Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is one of the commonly diagnosed disruptive behavior disorders of a group of behavioral problems in children and adolescents. While challenging behaviors are the hallmark of all of these disorders, ODD is specifically characterized by frequent episodes of anger, deliberately irritating or hostile behavior, and a pronounced intolerance for authority.

The term “oppositional” means actions that are in opposition to rules and norms for socially acceptable behavior. Children with ODD typically have a persistent pattern of irritable, angry outbursts, arguments, and disobedience. While this behavior is usually directed at authority figures like parents and teachers, it can also target siblings, classmates, and other children.

ODD is a relatively common problem, and with the right care, it can be treated with a great degree of success. The key to successfully “nipping problem behaviors in the bud” is stopping the sequence of events that leads to these behaviors as early as possible. If the pattern of behavior is detected, halted, and treated, the problem behaviors are likely to decrease.

Children with ODD usually begin showing symptoms around 6 to 8, although the disorder can emerge in younger children, too. Symptoms can last throughout the teen years. Your child may be diagnosed with ODD if these symptoms are persistent and continue for at least six months.

Warning signs of ODD to look out for include:

• Frequent temper tantrums
• Excessive arguments with adults
• Refusing to comply with adult requests
• Always questioning rules
• Refusing to follow rules
• Behavior intended to annoy or upset others
• Blaming others for misbehavior or mistakes
• Becoming easily annoyed with others
• Frequently demonstrating an angry attitude
• Speaking harshly or unkindly to others

Determining whether your child might have ODD can be difficult, since most children will exhibit some of the symptoms every now and then (especially when they're tired, hungry, or upset).

A child with oppositional defiant disorder, however, will:

• Display these symptoms much more often than other children
• Consistently demonstrate behavioral issues for a period of at least six months
• Often have problems with school and friendships as a direct result of the behavior
• Have their overall functioning appreciably compromised by their challenging behaviors

The exact cause of ODD is not known, but both developmental and learned factors are believed to play a possible role in the disorder.

Developmental factors

One theory suggests that children with ODD:

• May have underlying “temperamental” challenges that make them quick to anger and slow to calm, making them vulnerable
• Begin to experience problems in their toddler years
• May have had an unusually hard time separating from parents (“standing on their own two feet") while younger
• Did not resolve their normal development issues in their younger years, leading to later behavioral problems

Learned factors

Another theory suggests that children with oppositional defiant disorder:

• Developed unusually strong levels of negativity and pessimism (two main traits of ODD) because of a parent or other authority figure who meted out excessive punishment or other forms of negative reinforcement
• Began to associate the parent or authority figure’s negative reinforcement with getting more attention, time and concern
• Started a pattern of acting out in order to obtain more of this perceived “extra attention”

Other possible factors

Other possible factors in the development of ODD may include:

• Permissive parenting, when a parent too often and too easily gives in to the child’s demands
• Strong will in the child, which can be caused by any or all of the following:
  • Ingrained personality characteristics
  • The mother’s exposure to certain harmful agents (such as cigarette smoke) while pregnant
  • Lack of positive attachment to a parent
  • Significant stress or a lack of predictable structure in the home or community environment

In order to outgrow the oppositional behavior, your child would need to realize the behavior is inappropriate and make a conscious decision to change. While this natural resolution might be possible, there’s always a risk in leaving any behavioral issue untreated. Therapy with a licensed professional ensures that your child's behavior is addressed at the root cause, and helps her learn strategies for healthier, appropriate behavior.

The likelihood of a child with ODD experiencing greater difficulty in late adolescence and adulthood depends upon his individual circumstances. Generally, they are at greater risk for problems with depression and substance abuse, and this is particularly true if their childhood ODD was accompanied by other common co-morbid disorders (ADHD, depression, learning disabilities). In some cases, the diagnosis may change from ODD — which involves behavior that is problematic, annoying and hostile, but not violent or extremely aggressive — to a much more serious type of disruptive behavior disorder called conduct disorder.

People with conduct disorder are likely to engage in:

• Serious law-breaking behavior
• Destruction of property
• Cruelty to animals and people

A child diagnosed with ODD is not automatically going to develop conduct disorder. It is important, however, for parents to closely monitor the behavior of their child and to seek treatment from a credentialed professional as early in the child's life as possible.

At Boston Children’s Hospital, a mental health clinician (typically a child and adolescent psychiatrist, child psychologist, or psychiatric social worker) will make the diagnosis following a comprehensive psychiatric assessment with you and your child. During the assessment, you will be asked to talk about your child’s behavioral problems and to give an overview of your child’s family history, medical history, school life, and social interactions.

Your child’s mental health clinician will help explain the disorder and answer any questions you or your child may have. The next step is developing a mutually agreed-upon treatment plan that works for you, your child and your family.

