Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is a condition prevalent in a significant percentage of children that adversely impacts the individual and also affects the family, school, community, and society. Early awareness of and intervention in ODD is crucial in stopping a potentially dangerous and destructive progression to a more serious disorder. However, as oppositional behavior is a normal part of development for young children and early adolescents, clinicians need to exercise caution when assessing and diagnosing ODD in order to avoid misdiagnosis.

Oppositional Defiant Disorder Definition

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines ODD as a childhood disorder characterized by an ongoing and persistent pattern of hostile, noncompliant, and resistant behaviors manifested toward authority figures. In order to attain a diagnosis of ODD, behaviors must consistently occur for at least 6 months. Individuals with ODD are often described as stubborn, easily angered, argumentative, verbally aggressive, quickly annoyed by others, externally blameful for personal mistakes, deliberately annoying, and physically aggressive. In addition, such children easily lose their temper on a consistent basis and may demonstrate vindictive behavior. Often, children with ODD possess a low frustration tolerance and have difficulty controlling impulses. Last, individuals with ODD typically procrastinate and dawdle when expected to comply with a command. They commonly lack insight into their behavior and view their noncompliant behavior as an acceptable response to overdemanding situations.

ODD can cause significant difficulties in many areas of a child’s life, including the family and school environment. Typically children with ODD have a difficult time getting along with family members (i.e., siblings, parents) and may find it hard to initiate or maintain peer relationships. Although children with ODD often have difficulty forming positive relationships with individuals of authority (i.e., teachers, coaches), defiant behaviors are sometimes solely present with individuals with whom the child has a close relationship.

Oppositional Defiant Disorder Prevalence and Onset of Symptoms

Although studies differ in reported statistics, an estimate of the prevalence rate for ODD ranges from 2% to 16%. In addition, the DSM-IV states that ODD tends to be more common in males prior to puberty, but prevalence rates even out between males and females following puberty. ODD is typically noticeable before the age of 8 and is not commonly evident soon after adolescence commences. Onset of symptoms is not sudden, and behaviors tend to slowly manifest over the course of several months or years. As younger children develop more sophisticated verbal capabilities, defiance may advance from simple refusals to more sophisticated oppositionality (i.e., negotiations).

Associated Difficulties

Problems commonly associated with ODD include low self-esteem, substance use or abuse, and frequent mood fluctuations. In addition, ODD may be an early indicator of a more severe psychopathology but does not necessarily precede a more severe condition. In some cases, ODD may progress into conduct disorder (CD), a disorder characterized by socially inappropriate (i.e., law breaking) and destructive behaviors. Children with ODD were 4 times more likely to develop CD than were children without ODD, although the risk of development from ODD to CD in females is somewhat unclear. Longitudinal research conducted by Hinshaw, Lahey, and Hart has shown that half of children with ODD progress to CD, 25% maintain the ODD diagnosis, and 25% eventually discontinue showing clinically significant levels of externalizing behavior. Last, attention deficit hyperactivity disorder (ADHD), learning disabilities, and mood disorders commonly coexist with ODD, and interventions targeting these conditions may reduce oppositional behavior.

Oppositional Defiant Disorder Assessment

In order to obtain a comprehensive assessment of ODD, a clinician should adopt a multifaceted approach in which a variety of domains are explored. In addition, the assessment should employ a number of ways to gather information from multiple individuals in the child’s life.

Often when assessing for ODD, clinicians engage in a structured diagnostic or clinical interview with both the child and the parent(s). A structured interview is a diagnostic assessment with pre-established questions that can be scored in an objective fashion. A clinical interview is important in order to assess the frequency of behaviors, level of impairment for the child and family, and antecedents (e.g., a request from a parent or teacher) and consequences (e.g., time-out) that surround the oppositional behavior. In addition, both structured and clinical interviews are helpful in determining the presence of other psychiatric conditions. Last, interviews with the child are helpful aids to parent interviews.

In addition to interviewing the child and other authority figures in the child’s life, clinicians also administer self-report behavioral rating scales, such as the Child Behavior Checklist (CBCL), to the child, parents, and teachers. These assessments are useful in gathering a broad range of information as well as information about specific behaviors. Also, like the interview, some rating scales provide data that may be helpful to guide diagnostic decisions.

Last, in order to corroborate information gathered in both the interview and the self-report measures, behavioral observations are often conducted. McMahon and Wells point out that behavioral observation is crucial in the assessment process in that it allows a clinician to observe parent-child or teacher-child interaction patterns and to assess change in the communication patterns as treatment progresses.

Psychosocial Intervention

Treatments for ODD are eclectic and may include individual therapy, family therapy, and behavioral modification plans. Although psychodynamic and humanistic approaches to treatment are available, treatment typically focuses on cognitive-behavioral approaches, as they have received the most empirical support. Behavioral parent training programs are based on social learning principles that suggest children learn noncompliance through a process of modeling and reinforcement for externalizing behaviors from individuals in their environment, particularly parents. Therefore, parents are taught to recognize and change their parenting behaviors in order to enhance their child’s prosocial behaviors and decrease inappropriate behaviors.

Behavioral parent training programs also focus on relationship building and teaching effective discipline techniques. In the relationship component, parents are taught skills to enhance communication patterns and to foster a stronger parent-child bond. During this component, parents are taught to follow the child’s lead during a play situation, to recognize and praise positive behaviors, and to systematically ignore minor inappropriate behaviors (e.g., differential attention). The discipline portion of behavioral parent training focuses on teaching parents how to give effective commands, to consistently praise compliant behavior, and to effectively implement a time-out contingent upon noncompliant behavior. Behavioral parent training programs employ a variety of methods to teach behavior modification techniques, including didactic instruction, role-play, modeling, live coaching, and practicing in both the clinic and home environment.

