Although nursing school was more than twenty years ago now... woah, no, almost thirty years ago, I can't say that I remember learning about Oppositional Defiant Disorder in my undergraduate training. I am not even sure that I remember this particular psychiatric, or conduct disorder being discussed in any of my graduate programs, but today in clinical practice, it's quite common that my pediatric clientele present already having been identified as ODD.
Oppositional defiant disorder (ODD) is a type of childhood disruptive behavior disorder that primarily involves problems with self-control of emotions and behaviors. According to the Diagnostic and Statistical Manual of Mental Disorders - the DSM-5 - the main feature of ODD is a persistent pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness towards others. Know anyone like this?
Why Might This Happen?
Like most all other physical and mental ailments, the cause is a bit complex. Genetics plays a role. Attention deficit disorder, depressive disorder, and oppositional defiant disorder are all significant family traits. One study identified that a low activity level of the neurotransmitter-metabolizing enzyme, monoamine oxidase A (MAO-A), alongside childhood abuse are far more likely to be reported as having conduct problems and hostility later in development. Changes in cortisol, our stress hormone, and neuroimaging findings, particularly in the prefrontal cortex, amygdala, and insula appear to be involved. Stress and #trauma seem to turn this genetic predisposition on, unfortunately.
Harsh, inconsistent parenting are often identified within families of children with ODD. Certainly this isn't a necessity, nor does the diagnosis indicate there was abuse, but these two variables do seem related. Temperamental factors such as irritability, impulsivity, poor frustration, tolerance, and high levels of emotional reactivity are commonly associated with #ODD. Trauma in itself can be the cause, such as divorce, a parent with an addictive disorder, or having a bad relationship with one of their parents, or any family instability. ODD symptoms worsen in children who struggle with peer acceptance in addition to family issues.
While not all children diagnosed with ODD show callous and unemotional traits, it has been shown that such traits are highly heritable and may be seen more frequently in a subset of children with more significant disruptive behaviors. Peer rejection, deviant peer groups, poverty, neighborhood violence, and other unstable social or economic factors are known to exert significant negative effects on children's behaviors and may contribute to the development of ODD.
ODD is four times more common in boys than in girls, and more often diagnosed in preadolescents. However, once into the teenage and adult years, ODD seems to be fairly distributed among the genders. Symptoms seem to remain stable between the ages of five and ten years, and are thought to decline afterward.
What Might This Look Like in My Child?
Oppositional defiant disorder can be identified during preschool years, but more often in the elementary years. Most often, these children also suffer another mental health disorder, including mood disorders, anxiety disorders, impulse control disorders, autism and substance use disorders. There is a lot of shame here though, in that parents are often to blame. As most Child Protective workers will say today, "We believe the child," and the school often assumes the child is coming from a rough home so parents are hesitant to share their homelife difficulties. When they do, they are not often believed.
As a clinician, when parents share their concerns with me, to meet diagnostic criteria for ODD, I am looking for at least four of these symptoms - present most days for at least the last six months, demonstrating a pattern of angry or irritable mood, #argumentative or defiant behavior, or vindictiveness:
often loses temper,
often touchy or easily annoyed,
often angry and resentful,
often argue with authority figures or, for children and adolescents, with adults,
often actively refuse or defy to comply with requests from authority figures or with rules,
often deliberately annoys others,
often blames others for his or her mistakes or misbehavior, and
the child has been spiteful or vindictive at least twice within the past six months.
There should be real evidence of some sort of consequence of this behavior on the child, their family, or their peers and/or a negative impact on social, educational, occupational, or other important areas of functioning. These behaviors aren't exclusive to substance abuse, psychotic behavior, depression, or even #bipolar disorder, and they must not meet the criteria for disruptive mood dysregulation disorder.
Part of my evaluation is also determining severity, so when talking to the child and family, if these behaviors are really only confined to one setting, the diagnosis is considered mild but that doesn't mean the impact is mild, because often what happens in this scenario is the poor behavior is at home and the child behaves well at school, so then parents aren't believed and are often blamed. Sometimes this progresses too, so when it becomes more a moderate severity, when which is occurs in to settings, then the relationship between school and parents or parents and therapist may already be broken. ODD is considered severe if symptoms are present in three or more settings, such as both parents homes if #divorced, and at school. In this latter scenario, support systems are often exhausted and police can be involved, but again, this doesn't mean there is any collaboration and often parents are penalized with #truancy charges, #abandonment or #neglect if the child runs away, or damages for any conduct behavior.
It is optimal of course to have the child evaluated by multiple professionals and specialities and with multiple informants (parents, siblings, friends, and teachers) but again, because the system doesn't support the family, what I have found in clinical practice is parents afraid of being reported yet again to Child Protective Services. They often have other children they need to protect. They may be physically harmed by their child, or their children afraid of them and when calling police, the parents are identified as the predator because again, the child will always be viewed as the victim by the Department of Child Services. If this is your scenario, you have my sympathy, but so does your child. Many know they do this and don't know why, and are heartbroken about it. They don't want to misbehave. They don't understand why they do it, so they blame others and hurt their relationships, isolating themselves and worsening their depression. It's a horrific scenario. Many times though, these individuals with ODD do not seem themselves as angry and defiant and consider their behavior justified by the unreasonable demands of others, so they speak ill of friends, parents and teachers which tears down the support system and collaboration among resources.
A complete academic assessment should be obtained to rule out underlying challenges such as a learning disability. Intelligence testing should be completed, and I recommend a opthoneuro evaluation or a sensory integration evaluation by a specialized occupational therapist.
