17.12.07

Children With Oppositional Defiant Disorder from AACAP

All children are oppositional from time to time, particularly when tired, hungry, stressed or upset. They may argue, talk back, disobey, and defy parents, 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 children of the same age and developmental level and when it affects the child's social, family, and academic life.

In children with Oppositional Defiant Disorder (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:

  • frequent temper tantrums
  • excessive arguing with adults
  • active defiance and refusal to comply with adult requests and rules
  • deliberate attempts to annoy or upset people
  • blaming others for his or her mistakes or misbehavior
  • often being touchy or easily annoyed by others
  • frequent anger and resentment
  • mean and hateful talking when upset
  • 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 children have ODD. The causes of ODD are unknown, but many parents report that their child with ODD was more rigid and demanding than the child's siblings from an early age. Biological and environmental factors may have a role.

A child 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 children with ODD may go on to develop conduct disorder.

Treatment of ODD may include: Parent Training Programs to help manage the child'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 child with ODD can be very difficult for parents. These parents need support and understanding. Parents can help their child with ODD in the following ways:

  • Always build on the positives, give the child praise and positive reinforcement when he shows flexibility or cooperation.
  • Take a time‑out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if he decides to take a time‑out to prevent overreacting.
  • Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child 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."
  • Set up reasonable, age appropriate limits with consequences that can be enforced consistently.
  • Maintain interests other than your child with ODD, so that managing your child 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 child.
  • Manage your own stress with exercise and relaxation. Use respite care as needed.

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

Identifying the Signs
It's not easy to distinguish oppositional defiant disorder (ODD) from age appropriate normal oppositional behavior. Symptoms of the disorder tend to mirror, in exaggerated form, child 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 children 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 children often appear touchy, angry, resentful, spiteful, or vindictive. Although overtly aggressive behavior tends to be limited, some children engage in mild physical aggression. However, their language tends to be aggressive and often obscene.

Children 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 children. These oppositional episodes typically center around eating, toilet training, and sleeping. Tamper tantrums are usually extreme in a child with ODD.

Children with ODD consistently dawdle and procrastinate. Thee 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 child 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 child 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 child may be more passively resistant and uncooperative. More severe forms involve defiance toward other authority figures such as teachers and coaches.

The child 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 oppositional defiant disorder arises out of a circular family dynamic. A baby who is by nature more difficult, fussy, and colicky, may be harder to soothe. The parents often feel frustrated and unsuccessful as parents. If they perceive their child as unresponsive or "bad," they may begin to anticipate that the child will be unresponsive or noncompliant. They may then become unresponsive or unreliable in return, adding to the child's feelings of helplessness, neediness, and frustration.

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

As a child 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 child reacts in defiant, provocative ways, the more negative feedback is elicited from the parents. In an attempt to achieve compliance, the parent or authority figures remind, lecture, berate, physically punish, and nag the child. But far from diminishing oppositional behavior, these kinds of responses toward the child 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 child relationships, discipline is often inconsistent. At times, parents may explode in anger as they attempt to control and discipline their child. At other times, they may withhold appropriate consequences which soon become hollow threats. As the child continues to provoke and defy, parents 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 child starts school, this pattern of passive aggressive, oppositional behavior tends to provoke teachers and other children as well. At school the child is met with anger, punitive reactions, and criticism. The child then argues back, blames others, and gets angry.

These children 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, children often experience school failure and social isolation. This, coupled with chronic criticism, can lead to low self esteem. Usually, ODD children 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 children 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 child and a history of disruptive disorders, substance abuse, or other emotional disorders in other family members.

How to Respond
Parents who are concerned that their child 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 child.” During the evaluation process, parents may come to appreciate the interactive aspect of this disorder and look for ways to improve their management of the child. Books and parenting workshops given under the auspices of churches, schools, and community agencies may also help parents respond better to the needs of their children.

Once ODD has been diagnosed, the child 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 parents are helped through formal parent training programs. In these sessions, parents learn strategies for managing their children's behavior. These are practical approaches to dealing with a child with ODD. The emphasis is on observing the child and communicating clearly. Parents are taught negotiating skills, techniques of positive reinforcement, and other means of managing the behavior of the child with ODD.

Individual Psychotherapy The therapeutic relationship is the foundation of a successful therapy. It can provide the difficult child 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 child with problem solving skills and in identifying solutions to interactions that seem impossible to the child. The support gained through therapy can be invaluable in counterbalancing the frequent messages of failure to which the child 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 parents 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 child responds to treatment.

Cognitive Behavioral Therapy Behavioral therapy can help children control their aggression and modulate their social behavior. Children are rewarded and encouraged for proper behaviors. Cognitive therapy can teach children 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 children 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 child 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, children can learn to evaluate social situations and adjust their behavior accordingly, The most successful therapies are those that provide training in the child'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 child. There is no medication specifically for treating symptoms of ODD where there is no other emotional disorder.

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