Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a behavioral pattern seen in children and teens who are at near constant odds with the authority figures in their lives.  It creates tremendous tension and spiraling conflict in the parent-child relationship and in interactions with teachers and other adults. A child with ODD is highly temperamental and resists rules and expectations, refuses to follow directions, and is spiteful or vindictive to an extent far beyond the usual behavior of his age group. This behavior significantly undermines his schooling and relationships with peers and family. Untreated, ODD typically leads to other behavioral and learning problems, as the low frustration tolerance impacts so many areas of a child’s life. 

Your child may have ODD if he is very quick to lose his temper, often disobedient at home or at school, apt to ignore or rebel against rules, quick to blame others for mistakes or misbehavior, prone to annoy others (and be easily annoyed himself). Within limits, every one of these behaviors is typical in children, but those with ODD have problems containing these impulses, and act out so often that it dramatically compromises their ability to get along with others.  The extraordinary level of oppositionalbehavior means children with ODD are sometimes described as having a “reflexive ‘No!’”—they will refuse to cooperate even before they know what is being asked of them. Symptoms of ODD can become apparent as early as pre-school or much later, in adolescence.

While the causes of ODD are not known, the disorder does run in families, and family behaviors—especially parental responses as children begin to assert their independence—may play a role.  There is a strong association between authoritarian parenting and harsh or inconsistent discipline practices and the onset of ODD.  The opposite is also true—not setting enough limits, or what professionals call “laissez-faire” parenting, is also associated with the onset of oppositional and defiant behavior.

 

There is also evidence that brain dysfunction is involved in the onset or course of ODD, but just how is difficult to discern as so many children with ODD also have other disorders known to be affected by neurobiological factors.

Because of the possible confusion between signs and symptoms of ODD and normal childhood or adolescent rebellion, professionals adhere to a strict protocol when diagnosing the disorder. The clinician will depend on a detailed history of behaviors in various situations, from parents and other caregivers such as teachers, to confirm that a variety of oppositional and defiant behaviors have been present for an extended period, that they significantly interfere with the child’s activities, and that they aren’t normal for his age and development. This is difficult because ODD is often diagnosed along with ADHD, and the signs can be confused; in addition, many of the signs of ODD are related to the more severe conduct disorder. Though ODD can develop into conduct disorder, the two conditions cannot be diagnosed together.

 

Even if the number and intensity of these behavioral issues does not reach the minimum criteria for a diagnosis of ODD, specialized help may still be warranted to address your concerns about your child and to prevent the onset of this disorder.

ODD is treatable, usually with behavioral therapy or a combination of behavioral intervention and medication.

 

Psychotherapeutic: A popular evidence-based treatment is a type of behavior therapy called parent management training. The parent and child are seen and coached together in real time, with the therapist present, to practice a series of skills. In many cases, the therapist may coach the parent during interactions, sometimes by whispering into their ear or even communicating from a viewing room via an in-ear receiver. Typically, this is a two-phase treatment with the first phase devoted to increasing positive parent-child interactions, and the second focused on specific limit-setting and discipline skills.

 

Treatment for ODD typically requires a great deal of coordination between the authority figures in your child’s life, including you—the parents—and your child’s teachers and other caregivers, such as grandparents or daycare providers. It may also require you to do a bit of studying yourself, and learn how to effectively manage your child’s disorder with a minimum of painful outbursts—be they his or yours.

 

Pharmacological: Medicines are not specifically indicated for ODD.  However, as many children with ODD have co-occurring conditions such as ADHD, they may be on medications for those other disorders.  In addition, some patients are so troubled by their own aggression, and their difficulties managing their painfully low frustration tolerance, that a child psychiatrist or other medical doctor may recommend medication—like psychostimulants used to treat ADHD—along with behavioral therapy to help them control those responses. In these cases, medicine could make the difference between the child being able to participate in the therapy and not.

As noted above, ODD is often diagnosed alongside ADHD. In adolescents and children younger than 18, ODD is diagnosed only in those who do not meet the more stringent and severe criteria of conduct disorder. In those over 18, ODD is diagnosed only in those who are not diagnosed with antisocial personality disorder.  Children with ODD often have co-occurring mood disorders like depression, anxiety disorders, or learning or communication disorders. Professionals warn that ODD that goes untreated early in life is often linked to more severe disorders later, including substance abuse. 

Does bad parenting cause it?
Experts believe that ODD is caused by a combination of a biological vulnerability—perhaps genetic—and environmental factors. Brain scans suggests that there are differences in areas dedicated to judgment and impulse control in people with ODD; still, inconsistent discipline at home is obviously a factor. The good news is that parents, as well as children, can be retrained to change the pattern of behavior.
Will my kid grow out of it?
Yes and no. Research suggests that most children diagnosed with ODD grow out of the diagnosis, though they may still exhibit some of the worrying behaviors. A small but significant percentage of kids with ODD may later develop more severe symptoms consistent with conduct disorder.
Is there a cure?
Children with ODD respond very well to properly designed therapy, often without the need for medication. Symptoms of ODD can be managed—some may even go away—but only with the combined efforts of the child and parents.
What distinguishes ODD from normal behavior?
While none of the signs and symptoms of ODD are uncommon in children and adolescents, the degree which they manifest in kids with the disorder is key to diagnosis. Not only must a child be much more oppositional than his peers to warrant diagnosis; his behaviors must interfere with his life and cause “clinically significant impairment in social, academic, or occupational functioning.”
How long is treatment?
A typical course of treatment can last several months or longer, depending on the severity of the case. After initial treatment, it’s typical for a child to have sporadic “booster sessions” with his therapist to keep the tools he’s learned to control his ODD “sharp,” as it were.
What sort of medications might be used to treat ODD?
There is no specific medication indicated for treatment of ODD, and medication alone is rarely if ever used to treat ODD. Still, kids with ODD are often prescribed drugs to help with other mental disorders they might have, like psychostimulants for ADHD, and controlling them with medication can vastly increase the effectiveness of behavioral therapies.