Psychopharmacological Intervention

Although some pharmacological interventions have shown promise in reducing oppositional defiant behavior, the literature continues to assert that psychosocial treatment is the gold standard in treating this disorder. Few randomized clinical trials have investigated the effects of medication on ODD in isolation. However, Newcorn, Spencer, Biederman, Milton, and Michelson examined the effect of psychopharmacological agents on ODD when the disorder is an adjunct to ADHD and have found positive results. Although research suggests that certain psychopharmacological agents may be a well-tolerated and effective treatment for ODD, further investigation is warranted in this area.

Clinical Considerations

Assessing Age-Appropriate Behavior

One factor that needs to be considered in making a diagnosis of ODD is whether the frequency and intensity of behavior problems occur outside of the expected range for a child’s mental age and developmental level. An individual with ODD tends to show a recurrent pattern of negativistic behavior as opposed to episodes of transient temper tantrums and disobedience that do not greatly impair daily functioning. It is developmentally appropriate for young children to occasionally act out and refuse to obey commands. For example, normally developing 2- or 3-year-old children typically begin to seek more autonomy from their parents, and with this independence come more occasions for parent-child disagreements. In addition, beginning school can be a difficult endeavor for any young child and may set the stage for mild disagreements with peers. Typically, peer-related arguments and disagreements quickly diminish as children learn more positive ways to interact. For this reason, a clinician must separate behavior that is developmentally appropriate from that which occurs more frequently and with more severity.

Differential Diagnosis

As externalizing behaviors exist on a spectrum, it is important to differentiate ODD from other behavior disorders such as conduct disorder. The chief factor separating ODD from CD is that children with ODD do not engage in behaviors that violate the basic rights of others or break age-appropriate societal norms. Children with ODD tend to manifest overt, nondestructive behaviors that are typically easy to detect. On the other hand, children with CD typically demonstrate more destructive, aggressive behaviors (overt and covert) that may endanger the safety of themselves or others. For example, an individual with CD may cause harm to animals, set fires, vandalize, or run away from home for long periods of time. It is worth noting that most individuals with CD meet diagnostic criteria for ODD, but a diagnosis of CD is made when both diagnoses can be given.

Case Example

Daniel, age 5, was referred to the clinic due to his oppositional and verbally aggressive behaviors at home and at school. At home, Daniel often refused to listen to his parents and would lash out at his little sister. On more than one occasion, Daniel’s parents felt unsafe around him during his meltdowns. Daniel’s parents stated that they felt like they were constantly walking on eggshells at home, and even the smallest incident would set him off. They described Daniel as a “difficult” baby and said they felt like he had never progressed beyond 2 years of age. Daniel often would scream, “I hate you” to his parents when they asked him to do even the simplest task. In addition, Daniel constantly blamed his little sister for incidents that he was clearly responsible for.

At school, Daniel was constantly getting in trouble for his behavior. He frequently yelled at his teacher and rarely listened to instructions. On occasion, Daniel would run out of the classroom without permission and disrupt other children in the hallway. Daniel’s teachers said that he was constantly teasing other children for “no reason whatsoever” and often held grudges against other children. For his bad behavior, Daniel consistently received “red lights” from his teacher and missed recess at least 3 times a week. Daniel had seldom been physically aggressive with others and did not engage in more dangerous behaviors such as fire-setting, maliciously lying, or displaying developmentally inappropriate sexual behavior.

Daniel’s parents stated that they had “tried everything,” and nothing seemed to work with Daniel. They reported that he was constantly in time-out but that it did little to diminish his bad behavior. Also, they said that they took everything away from Daniel when he acted out until they had no privileges left to take away. Daniel’s parents were concerned that his quick temper and lack of flexibility would lead to a larger problem in the future and negatively affect his relationships with them, his sister, and his peers.

In order to reduce Daniel’s oppositional behavior and improve the quality of life at both home and school, the therapist recommended behavioral parent training and had Daniel’s parents commit to six sessions. During treatment, Daniel’s parents learned ways to effectively communicate with Daniel. For example, Daniel’s parents learned the importance of social reinforcement and that praising Daniel for a specific behavior would increase the likelihood of that behavior occurring again. Also, Daniel’s parents learned how to remove their attention for negative behaviors. Last, his parents learned effective ways to give instructions to Daniel and to administer appropriate consequences to Daniel’s responses. After eight sessions, Daniel’s oppositional behavior diminished at both home and school, and he not only began to receive fewer “red lights” but also began to bring home “green lights” for good behavior.

References:

Brestan, E. V., & Eyberg, S. M. (1998). Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psychology, 27, 180-189.
Burke, J. D., Loeber, R., & Birmaher, B. (2002). Oppositional defiant disorder and conduct disorder: A review of the past 10 years, part II. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 1275-1293.
Hembree-Kigin, T. L., & McNeil, C. B. (1995). Parent-child interaction therapy. New York: Plenum Press.
McMahon, R. J., & Forehand, R. L. (2003). Helping the noncompliant child: Family-based treatment for oppositional behavior (2nd ed.). New York: Guilford Press.
McNeil, C., Eyberg, S., Eisenstadt, T., Newcomb, K., & Funderburk, B. (1991). Parent-child interaction therapy with behavior problem children: Generalization of treatment effects to the school setting. Journal of Clinical Child Psychology, 20, 140-151.
Spencer, T. J., Abikoff, H. B., Connor, D. F., Biederman, J., Pliszka, S. R., Boellner, S., et al. (2006). Efficacy and safety of mixed amphetamine salts extended release (Adderall XR) in the management of oppositional defiant disorder with or without comorbid attention-deficit/hyperactivity disorder in school-aged children and adolescents. Clinical Therapeutics, 28, 402-418.