problem. Instead, he or she will probably complain about unreasonable demands or blame others for problems. If your child shows signs that may indicate ODD or other disruptive behavior, or you're concerned about your ability to parent a challenging child, seek help from a child psychologist or a child psychiatrist with expertise in disruptive behavior problems.

Ask your primary care doctor or your child's pediatrician to refer you to the appropriate professional.

Causes

There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including:

  • Genetics — a child's natural disposition or temperament and possibly neurobiological differences in the way nerves and the brain function

  • Environment — problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect
     

Risk factors

 

Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include:

  • Temperament — a child who has a temperament that includes difficulty regulating emotions, such as being highly emotionally reactive to situations or having trouble tolerating frustration

  • Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of parental supervision

  • Other family issues — a child who lives with parent or family discord or has a parent with a mental health or substance use disorder

  • Environment — oppositional and defiant behaviors can be strengthened and reinforced through attention from peers and inconsistent discipline from other authority figures, such as teachers
     

Complications

 

Children and teenagers with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, and at work with supervisors and other authority figures. Children with ODD may struggle to make and keep friends and relationships.

 

ODD may lead to problems such as:

  • Poor school and work performance

  • Antisocial behavior

  • Impulse control problems

  • Substance use disorder

  • Suicide

Many children and teens with ODD also have other mental health disorders, such as:

  • Attention-deficit/hyperactivity disorder (ADHD)

  • Conduct disorder

  • Depression

  • Anxiety

  • Learning and communication disorders

 

Treating these other mental health disorders may help improve ODD symptoms. And it may be difficult to treat ODD if these other disorders are not evaluated and treated appropriately.

Prevention

 

There's no guaranteed way to prevent oppositional defiant disorder. However, positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that ODD can be managed, the better.

Treatment can help restore your child's self-esteem and rebuild a positive relationship between you and your child. Your child's relationships with other important adults in his or her life — such as teachers and care providers — also will benefit from early treatment.