Oppositional Defiant Disorder (ODD)

Oppositional Defiant Disorder (ODD)

All kids are oppositional from time to time, particularly when tired, hungry, stressed or upset. They may argue, talk back, disobey, and defy moms & dads, teachers, and other adults. Oppositional behavior is often a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other kids of the same age and developmental level and when it affects the youngster's social, family, and academic life.

1. Can ODD be prevented? For preschool kids, there is some evidence that programs such as Head Start and home visitation to high risk families can have a positive impact in areas related to ODD. In school–age kids, parent management, social skills training, conflict resolution and anger management programs have all been utilized with varying degrees of success. For adolescents, psycho-educational programs, including cognitive interventions and skills training, vocational training, and academic preparations appear to reduce the disruptive behaviors usually associated with ODD. A number of school-based prevention programs have also produced promising results. The focus of the school programs ranges from bullying prevention to interventions aimed at reducing anti-social behavior and helping kids resist negative peer group influences. However, there is some evidence that group treatment can also have negative effects on outcome, especially among kids and adolescents who are already showing signs and symptoms of difficulties.

2. Does ODD get better or go away over time? For many kids, ODD does improve over time. Follow up studies have shown that the signs and symptoms of ODD resolve within 3 years in approximately 67% of kids diagnosed with the disorder. However, research has also shown that approximately 30% of kids with ODD eventually develop conduct disorder. The risk is 3 times greater for kids who were initially diagnosed at a very young (e.g., preschool) age. Preschool kids with ODD are also likely to exhibit additional disorders several years later, including ADHD, anxiety or mood disorders. Overall, approximately 10% of kids diagnosed with ODD will eventually develop a more lasting personality disorder, such as Anti-Social Personality Disorder.

3. How is ODD treated? There is no single treatment for all kids and adolescents with ODD. The most effective treatment plan will be individualized to the needs of each youngster and family. Specific treatment modalities may be helpful for a particular youngster, depending on his or her age, the severity of the presenting problems, and the goals, resources, and circumstances of the family. Treatment must be delivered for an adequate duration (usually several months or longer) and may require multiple episodes either continuously or as periodic "booster" sessions. Treatment will often include both individual therapy and family therapy. It may also include work with the youngster's teacher or school. Treatment may also include the use of medication, although medication alone would rarely be considered an adequate or appropriate intervention for kids with ODD. Two types of evidenced-based treatments for kids with ODD are individual approaches in the form of problem-solving skills training and family interventions in the form of parent management training. Individual approaches should be specific to the youngster's problems, behaviorally-based, geared to the youngster’s age, and focused on helping the youngster acquire new problem-solving skills. Family interventions include training in effective discipline techniques and age-appropriate supervision. With preschool kids, the emphasis is usually placed on parent education and training. For school-age kids, school-based interventions, family-based treatment, and individual therapy are often used in combination. For adolescents, individual therapy is often used in conjunction with family intervention. Throughout all ages, medication may be a useful component of treatment to help address specific symptoms or to treat co-existing conditions (e.g., depression, ADHD, or anxiety disorders), although there is no single medication which specifically treats ODD. There is also limited research data on the safety and efficacy of medications in the treatment of ODD. Moms & dads should discuss the potential risks and benefits of specific medications with their youngster’s physician. In general, medications should be started only after an appropriate baseline of symptoms or behaviors has been obtained.

4. What causes ODD? ODD is thought to be caused by a combination of biological, psychological, and social factors. ODD tends to occur in families with a history of Attention Deficit Hyperactivity Disorder (ADHD), substance use disorders, or mood disorders such as depression or bipolar disorder. Brain imaging studies have also suggested that kids with ODD may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control. Psychological studies have also demonstrated that kids who display aggressive behavior have trouble accurately identifying and interpreting social cues from peers. Specifically, aggressive kids tend to see hostile intent in neutral situations. They also generate fewer solutions to problems and expect to be rewarded for their aggressive responses. Lack of structure or parental supervision, inconsistent discipline practices, and exposure to abuse or community violence have also been identified as factors which may contribute to the development of ODD.

In kids with ODD, there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngster's day-to-day functioning. Symptoms of ODD may include:

· active defiance and refusal to comply with adult requests and rules
· blaming others for his or her mistakes or misbehavior
· deliberate attempts to annoy or upset people
· excessive arguing with adults
· frequent anger and resentment
· frequent temper tantrums
· mean and hateful talking when upset
· often being touchy or easily annoyed by others
· seeking revenge

The symptoms are usually seen in multiple settings, but may be more noticeable at home or at school. Five to fifteen percent of all school﷓age kids have ODD. The causes of ODD are unknown, but many moms & dads report that their youngster with ODD was more rigid and demanding than the youngster's siblings from an early age. Biological and environmental factors may have a role.

