Gail Fernandez, MD (Child Psychiatrist) & Robert Myers, PhD (Child Psychologist)
All children have the capacity to assert their opinion and do so to varying degrees of intensity. This trait can be wonderful when the child is agreeable and articulate; it can be excruciating when he or she has a tendency towards very strong, negative opinions. How a child manifests his or her needs, wants, likes, and dislikes is governed by a complex set of factors that is still not clearly understood on a biological level.
Oppositional Defiant Disorder is a childhood psychiatric disorder that affects 6 to 10% of children. Since all children have moments or periods of time when they are more argumentative, sullen, or disagreeable, the diagnosis of Oppositional Defiant Disorder needs to be made carefully and symptoms need to be present for a consistent period of time and over various settings.
According to the Diagnostic and Statistical Manual (DSM-IV-TR), the symptoms are as follows:
DSM-IV TR Diagnostic criteria for 313.81 Oppositional Defiant Disorder
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults’ requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder .
This disorder is more common in boys than in girls, and can be diagnosed as early as age three, although there is some controversy as to when a set of negative behaviors gets severe enough to fall outside the normal range of behaviors, especially in younger children.
Factors that lead to the development of ODD can be separated into several categories:
Biological causes could be related to neurotransmitter imbalances in the brain. Decreased cortisol, a hormone produced by the adrenal cortex during times of stress, is another biological factor. Studies have also suggested dysfunction in the frontal lobes of the brain.
There also appears to be a genetic component in the development of ODD, and this includes a family history of behavioral disorders as well as the concept of temperament. Children with a difficult temperament (i.e. moody, negative, and prone to tantrums) or a tendency to display dominant behavior are more likely to develop ODD.
Environmental causes play a strong role, including dysfunctional family relationships or inappropriate parenting or a parenting style that does not meet the needs of a particular child. Other environmental factors can be living in harsh surroundings or psychosocial stresses such as poverty.
The fact that the disorder is more common in boys may display a combination of factors, such as the encouragement of more aggressive behavior in boys along with biological factors.
If ODD becomes severe and the child or adolescent shows a lack of empathy or regard for the rights of other’s with the additional symptoms of property destruction, physical aggression, criminal behavior, cruelty to animals, or other serious behaviors, he or she may be diagnosed with Conduct Disorder (CD), a more severe behavioral disorder that can lead to Antisocial Personality Disorder, a severe disorder that is difficult to overcome and is associated with criminal behaviors and incarceration.
To make matters more complicated, ODD is often comorbid with other psychiatric disorders, especially Attention Deficit Hyperactivity Disorder, Learning Disorders, and Major Depression. If a child is diagnosed with ODD, it is important for the clinician to evaluate for other psychiatric disorders as well.
Treatment of Oppositional Defiant Disorder
The first step in treatment of ODD is to make sure that a thorough evaluation has eliminated other causes of the presenting symptoms. Once the diagnosis of ODD is confirmed, there are several principles to understand, including:
- ODD tends to be a chronic disorder
- Psychosocial interventions should be the mainstay of treatment, even if medications are used
- Early treatment leads to a better outcome
- Family involvement is crucial
- Behavioral issues may need to be treated differently in different settings
Psychosocial interventions used in ODD
Children who have ODD in the absence of any other psychiatric condition such as ADHD are most likely children with temperament traits that result in them becoming what are known as “difficult to raise” children. Parents usually are not expecting this and thus are not prepared to provide the highly specific parenting techniques required to successfully raise them to become well-adjusted children and adolescents.
There is an often what child development experts refer to as a “miss-match of parenting style” to the child’s personality. As this persists over time the parent/child relationship becomes more strained with anger and frustration building for the child and the parents. Parents often continue to increase the intensity and severity of the original (unsuccessful) parenting style rather than take a step back and look for a more adaptive style that is a better fit for the child and still leads to appropriate behavior and emotional regulation.
Research has found that there are three basic parenting styles:
Cop – Authoritarian Parenting Style. The parent implements behavioral programs and dishes out consequences for behavior. Tries to control situations to insure appropriate behavior. Fosters fear and conformity. Wants the child to always be obedient.