ODD is typically treated with one or a combination of the following methods:

Parenting guidance and modification

Your involvement as a parent is crucial to the treatment of your child's oppositional defiant disorder. We've learned that the best approach to ODD is helping parents learn and use effective parenting strategies; anticipate and prepare for problematic behavior; manage and respond to outbursts and tantrums; and implement structure and consistency in the child's life and daily routine.

Parenting modification strategies taught at Boston Children's focus on:

• Developing a warm, loving relationship between parent and child
• Providing a predictable, structured household environment
• Setting clear and simple household rules
• Consistently praising and rewarding positive behaviors (such as getting ready for school and bed on time)
• Consistently ignoring annoying behaviors (such as whining or badgering), followed by praise when the annoying behavior ceases
• Consistently delivering consequences (such as “time-outs” or loss of privileges) for dangerous or destructive behaviors (such as physical aggression or destroying possessions)

Social-emotional skills training

Strengthening the impact of the parenting modification techniques you are learning, therapy for ODD will also focus on providing social-emotional skills training for your child. Through the course of therapy sessions with the clinician, your child will learn:

• Skills for identifying and managing feelings
• How to get along better with others
• Strategies for making good decisions that are based on thinking rather than feeling

Psychiatric medication

In addition to therapy, your clinician may recommend medication to treat your child's oppositional defiant disorder. There currently are no drugs prescribed specifically for ODD, but certain symptoms of the disorder, when found in conjunction with another disorder, can respond very well to medication in conjunction with psychotherapy (which is also referred to as "talk therapy").

Drugs that may be prescribed to treat ODD symptoms include:

Stimulants for ADHD

• Methylphenidate (Ritalin)
• Dextroamphetamine (Dexedrine)

Antidepressants for depression or anxiety

• Escitalopram (Lexapro)
• Fluoxetine (Prozac)

Other medications that may help decrease disruptive behaviors

• Guanfacine (Tenex)
• Clonidine (Catapres)
• Risperidone (Risperdal)
• Aripiprazole (Abilify)

Boston Children's Department of Psychiatry and Behavioral Sciences has a specialized Psychopharmacology Clinic to help determine whether psychiatric medication might be a useful addition to a child's treatment plan, but we never prescribe medication as a standalone treatment. Medication, when prescribed, is always part of a two-step approach in conjunction with talk therapy.

Learn about psychiatric medications for children and adolescents.

Boston Children’s has a long history of pioneering important advances in behavioral and mental health for children, adolescents, and families. Our clinicians are committed to evidence-based treatments — therapies that have been tested and proven effective through careful scientific analysis, both here at our hospital and at other top health centers around the world.

At the same time, we practice medicine that’s patient-focused and family centered. We never lose sight of the fact that your child is, first and foremost, an individual — not merely a patient — and we include your family at every stage of the treatment process.

Here at Boston Children’s, our clinicians use several techniques to treat oppositional defiant disorder, including:

• First clarifying if there are other co-existing underlying disorders
• Parenting modification strategies
• Social and emotional skills training for children
• In some cases, the addition of medication to the therapy plan

Working with your clinician, you can make a difference for your child by learning and using new:

• Communication skills
• Parenting skills
• Conflict resolution skills
• Anger management skills

Oppositional defiant disorder: Reviewed by David R. DeMaso, MD
© Boston Children’s Hospital, 2012

Here at Boston Children’s Hospital, we refine our treatment methods through careful analysis of sophisticated scientific data. Our research program is one of the largest and most active of any pediatric hospital in the world, and our research in psychiatry and psychology supports our goal of enhancing mental health care for all children and families.

We continue to work toward critical new insights that can propel advances in preventing, diagnosing and treating behavioral and mental health disorders. Our progress in the laboratory strengthens the exceptional care we provide at each child's bedside.

Among our current research projects with promise for treating oppositional defiant disorder are:

Incorporating mindfulness as a parenting modification strategy

Boston Children’s is conducting a study of mindfulness techniques, which combine elements of traditional Buddhist meditation with the practice of consciously reflecting on one’s thoughts. Should these techniques prove useful, they will be added to the parenting modification strategies we teach as part of our family treatment plans for ODD.

Using a computer game to teach children emotional control

Incorporating advances in neurobiology and computer science, Boston Children’s clinicians are designing special interventions to help kids learn to better control their emotions.

Boston Children’s Psychopharmacology Clinic chief, Joseph Gonzalez-Heydrich, MD, working with colleagues Peter Ducharme, LICSW, and Jason Kahn, PhD, has developed a computer game called “RAGE-Control (Regulate and Gain Emotional Control).” Using the popular arcade staple “Space Invaders” as a model, RAGE-Control teaches children to simultaneously focus, react, inhibit impulses, and keep their heart rate down.

The game is now being tested in a clinical trial on Boston Children’s Inpatient.