A youngster presenting with ODD symptoms should have a comprehensive evaluation. It is important to look for other disorders which may be present; such as, attention﷓deficit hyperactive disorder (ADHD), learning disabilities, mood disorders (depression, bipolar disorder) and anxiety disorders. It may be difficult to improve the symptoms of ODD without treating the coexisting disorder. Some kids with ODD may go on to develop conduct disorder.

Treatment of ODD may include: Parent Training Programs to help manage the youngster's behavior, Individual Psychotherapy to develop more effective anger management, Family Psychotherapy to improve communication, Cognitive﷓Behavioral Therapy to assist problem solving and decrease negativity, and Social Skills Training to increase flexibility and improve frustration tolerance with peers. A youngster with ODD can be very difficult for moms & dads. These moms & dads need support and understanding. Moms & dads can help their youngster with ODD in the following ways:

· Take a time﷓out or break if you are about to make the conflict with your youngster worse, not better. This is good modeling for your youngster. Support your youngster if he decides to take a time﷓out to prevent overreacting.

· Set up reasonable, age appropriate limits with consequences that can be enforced consistently.

· Pick your battles. Since the youngster with ODD has trouble avoiding power struggles, prioritize the things you want your youngster to do. If you give your youngster a time﷓out in his room for misbehavior, don't add time for arguing. Say "your time will start when you go to your room."

· Manage your own stress with exercise and relaxation. Use respite care as needed.

· Maintain interests other than your youngster with ODD, so that managing your youngster doesn't take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your youngster.

· Always build on the positives, give the youngster praise and positive reinforcement when he shows flexibility or cooperation.

Many kids with ODD will respond to the positive parenting techniques. Moms & dads may ask their pediatrician or family physician to refer them to a youngster and adolescent psychiatrist, who can diagnose and treat ODD and any coexisting psychiatric condition.

Identifying the Signs-- It's not easy to distinguish ODD from age appropriate normal oppositional behavior. Symptoms of the disorder tend to mirror, in exaggerated form, youngster rearing problems common in all families. In addition, different families have various levels of tolerance for oppositionality. In some, a minor infraction of the rules produces major consequences, while in more tolerant homes, oppositional behaviors are largely ignored until they cause ongoing difficulties.

In kids with ODD, there is a pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngsters day to day functioning. Regularly, they lose their temper, argue with adults, actively defy adult rules, refuse adult requests, and deliberately annoy others. The symptoms are seen in multiple settings - at home, at school, in the neighborhood - and are not simply the result of a conflict with a particular parent or teacher.

Blaming others for their mistakes, these kids often appear touchy, angry, resentful, spiteful, or vindictive. Although overtly aggressive behavior tends to be limited, some kids engage in mild physical aggression. However, their language tends to be aggressive and often obscene.

Kids with ODD were, in many instances, fussy, colicky, or difficult to soothe as infants. During the toddler and preschool years, when a certain degree of oppositional attitude is considered normal, ordinary points of contention in the family become battlegrounds for intractable power struggles with these kids. These oppositional episodes typically center around eating, toilet training, and sleeping. Tamper tantrums are usually extreme in a youngster with ODD.

Kids with ODD consistently dawdle and procrastinate. They claim to forget or fail to hear and, as a result, are often referred for hearing evaluations, only to be found to have normal hearing. The issue is not obeying what was heard rather than a problem with not hearing.

As the youngster matures, struggles may center on keeping his room neat, picking up after himself, taking baths, going to bed on time, not interrupting or talking back, and doing homework. In all instances, winning becomes the most important aspect of the struggle. At times a youngster with ODD will forfeit cherished privileges rather than lose the argument.

Milder forms of ODD arc limited to the home environment, while, at school, the youngster may be more passively resistant and uncooperative. More severe forms involve defiance toward other authority figures such as teachers and coaches.

The youngster typically has little insight and ability to admit to the difficulties. Rather, he tends to blame his troubles on others and on external circumstances. He is always questioning the rules and challenging those he perceives to be unreasonable.

Before puberty, the rate of ODD is higher in boys than in girls. In adolescence, the disorder is equally shared.

Causes and Consequences-- It appears that ODD arises out of a circular family dynamic. A baby who is by nature more difficult, fussy, and colicky, may be harder to soothe. The moms & dads often feel frustrated and unsuccessful as moms & dads. If they perceive their youngster as unresponsive or "bad," they may begin to anticipate that the youngster will be unresponsive or noncompliant. They may then become unresponsive or unreliable in return, adding to the youngster's feelings of helplessness, neediness, and frustration.

As moms & dads attempt to assert control by insisting on compliance in such areas as eating, toilet training, sleeping, or speaking politely the youngster may demonstrate resistance by withholding or withdrawing.

As a youngster matures, increasing negativism, defiance, and noncompliance become misguided ways of dealing with adults. In this way the disorder may be a tenacious drawing out of the "terrible twos."

The more a youngster reacts in defiant, provocative ways, the more negative feedback is elicited from the moms & dads. In an attempt to achieve compliance, the parent or authority figures remind, lecture, berate, physically punish, and nag the youngster. But far from diminishing oppositional behavior, these kinds of responses toward the youngster tend to increase the rate and intensity of non-compliance. Ultimately, it becomes a tug of war and a battle of wills.