Social Worker – Permissive Parenting Style. The parent protects the child and tries to minimize consequences for behavior. Always tries to understand the child and wants others to understand and accept the child. Fosters dependence. Wants the child to always be happy.
Coach – Authoritative Parenting Style. The parent works alongside the child to encourage and teach him or her to develop an attitude and a set of skills that will lead to success. Helps the child to set reasonable goals and achieve them. Fosters independence. Wants the child to be as successful as possible.
[Research indicates that the Authoritative Parenting Style works best for all children].
Primary (evidence-based) intervention usually includes one or more of the following:
Parent Management Training – The child’s behavior and the parent/child relationship are analyzed by a child mental health professional. A comprehensive intervention is developed which usually includes some modifications in parenting style and some form of a behavior modification program tailored to meet the specific circumstances.
Cognitive Behavioral Therapy – A highly trained child therapist meets with the child or teen to improve coping skills, self-esteem, emotional regulation (such as anger management) and social skills.
Family Therapy – A therapist meets with the entire family to improve functioning.
Medications used in ODD
As has been brought up before, ODD is likely to be comorbid, or combined with, another psychiatric disorder. Therefore, it is important to diagnose and treat that disorder first. If ODD is the only diagnosis, the first line of treatment should be therapeutic and behavioral interventions. If these treatments fail, or if the Child’s behavior is so disruptive or dangerous that it is unmanageable, medications may be a helpful adjunctive treatment. Unfortunately, there are no medications that are specifically designed for ODD or are FDA-approved for the disorder. However, several research studies have looked at the effects of medication on aggression, irritability, and impulsive behavior and since these symptoms are seen ODD they are often helpful.
The following is a brief guide to these medications:
Antipsychotics - Several studies have shown that antipsychotics are effective in reducing aggressive and irritable behavior. The atypical antipsychotics include Abilify, Geodon, Risperdal, Saphris, Seroquel, and Zyprexa. Older antipsychotics, called “typical” antipsychotics include Haldol, Loxitane, Mellaril, Navane, Prolixin, Stelazine, Thorazine, and Trilafon. These medications are thought to work by decreasing a neurotransmitter, dopamine, in the brain which improves thought processing and impulse control.
Mood stabilizers - Mood stabilizers are medications used to treat bipolar disorder. These medications include Depakote, Tegretol, Topamax, Trileptal, and Lamictal, and other medications originally used to treat seizures. These medications are also anticonvulsants used to treat seizure disorders. Studies have shown that these medications also help with irritable, aggressive, and impulsive behavior. Lithium, another mood stabilizer, may also be useful for some children with ODD.
Blood Pressure Medications - Catapres and Tenex, medications originally used to treat high blood pressure, have also shown to be helpful for aggression and impulsivity.
Serotonergic Antidepressants - Since some studies have shown that people with aggression may be deficient in serotonin, there may be some benefit to using antidepressants such as Prozac, Paxil, Lexapro, Celexa, or Luvox.
Since most of these medications have uses in other psychiatric disorders, it makes sense to choose the medication that treats the child’s comorbid disorder, if they have one. Otherwise, the choice of medications is based on a dialogue between the patient’s family and his or her psychiatrist.
A comprehensive treatment program should be implemented only after a thorough psycho/social evaluation by qualified child/mental health clinicians with specialized training in working with children, adolescents and their families. There are only three professions that have this training: Child Psychiatrists, Child Psychologists and Clinical Social Workers. In some cases, several of these professionals will work together as a treatment team.
Our Recommendations for Further Help:
Helpful Parenting Books:
- 10 Days to a Less Defiant Child: The Breakthrough Program for Overcoming Your Child’s Difficult Behavior
- Your Defiant Teen: 10 Steps to Resolve Conflict and Rebuild Your Relationship
Ask your child’s physician or school official for a referral to a mental health professional. You may also contact the American Psychological Association or American Academy of Child & Adolescent Psychiatry.