Oppositional Defiant Disorder (ODD) 9/8/2021

Most children exhibit oppositional and defiant behavior at least some of the time.  Particularly in young and early latency age children, these behaviors are considered developmentally appropriate.   The key to considering a diagnosis of ODD is that the child’s behaviors have to be pervasive and occur across multiple settings and be present in a pervasive manner for at least 6 months.  DSM 5 notes that symptoms have to significantly more severe than normal developmental expectations, occurring excessively, and leading to functional impairment. For example, some minor or modest temper outbursts are common in many preschool-aged children, but they would be considered abnormal if they occur on most days and the child is frequently asked to leave school, community activities or is highly disruptive to siblings and parents within the family setting.

Per DSM 5, Oppositional Defiant Disorder (ODD) is defined as a disruptive behavior disorder characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness lasting for at least 6 months. The prevalence of ODD is noted to be at ~3% across multiple cultures. It is diagnosed more commonly for males than females. Studies in younger children (ages 2-5 years old) with pervasive and persisting oppositional and defiant behaviors have shown that many of these children may go on to have diagnoses in the depression and anxiety realms, rather than in the disruptive disorders realms when they reach latency age.  However, ODD, if sustained for extended periods, is a risk factor for future development of conduct disorder in the adolescent years and antisocial personality disorder in adulthood.

The etiology of ODD is thought to be multifactorial, including biologic, genetic and environmental factors. Biologic factors include parental nicotine use, other prenatal stressors, and the presence of developmental delays. Environmental factors within the family include poor attachment, unresponsive parents, strict parenting and excessive punishment by parents. Recent studies highlight that parents’ behavior is most often a causal factor for developing the disorder rather than just a reaction to the child’s symptoms.  Family poverty with its multiplicity of challenges is also a known risk factor.  The presence of social supports is a protective factor.

ODD should be considered a diagnosis of exclusion, meaning a clinician should assess for other mental health and/or environmental concerns that could be a reason behind a child’s oppositional behaviors prior to making a diagnosis of ODD.

For example, children who have underlying ADHD, a depressive disorder, a learning disability or be mild on the Autism spectrum may present with oppositional behaviors because of their adaptive and functional challenges they experience.

Children with ADHD can present with difficulty following directions, talking back and noncompliance as part of their ADHD diagnosis and potentially ameliorable with appropriate treatment and interventions, but when unrecognized and untreated, opposition and defiant behaviors may become established patterns for some youth.

Children with depression and mood disorders may present with irritability, defiance and argumentativeness during their mood episodes, but they would not typically exhibit these symptoms during periods of normal mood. Children with Disruptive Mood Dysregulation Disorder (DMDD) can exhibit chronic negative mood and temper outbursts like children with ODD but the anger outbursts are more severe with DMDD — if a child qualifies for a diagnosis of DMDD, they should not also be diagnosed with ODD.

Children with anxiety disorders can exhibit oppositional and exaggerated behaviors in response to fears and anxiety and children who have experienced trauma can present with aggression and defiance owing to their chronic anxiety and/or their lack of secure emotional attachments and relatedness with adults.

Children on the autism spectrum have a hard time showing empathy and can come across as displaying intentional defiance and oppositionality. Children on the autism spectrum or with intellectual disabilities or learning disabilities should not generally be diagnosed with ODD unless their oppositional behaviors are entrenched behavioral profiles beyond what may typically be seen for other children with similar disabilities.

There is no specific screening tool for ODD per se, but many of the screening tools for ADHD have multiple questions about ODD symptoms, which can be helpful in identifying that there might be a concern. These include the Conners and Vanderbilt rating scales.

The first line treatment for ODD is intensive behavioral therapy, focused primarily on the parents and the parent-child dyad. It is important that the therapy involve parent training in managing the child’s and their own behaviors and attitudes, coupled with skill building for collaborative problem solving. These behavioral strategies, when generalized consistently into the home and school, can be very effective. This said, behavioral strategies can be very challenging for some parents, particularly those who might be used to a domineering and controlling parenting style and/or for families where the child with ODD plays a role of maintaining an unhealthy homeostasis for the family.

While medication is not first line treatment for ODD, it can often be helpful particularly for those with co-morbid conditions like ADHD, mood disorders and anxiety disorders.  Even in these cases, it is important to make sure that the child and his/her parents do not have an expectation that a medication intervention alone is going to resolve the noncompliance, defiance and oppositional symptoms.

Case studies have shown that stimulant and non-stimulant medications given to children with ADHD have some benefit for the oppositional behaviors. Other studies have shown that antidepressant medications given to children with depressive and anxiety disorders have some benefit for the related oppositional behaviors that may occur. Alpha adrenergic agents may be helpful in reducing the intensity of disruptive behaviors regardless of the underlying diagnoses.   Antipsychotic medication and mood stabilizers can be quite helpful for aggression but are not indicated as a first line for ODD and should be considered a last resort treatment option, accompanies by close monitoring for side effects.

The following is a useful handout that can be given to parents that answers some basic questions about ODD:    Oppositional Defiant Disorder

Reference:   https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Oppositional_Defiant_Disorder_Resource_Center/Home.aspx


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