It is also important to identify any modifiable risk factors such as bullying or poor school performance that might contribute to oppositional behaviors. ODD is a common diagnosis in those who already suffer Attention Deficit Hyperactivity Disorder and Obsessive Compulsive Disorder, so identifying the gamet of challenges is part of this evaluation. #Autism may also play a role.
A number of screening tools exist, which you clinician may utilize to help in diagnosis and monitor treatment, with The Child Behaviour Checklist being quite commonly used. The Conners Child Behaviour Checklist, The Behaviour Assessment for Children (BASC-1), Strengths & Difficulties Questionnaire (SDQ), The Development & Well-Being Assessment (DAWBA), and the Disruptive Behaviour Diagnostic Observation Schedule, and the Child and Adolescent Psychiatric Assessment are others.
How is ODD Treated?
This too is complex and best done as a family unit, with school and the community all collaborating. Admittedly, I have yet to see this scenario. My unfortunate experience is typically the parents being at odds with the school or facing investigation with disrespectful treatment from police and/or CPS. Therapists don't often want to involve parents in an attempt to respect the privacy of the child, but that leaves the full perspective out of therapy as well as dividing parent from child. Mental health resources are also hard to come by at all, let alone finding one the child and parent really resonate.
When these scenarios present, it is imperative, in my opinion, for parents to gain, alongside the child, a full understanding of the child's challenges and offered the opportunity for respite, support, and tools so they can better meet the needs of their child. Modifiable risk factors should be addressed, which may require an #IEP with the school. ADHD, #depression, or #anxiety may need to be treated and while our practice is all in with the functional and integrative mindset, these scenarios can be exceedingly overwhelming, quite pervasive, and more like triaging a trauma scene. We don't give a woman hemorrhaging in childbirth herbs initially. We save her life with pharmaceuticals, but then we can support her with herbs and identifying the underlying cause to restore her health.
#Risperidone has the best evidence for control of aggressive behaviors, followed by #aripiprazole. Quetiapine has also shown some effectiveness, but it has a much wider range of side effects. If aggression continues to be unmanaged, then the clinician may add a mood stabilizer after thorough evaluation, although the use of lithium, carbamazepine, and lamotrigine is not robust.
When we are also needing to treat ADHD, #stimulants such as methylphenidate may provide helpful, or non-stimulants, such as atomoxetine, guanfacine, and clonidine may be appropriate. Of course, our practice would want to help find some stability for the family, offering everyone a moment to breathe from what can feel like a fast and dangerous downward spiral, fully engaging your fight-or-flight responses, but then once some stability is obtained, working to understand the child's epidemiology can be exceedingly helpful. Many times, I find this is related to inflammation or underlying triggers which when identified and addressed are completely life-changing, eliminating the needs, eventually, for ongoing pharmaceutical therapy.
Cognitive behavioral therapy may be helpful for the child in managing anger or communicating their needs and emotions, even identifying them. Parent management training can be helpful too, as some really do struggle to identify how best to interact with their child, but more often I hear parents find these methods condescending. Their efforts aren't validated, appreciated, or believed. Functional family therapy or brief strategic family therapy within a mutually respectful and trusting relationship with a therapist would really be ideal.
Conduct Disorder
While both conduct disorder (CD) and Oppositional Defiant Disorder deal with conflicts with authority figures, behaviors in ODD are less severe than in conduct disorder and tend to involve primarily angry or argumentative behavior or behaviors that are intentionally annoying. Conduct disorders though are a bit more severe and involve problems with physical aggression, fire-setting, animal cruelty, truancy from school, property damage, or stealing. Conduct disorder and ODD share common genetic influences although are not one in the same, although this is somewhat controversial in the literature.
Attention Deficit Hyperactivity Disorder (ADHD)
The association between ODD and ADHD is well-studied in the literature, with the latter being more a restlessness or fidgety behavior, an inability to sustain focus on tasks or waiting their turn, and problems with following rules in multiple settings. Theses two disorders do tend to co-exist. Oppositionality is not uncommonly seen in ADHD or even autism when there is a change in routine or other sensory disruption.
Mood Disorders
Emotional dysregulation, negative affect, and irritability are commonly seen in mood disorders, including depression and bipolar disorders. Mood disorders are unsurprisingly common comorbidities alongside ODD because when one is oppositional, they are often struggling to regulate their emotions. ODD can also be the prodromal heads-up for mood disorders later in life, as these have similar risk factors. These need ruled out and managed if diagnosed to find success with ODD. Keep in mind that if symptoms are present only during a mood disorder, ODD isn't an appropriate diagnosis.
Disruptive Mood Dysregulation Disorder (DMDD)
DMDD is a childhood disorder characterized by frequent temper outbursts along with a persistently irritable mood in between outbursts. This use to be diagnosed as bipolar in the younger years, but experts found they did not typically grow up to have more manic episodes, but rather, much more significant depression.
This severe, irritable mood should be ongoing for a year and be present in multiple settings, and occur prior to the age of ten years. The severity of the outbursts are more severe with DMDD and the irritable mood remains between fits. The DMS-5 states that if the child meets criteria for both, only DMDD should be diagnosed.
What Does This Mean for My Child?
If your child is diagnosed with oppositional defiant disorder, then they are likely struggling socially, academically, and in their work life. They are very likely to have conflicts with their parents, teachers, and peers, and especially their siblings. These little ones don't often adjust well in adulthood, and while mild to moderate forms of ODD often do improve with age, more severe forms can evolve into conduct disorder. When they also have lower intelligence or lack of proper supervision, their prognosis is much worse. Treating other diagnosis, such as ADHD or mood disorders, can greatly improve their outcomes, as does individual and family therapy.
References
Aggarwal, A. & Marwaha, R. (2022). Oppositional Defiant Disorder. StatPearls.