You are in: eMedicine Specialties > Pediatrics: Developmental and Behavioral > MEDICAL TOPICS Oppositional Defiant DisorderArticle Last Updated: Feb 8, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 8
  Author: W Douglas Tynan, PhD, Chief Psychologist, Nemours Health and Prevention Division Programs; Director, Primary Care Mental Health Program, A I duPont Hospital for Children; Consulting Psychologist, Nemours Clinical Management W Douglas Tynan is a member of the following medical societies: American Academy of Pediatrics, American Psychological Association, Society for Developmental and Behavioral Pediatrics, and Society for Research In Child Development Editors: Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine; Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School; Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine Author and Editor Disclosure Synonyms and related keywords: oppositional defiant disorder, ODD, conduct disorder, disruptive behavior, defiant behavior, negativistic behavior, hostile behavior, disobedience, stubbornness, attention-deficit/hyperactivity disorder, ADHD, irritability, impulsivity, harshly punitive behaviors, peer rejection, noncompliance with commands, overreaction to life events, antisocial actions, learning disorders, parent management training, maladaptive parent-child interactions DEFINING OPPOSITIONAL DEFIANT DISORDERSection 2 of 8
  The American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition (DSM IV), defines oppositional defiant disorder (ODD) as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. Behaviors included in the definition include the following: losing one's temper; arguing with adults; actively defying requests; refusing to follow rules; deliberately annoying other people; blaming others for one's own mistakes or misbehavior; and being touchy, easily annoyed or angered, resentful, spiteful, or vindictive. ODD is usually diagnosed when a child has a persistent or consistent pattern of disobedience and hostility toward parents, teachers, or other adults. The primary behavioral difficulty is the consistent pattern of refusing to follow commands or requests by adults. Children with ODD are often easily annoyed; they repeatedly lose their temper, argue with adults, refuse to comply with rules and directions, and blame others for their mistakes. Stubbornness and testing limits are common, even in early childhood. The criteria for ODD are met only when the problem behaviors occur more frequently in the child than in other children of the same age and developmental level. These behaviors cause significant difficulties with family and friends, and the oppositional behaviors are the same both at home and in school. Sometimes, ODD may be a precursor of a conduct disorder. ODD is not diagnosed if the problematic behaviors occur exclusively with a mood or psychotic disorder. PREVALENCE AND COMORBIDITYSection 3 of 8
The base prevalence rates for oppositional defiant disorder (ODD) range from 1-16%, but most surveys estimate it to be 6-10% in surveys of nonclinical, nonreferred samples of parents' reports. In more stringent population samples, rates are lower when impairment criteria are stricter and when the information is obtained from both parents and teachers, rather than from parents only. Before puberty, the condition is more common in boys; after puberty, it is almost exclusively identified in boys, and whether the criteria are applicable to girls has been discussed. The disorder usually manifests by age 8 years. ODD and other conduct problems are the single greatest reasons for referrals to outpatient and inpatient mental health settings for children, accounting for at least half of all referrals. Diagnosis is complicated by relatively high rates of comorbid, disruptive, behavior disorders. Some symptoms of attention deficit hyperactivity disorder (ADHD) and conduct disorder overlap. Researchers have postulated that, in some children, ODD may be the developmental precursor of conduct disorder. Comorbidity of ODD with ADHD has been reported to occur in 50-65% of affected children. In some children, ODD commonly occurs in conjunction with anxiety disorders and depressive disorders. Cross-sectional surveys have revealed the comorbidity of ODD with an affective disorder in about 35% of cases, with rates of comorbidity increasing with patient age. High rates of comorbidity are also found among ODDs, learning disorders, and academic difficulties. Given these findings, children with significant oppositional and defiant behaviors often require multidisciplinary assessment and may need components of mental health care, case management, and educational intervention to improve. RISK FACTORS AND ETIOLOGYSection 4 of 8
The best available data indicate that no single cause or main effect results in oppositional defiant disorder (ODD).1 Most experts believe that biological factors are important in ODD and that familial clustering of certain disruptive disorders, including ODD and ADHD, substance abuse, and mood disorders, occurs. CLINICAL COURSESection 5 of 8
In toddlers, temperamental factors, such as irritability, impulsivity, and intensity of reactions to negative stimuli, may contribute to the development of a pattern of oppositional and defiant behaviors in later childhood. Family instability, including economic stress, parental mental illness, harshly punitive behaviors, inconsistent parenting practices, multiple moves, and divorce, may also contribute to the development of oppositional and defiant behaviors. The interactions of a child who has a difficult temperament and irritable behavior with parents who are harsh, punitive, and inconsistent usually lead to a coercive, negative cycle of behavior in the family. In this pattern, the child's defiant behavior tends to intensify the parents' harsh reactions. The parents respond to misbehavior with threats of punishment that are inconsistently applied. When the parent punishes the child, the child learns to respond to threats. When the parent fails to punish the child, the child learns that he or she does not have to comply. Research indicates that these patterns are established early, in the child's preschool years; left untreated, pattern development accelerates, and patterns worsen. Developmentally, the presenting problems change with the child's age. For example, younger children are more likely to engage in oppositional and defiant behavior, whereas older children are more likely to engage in more covert behavior such as stealing. By the time they are school aged, children with patterns of oppositional behavior tend to express their defiance with teachers and other adults and exhibit aggression toward their peers. As children with oppositional defiant disorder (ODD) progress in school, they experience increasing peer rejection due to their poor social skills and aggression. These children may be more likely to misinterpret