Oppositional defiant disorder (ODD) is a pattern of behaviors seen in children and adolescents who are almost always in conflict with the authority figures in their lives.  The behavior problems result in tremendous tension and spiraling conflict in the parent-child relationship, with teachers and with other adults.

A child with ODD is highly temperamental and resists rules and expectations, refuses to follow directions, and is spiteful or vindictive to an extent far beyond the usual behavior of his age group. This behavior significantly undermines his schooling and relationships with peers and family. Untreated, ODD typically leads to other behavioral and learning problems, as the low frustration tolerance impacts so many areas of a child’s life.

Associated Diagnoses

ODD is often diagnosed alongside ADHD.

  • In adolescents and children younger than 18, ODD is diagnosed only in those who do not meet criteria for the more severe diagnosis of conduct disorder.
  • In those over 18, ODD is diagnosed only in those who are not diagnosed with antisocial personality disorder.
  • Many youth who meet criteria for ODD have a history of physically and or emotionally abusive parenting, and may also exhibit emotional dysregulation because of PTSD (post traumatic stress disorder)

Children with ODD often have co-occurring mood disorders like depression, anxiety disorders, or learning or communication disorders, including Aspergers syndrome and other autism spectrum disorders.

ODD that goes untreated early in life is often linked to more severe outcomes later, including conduct disorder, substance abuse, school failure, juvenile offenses and legal troubles.

Diagnosis

It can be very confusing trying to distinguish between ODD and normal efforts by children or adolescents to assert their independence.

Professionals therefore depend on a detailed history of behaviors in various situations, from parents, teachers,  and other caregivers.

They will use this history to confirm that:

  • several oppositional and defiant behaviors have been present for an extended period
  • the behaviors significantly interfere with the child’s activities
  • the behaviors aren’t normal for his age and development.

ODD is often diagnosed along with ADHD, and the signs can be confused

In addition, many of the signs of ODD are related to the more severe conduct disorder.

Even if the number and intensity of a child’s behavioral issues does not fulfill the minimum criteria for a diagnosis of ODD, specialized help may still be warranted to address a parent’s concerns about their child and to prevent the onset of this disorder.

Parent-Child Interaction Therapy

Parent-Child Interaction Therapy (PCIT) is an empirically-supported treatment for young children with emotional and behavioral disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns.

PCIT is for  children whose problematic behaviors—defiance, inability to follow directions, aggression–fall outside the range of what’s typical for their age. By restructuring interactions between parents and child, it reduces disruptive behavior and improves the child’s relationship with his family. Parents learn specific skills to increase positive attention to behavior they want to encourage, and specific disciplinary techniques to respond to undesired behaviors.

PCIT has been shown to effectively move disruptive behavior in these children back into the typical range. Children learn how to control their problematic behavior, and parents experience much less stress in handling challenging children.

The program is effective for children between the ages of 2 and 7, and usually takes 12 to 17 weekly sessions.

What happens during a PCIT session?

During many sessions, parents and children are seen together. Parents receive live coaching from their therapists behind a one-way mirror via wireless earbud, as they lead the child through a series of tasks, and practice specific responses to both desired and undesired behavior.

What happens outside of sessions?

Parents are asked to complete regular, brief practice sessions with their child under the guidance of their therapist. Home practice facilitates skill-building and confidence in using PCIT techniques and strategies.

PCIT is evidence-based

Outcome studies of PCIT have consistently demonstrated increases in positive parenting behaviors and decreases in negative parenting behaviors after treatment. Children demonstrate significant reductions in noncompliance and other disruptive behaviors, with gains maintained long after treatment ends. In addition, parents report much less stress managing their children’s behavior.

Signs and Symptoms

Children with ODD quickly lose their temper, are often disobedient at home or at school, often ignore or rebel against rules, often blame others for mistakes or misbehavior, are prone to annoy others (and are easily annoyed or irritated).

Every one of these behaviors is typical in children to a certain extent, but those with ODD have problems with impulsivity, and act out so often that it dramatically compromises their ability to get along with others.

