Oppositional Defiant Disorder

Key Takeaways

• Oppositional defiant disorder is a behavioral condition characterized by overly hostile, rule-breaking, or aggressive behaviors that last for at least 6 months.

• Like many behavioral health conditions, oppositional defiant disorder is caused by a combination of biological and environmental factors.

• Oppositional defiant disorder is best managed through a combination of family-based psychotherapy, school-based therapy, and parent management training. Medication is usually most effective when it treats conditions that co-occur with ODD, such as ADHD.

Understanding Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is a behavioral health condition that causes children to be unusually argumentative, vindictive, and defiant. Due to these main symptoms, ODD falls under the category of disruptive behavior disorders. What sets oppositional defiant disorder apart from other conditions is that hostile behaviors are usually directed toward authority figures and others who set rules and boundaries. However, the effects of ODD stand to impact a child’s peer interactions as well as their relationships with the entire family unit.

How common is it?

Oppositional defiant disorder affects anywhere between 3% and 6% of children.^[1][4] This condition is more commonly observed in school-aged children, likely due to the structure and rules set forth by academic institutions. ODD is twice as common in males as it is in females, especially in cases that develop during childhood. ^[3]

Oppositional Defiant Disorder Symptoms

According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), ODD symptoms fall into three main categories:^[1]

Irritable or angry mood

• Expressing feelings of resentment or acting in a resentful manner.

• Becoming easily frustrated or annoyed.

• Losing their temper often.

• Having low self-esteem.

Vindictiveness

• Behaving in a way that is spiteful or vengeful at least two times within 6 months.

Behavior that is defiant or argumentative

• Intentionally acting in a way that annoys others.

• Refusing to comply with requests or rules, or acting in a way that intentionally defies those rules.

• Speaking cruelly or harshly.

• Questioning rules.

• Arguing with authority figures (most often those who are familiar) on a routine basis over minor or major topics.

• Blaming others for their own behaviors or accidents.

• Getting disciplined at school often.

Those with ODD do not simply display the above symptoms; they must engage in such behaviors consistently and in a way that is not appropriate for their age. In order to attribute the above symptoms to ODD, someone must display behaviors across 6 months for more than half of the time. For patients who are 5 years or older, behaviors must occur at least once a week over the course of 6 months to be considered ODD.^[1]

In addition, ODD behaviors must cause a significant degree of strain on the person’s functioning or ability to be part of work, school, or home environments. Some of these behaviors may be due to other mental health concerns, in which case, someone would not receive an ODD diagnosis. While some conditions make a severity rating based on the amount of symptoms someone presents with, ODD severity is determined by the environments in which their symptoms are present:^[1]

• Mild ODD: Symptoms are displayed in 1 setting.

• Moderate ODD: Symptoms are displayed in 2 settings.

• Severe ODD: Symptoms are displayed in 3 or more settings.

The above criteria apply to individuals of any age, though other considerations affect ODD symptoms and functional impact in adults.

Signs of oppositional defiant disorder in adults

While less common, ODD can be diagnosed in adults. Evidence shows that children and adolescents who have ODD are more likely to experience poorer mental health outcomes and other behavioral disorders as adults. ^[5] Oppositional defiant disorder also increases someone’s risk of anxiety disorders, mood disorders, and substance use disorders later in life. ^[1] In addition, young adult men with ODD are more likely to experience difficulty with academic tasks, poor peer relations, familial conflict, and rejection from peers. ^[6]

The signs of oppositional defiant disorder are very similar between adults and children, yet severity may change due to the nature of a person’s life. For instance, a child whose primary behavioral concerns are at home and school will likely be diagnosed with moderate ODD. Once this person enters adulthood, they may experience the same difficulties at work, school, and home. This would lead their condition to be reclassified as severe.

Risk factors

Oppositional defiant disorder is known to stem from genetic and environmental factors. The following factors are known to increase someone’s risk of developing ODD: ^{[1] [2]}

• A history of abuse.

• Maternal depression or smoking during pregnancy.

• Negative influences from peers.

• Familial instability and unhealthy parental habits.

• Low socioeconomic status.

• Poor reactions to stress.

• Being raised with overly strict or inconsistent parenting.

• Having a low frustration tolerance or being emotionally reactive.