their peers' behavior as hostile, and they lack the skills to solve social conflicts. In problem situations, children with ODD are more likely to resort to aggressive physical actions rather than verbal responses. Children with ODD and poor social skills often do not recognize their role in peer conflicts; they blame their peers (eg, "He made me hit him.") and usually fail to take responsibility for their own actions. The following 3 classes of behavior are hallmarks of both oppositional and conduct problems: (1) noncompliance with commands; (2) emotional overreaction to life events, no matter how small; and (3) failure to take responsibility for one's own actions. When behavioral difficulties are present beginning in the preschool period, teachers and families may overlook significant deficiencies in the child's learning and academic performance. When many children with behavioral problems and academic problems are placed in the same classroom, the risk for continued behavioral and academic problems increases. ODD behavior may escalate and result in serious antisocial actions that, when sufficiently frequent and severe, become criteria to change the diagnosis to conduct disorder. Milder forms of ODD in some children spontaneously remit over time. More severe forms of ODD, in which many symptoms are present in the toddler years and continually worsen after the child is aged 5 years, may evolve into conduct disorder in older children and adolescents. TREATMENTSection 6 of 8
Given the high probability that oppositional defiant disorder (ODD) occurs alongside attention disorders, learning disorders, and conduct disturbances, an evaluation for these disorders is indicated for comprehensive treatment.3 Pharmacologic treatment (eg, stimulant medication) for ADHD may be beneficial once this is diagnosed. Children with oppositional behavior in the school setting should undergo necessary screening testing in school to evaluate for possible learning disabilities. With the multifaceted nature of associated problems in ODD, comprehensive treatment may include medication, parenting and family therapy, and consultation with the school staff. If children with ODD are found to have ADHD as well, appropriate treatment of ADHD may help them to restore their focus and attention and decrease their impulsivity; such treatment may enable their social and behavioral interventions to be more effective. Parent management training (PMT) is recommended for families of children with ODD because it has been demonstrated to affect negative interactions that repeatedly occur between the children and their parents.4 PMT consists of procedures in which parents are trained to change their own behaviors and thereby alter their child's problem behavior in the home. PMT is based on 35 years of well-developed research showing that oppositional and defiant patterns arise from maladaptive parent-child interactions that start in early childhood.5 These patterns develop when parents inadvertently reinforce disruptive and deviant behaviors in a child by giving those behaviors a significant amount of negative attention. At the same time, the parents, who are often exhausted by the struggle to obtain compliance with simple requests, usually fail to provide positive attention; often, the parents have infrequent positive interactions with their children. The pattern of negative interactions evolves quickly as the result of repeated, ineffective, emotionally expressed commands and comments; ineffective harsh punishments; and insufficient attention and modeling of appropriate behaviors. PMT alters the pattern by encouraging the parent to pay attention to prosocial behavior and to use effective, brief, nonaversive punishments. Treatment is conducted primarily with the parents; the therapist demonstrates specific procedures to modify parental interactions with their child. Parents are first trained to simply have periods of positive play interaction with their child. They then receive further training to identify the child's positive behaviors and to reinforce these behaviors. At that point, parents are trained in the use of brief negative consequences for misbehavior. Treatment sessions provide the parents with opportunities to practice and refine the techniques. Follow-up studies of operational PMT techniques in which parents successfully modified their behavior showed continued improvements for years after the treatment was finished. Treatment effects have been stronger with younger children, especially in those with less severe problems. Recent research suggests that less severe problems, rather than a younger patient age, is predictive of treatment success. Approximately 65% of families show significant clinical benefit from well-designed parent management programs. Regardless of the child's age, intervention early in the developing pattern of oppositional behavior is likely to be more effective than waiting for the child to grow out of it. These children can benefit from group treatment. The process of modeling behaviors and reactions within group settings creates a real-life adaptation process. In younger children, combined treatment in which parents attend a PMT group while the children go to a social skills group has consistently resulted in the best outcome. The efficacy of group treatment of adolescents with oppositional behaviors has been debated.6 Group therapy for adolescents with ODD is most beneficial when it is structured and focused on developing the skills of listening, empathy, and effective problem solving. OBSTACLES TO TREATMENTSection 7 of 8
Oppositional defiant disorder (ODD), and other conduct problems, can be intractable. Despite advances in treatment, many children continue to have long-term negative sequelae. PMT requires parental cooperation and effort for success. Existing psychiatric conditions in the parents can be a major obstacle to effective treatment. Depression in a parent, particularly the mother, can prevent successful intervention with the child and become worse if the child's behavior is out of control. Substance abuse and other more severe psychiatric conditions can adversely affect parenting skills, and these conditions are particularly problematic for the parents of a child with ODD. In situations in which the parents lack the resources to effectively manage their child, services can be obtained through schools or county mental health agencies. Many states have effective "wrap around" services, which include a full-day school program and home-based therapy services to maintain progress in the home setting. Thus, effective treatment can include resources from several agencies, and coordination is critical. If county mental health or school special education services are involved, one person is usually designated to coordinate services in those systems. REFERENCESSection 8 of 8
Oppositional Defiant Disorder excerpt Article Last Updated: Feb 8, 2008 |