The extraordinary level of oppositional behavior means children with ODD are sometimes described as having a “reflexive ‘No!’”—they will refuse to cooperate even before they know what is being asked of them.

Symptoms of ODD can become apparent as early as pre-school or much later, in adolescence.

Treatment

ODD is treatable, usually with behavioral therapy or a combination of behavioral intervention and medication.

Psychotherapeutic:

  • A popular evidence-based treatment is a type of behavior therapy called parent management training. The parent(s) and child are seen and coached together in real time, with the therapist present, to practice a series of skills. Often,  the therapist may coach the parent during interactions, sometimes by whispering into their ear or even communicating from a viewing room via an in-ear receiver. Typically, this is a two-phase treatment with the first phase devoted to increasing positive parent-child interactions, and the second focused on specific limit-setting and discipline skills.
  • Parent-child Interaction Therapy is another evidence-based behavior therapy that has been gaining popularity for the treatment of ODD.
  • Many equine-assisted therapies have been shown to effectively create challenging situations for parents and children in real time, with a therapist present. The therapist can then provide coaching to the parents as they  practice skills for managing their child’s frustration, defiance, and reactivity.

Treatment for ODD typically requires a great deal of coordination between the authority figures in a child’s life, including the parents, teachers and other caregivers, such as grandparents, coaches,  or daycare providers. It may also require parents to be very mindful and thoughtful in their parenting. Parents may need to study techniques and interventions to  learn how to effectively manage a child’s disorder with a minimum of painful outbursts—by both parent and child!

Medication

  • Medicines are not specifically indicated for ODD.
  • Many children with ODD have co-occurring conditions such as ADHD, they may be on medications for those other disorders.
  • Sometimes, medicine could make the difference between a child with ODD being able to participate in the therapy and not.
  • Recent studies of stimulants (medications indicated for the treatment of ADHD) have demonstrated that optimized doses of these agents may reduce aggressive dyscontrol in children, even in the absence of a diagnosis of ADHD.
  • Some patients are so troubled by their own aggression and difficulties managing their painfully low frustration tolerance, that a child psychiatrist or other medical doctor may recommend medication along with behavioral therapy to help the child or adolescent control those responses.

Frequently Asked Questions

Does bad parenting cause ODD?

Research suggests that ODD results from a combination of a biologic (possibly genetic) vulnerability and environmental factors

Brain scans demonstrate differences in areas related to judgment and impulse control in people with ODD.

There is an association between harsh, punitive, rigid parenting and ODD, and there is also an association between ODD and “laissez-faire” parenting with no expectations or supervision.

Do children outgrow ODD?

Research suggests that most children with a diagnosis of ODD will grow out of it, but may continue to show some concerning behaviors

A small but significant percentage of kids with ODD may later develop more severe symptoms consistent with conduct disorder.

These children are at risk for legal problems, school failure, and  substance abuse.

Is there a cure?

Children with ODD often respond very well to appropriate psychotherapy that includes regular appointments and intensive caregiver involvement– often without the need for medication.

Symptoms of ODD can be managed, so that some decrease, and some go away, but this requires the combined efforts of the child and parents.

What is the difference between ODD and normal behaviors?

The signs and symptoms of ODD include behaviors that are commonly seen in children and adolescents, but the frequency, severity and intensity of these behaviors  key to  the diagnosis.

A child be must be much more oppositional than his peers to warrant an ODD diagnosis, and the behaviors must interfere with the child’s life and cause “clinically significant impairment in social, academic, or occupational functioning.”

How long does treatment take?

Typically, the treatment of ODD can be several months or longer, depending on the severity of the case.

After this initial treatment, the child and family may return to the therapist intermittently for “booster sessions” to keep the tools learned to address the ODD behaviors  “sharp.”

What medications are used to treat ODD?

There are no specific medications indicated in the treatment of ODD

Medication should not be used alone to treat ODDSometimes, medications can help treat other disorders that a child with ODD may also have

Sometimes, medications can help a child with ODD be capable of engaging in treatment by helping the child manage their anger and help the child’s frustration tolerance improve.