When such patterns typify parent youngster relationships, discipline is often inconsistent. At times, moms & dads may explode in anger as they attempt to control and discipline their youngster. At other times, they may withhold appropriate consequences which soon become hollow threats. As the youngster continues to provoke and defy, moms & dads lose control. Then, feeling regret and guilt, especially if they’ve become verbally or physically explosive, the parent may become excessively rewarding and gratifying in order to undo what they now perceive to have been excessive discipline or punitive consequences.

When a youngster starts school, this pattern of passive aggressive, oppositional behavior tends to provoke teachers and other kids as well. At school the youngster is met with anger, punitive reactions, and criticism. The youngster then argues back, blames others, and gets angry.

These kids tend to have difficult adapting at school. Their behavior can cause disruption in the classroom and interfere with social and academic functioning. When their behavior and defiance affects their schoolwork and performance, kids often experience school failure and social isolation. This, coupled with chronic criticism, can lead to low self esteem. Usually, ODD kids feel unfairly picked on. In fact, they may believe that their behavior is reasonable and the treatment and criticism they receive unfair.

In many cases. oppositional disorders coexist with attention deficit/hyperactivity disorder. In fact, the impulsivity and hyperactivity of ADHD can greatly amplify the defiance and uncontrolled anger of ODD. Symptoms of ODD may also occur as part of major depressive disorder, obsessive compulsive disorder, or mania. Some kids with separation anxiety disorder may also have oppositional behaviors. Clingy attachment merges into or possibly reflects oppositional defiance. There also seems to be a correlation between ODD in a youngster and a history of disruptive disorders, substance abuse, or other emotional disorders in other family members.

How to Respond— Moms & dads who are concerned that their youngster may have ODD should seek a professional evaluation. This is important as a first step in breaking the cycle of ineffective parenting of the "bad youngster.” During the evaluation process, moms & dads may come to appreciate the interactive aspect of this disorder and look for ways to improve their management of the youngster. Books and parenting workshops given under the auspices of churches, schools, and community agencies may also help moms & dads respond better to the needs of their kids.

Once ODD has been diagnosed, the youngster and adolescent psychiatrist or other professional may recommend a combination of therapies for ODD. Among the options your clinician may recommend are following:

Parent Training Programs. Some moms & dads are helped through formal parent training programs. In these sessions, moms & dads learn strategies for managing their kid’s behavior. These are practical approaches to dealing with a youngster with ODD. The emphasis is on observing the youngster and communicating clearly. Moms & dads are taught negotiating skills, techniques of positive reinforcement, and other means of managing the behavior of the youngster with ODD.

Individual Psychotherapy. The therapeutic relationship is the foundation of a successful therapy. It can provide the difficult youngster with a forum to explore his feelings and behaviors. The therapist may be able to help the youngster with more effective anger management, thus decreasing the defiant behavior. The therapist may employ techniques of cognitive behavioral therapy to assist the youngster with problem solving skills and in identifying solutions to interactions that seem impossible to the youngster. The support gained through therapy can be invaluable in counterbalancing the frequent messages of failure to which the youngster with ODD is often exposed.

Family Therapy. Problems with family interactions are addressed in family therapy. Family structure, strategies for handling difficulties, and the ways moms & dads inadvertently reward noncompliance are explored and modified through this therapy. This approach can also address the family stress normally generated by living with ODD. Sometimes in the course of treatment, a parent is also found to have a psychiatric disorder. Treatment of that parent may be helpful since the adult's behavior can affect how the youngster responds to treatment.

Cognitive Behavioral Therapy. Behavioral therapy can help kids control their aggression and modulate their social behavior. Kids are rewarded and encouraged for proper behaviors. Cognitive therapy can teach kids with ODD self-control, self-guidance, and more thoughtful and efficient problem solving strategies.

Social Skills Training. When coupled with other therapies, social skills training has been effective in helping kids smooth out their difficult social behaviors that result from their angry, defiant approach to rules. Social skills training incorporates reinforcement strategies and rewards for appropriate behavior to help a youngster learn to generalize positive behavior, that is, apply one set of social rules to other situations. Thus, following the rules of a game may be generalized to rules of the classroom; working together on a team may generalize to working with adults rather than against them. Through such training, kids can learn to evaluate social situations and adjust their behavior accordingly, The most successful therapies are those that provide training in the youngster's natural environments - such as the classroom or in social groups as this may help them apply the lessons learned directly to their lives.

Medication. Medication is only recommended when the symptoms of ODD occur with other conditions, such as ADHD, obsessive-compulsive disorder (OCD), or anxiety disorder. When stimulants are used to treat attention deficit/hyperactivity disorders, they also appear to lessen oppositional symptoms in the youngster. There is no medication specifically for treating symptoms of ODD where there is no other emotional disorder.

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