Early studies have suggested that being bullied may also be a risk factor for ODD, but more research is needed to confirm this link.^[5]

Prevention

One of the most effective ways to prevent ODD is to identify and address emotion regulation concerns early in life.^[1] This may include attending early intervention programs that provide anger management and social skills training for young children, or psychotherapy, homework assistance, and social skills training for adolescents and teenagers.^[7]

Complications

Unmanaged ODD may lead to difficulty adjusting at school and at home, law-breaking behaviors, and conduct disorder.^[5] However, early intervention services are aimed at preventing and managing long-term complications of ODD. Such services improve functional outcomes for people living with oppositional defiant disorder. Without treatment, individuals with ODD are at risk of future mood disorders, anxiety disorders, substance use disorders, and other behavioral disorders.^[1]

Diagnosing

A child can be diagnosed with ODD as early as 3 years of age, but this typically happens before the age of 8.^[4] Mental health professionals, such as child psychiatrists and psychologists, are best suited to make a diagnosis of ODD. Providers must rule out anxiety disorders, depression, ADHD, and learning disabilities to ensure behaviors are not due to those conditions. A thorough mental health evaluation will also take a child’s culture, age, and development into consideration to ensure none of those are the source of behavioral concerns.^[7]

Professionals will then interview a child’s family, teachers, and caregivers, as well as the child if they are old enough to participate.^[9] It is important to note that behavior concerns are not considered ODD symptoms if they present themselves when a child is interacting with their sibling. This is the type of information providers will get from parents and those who know the child.

Tests and Assessments

Mental health providers will incorporate some specific tests into the evaluation to help them learn about the child’s behaviors. These tests may include the Eyberg Child Behavior Inventory, Conners Child Behavior Checklist, Strengths and Difficulties Questionnaire, Disruptive Behavior Diagnostic Observation Schedule, and Child Symptom Inventory.^[1]

Treating Oppositional Defiant Disorder

Children with ODD benefit from a multifaceted approach that involves the child, their family, and teachers. When behavioral concerns are suspected early on, treatment should focus on lowering a child’s risk factors. For example, bullying has been identified as a potential ODD risk factor. Therefore, preventive treatment for some children may focus on anti-bullying efforts. The exact treatment approaches used will depend on the child’s behavioral concerns, but they may include a combination of therapy, medication, and alternative modalities.

Therapy

• Parent management training (PMT): This is considered the primary treatment for ODD. PMT involves teaching positive reinforcement to encourage healthy behaviors and minimize adverse behaviors. Providers also teach communication techniques and non-violent consequences as responses to unwanted behaviors. ^[1]

• School-based therapy: This allows teachers to strengthen the academic performance and problem-solving skills of children with ODD. ^[1] School-based therapy also incorporates social skills training to help with peer interactions.

• Individual therapy: Through adapted Cognitive Behavioral Therapy (CBT), individual psychotherapy can help with anger problems in younger children. Approaches for adolescents and teenagers focus more on problem-solving skills to lessen aggression.

• Functional family therapy: This form of psychotherapy trains all family members to communicate more effectively with a child who has ODD. This helps them better manage difficult emotions and situations. ^[3]

Medication

While they are not considered the primary management method for ODD, pharmacological treatments may be recommended. Evidence supports the use of haloperidol, risperidone, lithium, and aripiprazole, though these are not FDA-approved and are considered an off-label treatment option. ^[1] However, there are several adverse side effects related to using these medications, so they are to be used with caution. The main instances when medication is effective for ODD are when they address co-occurring ADHD or when psychotherapy is not effective.

Alternative Therapies

Some alternative therapies that have been suggested to assist with ODD include yoga, mindfulness-based modalities such as meditation and deep breathing, animal-assisted therapy, play therapy, and dietary supplementation. It is important to remember these are only intended to be used alongside the aforementioned treatments, not in place of them. Even so, there is very little evidence on the effects of these methods in any capacity to manage ODD.

Living with oppositional defiant disorder

While ODD can present many challenges for an individual, early diagnosis and active participation in treatment are good signs that someone will experience positive outcomes. Someone with ODD should also receive treatment for any comorbid conditions to experience optimal benefits. Individuals who engage in comprehensive treatment along with individual or family therapy and have caregivers who utilize positive parenting techniques are likely to experience a good prognosis.

Supporting someone with oppositional defiant disorder

Participating in family therapy and staying involved in counseling and psychiatric care is one of the best ways to help a child who has ODD. If your child has academic difficulties as a result of ODD, talk to their teacher about reasonable accommodations or an Individualized Education Plan (IEP). Lastly, be sure you are also receiving support. This may involve separately speaking to a mental health provider or joining a support group. Remember that there is help available for all those affected by ODD and their loved ones.