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Oppositional Defiant Disorder (ODD)

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

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Oppositional defiant disorder is a recurrent or persistent pattern of negative, defiant, or even hostile behavior directed at authority figures. Diagnosis is by history. Treatment is with individual psychotherapy combined with family or caregiver therapy. Occasionally, drugs may be used to reduce irritability.

Prevalence estimates of oppositional defiant disorder (ODD) vary widely because the diagnostic criteria are highly subjective; prevalence in children and adolescents may be as high as 15%. Before puberty, affected boys greatly outnumber girls; after puberty, the difference narrows.

Although oppositional defiant disorder is sometimes viewed as a mild version of conduct disorder, similarities between the 2 disorders are only superficial. The hallmark of this disorder is an interpersonal style characterized by irritability and defiance. However, children with a conduct disorder seemingly lack a conscience and repeatedly violate the rights of others (eg, bullying, threatening or causing harm, being cruel to animals), sometimes without any evidence of irritability.

Etiology of oppositional defiant disorder is unknown, but it is probably most common among children from families in which the adults engage in loud, argumentative, interpersonal conflicts. This diagnosis should not be viewed as a circumscribed disorder but rather as an indication of underlying problems that may require further investigation and treatment.

Symptoms and Signs

Typically, children with oppositional defiant disorder tend to frequently do the following:

  • Lose their temper easily and repeatedly

  • Argue with adults

  • Defy adults

  • Refuse to obey rules

  • Deliberately annoy people

  • Blame others for their own mistakes or misbehavior

  • Be easily annoyed and angered

  • Be spiteful or vindictive

Many affected children also lack social skills.

Diagnosis

  • Clinical criteria

Oppositional defiant disorder is diagnosed if children have had 4 of the above symptoms for at least 6 mo. Symptoms must also be severe and disruptive.

Oppositional defiant disorder must be distinguished from the following, which may cause similar symptoms:

  • Mild to moderate oppositional behaviors: Such behaviors occur periodically in nearly all children and adolescents.

  • Untreated attention-deficit/hyperactivity disorder (ADHD): The symptoms that resemble those of oppositional defiant disorder often resolve when ADHD is adequately treated.

  • Mood disorders: Irritability caused by depression can be distinguished from oppositional defiant disorder by the presence of anhedonia and neurovegetative symptoms (eg, sleep and appetite disruption); these symptoms are easily overlooked in children.

  • Anxiety disorders and obsessive-compulsive disorder: In these disorders, the oppositional behaviors occur when children have overwhelming anxiety or when they are prevented from carrying out their rituals.

Treatment

  • Behavior modification therapy

  • Sometimes drugs

Underlying problems (eg, family dysfunction) and coexisting disorders (eg, ADHD) should be identified and corrected. However, even without corrective measures or treatment, most children with ODD gradually improve over time.

Initially, the treatment of choice for oppositional defiant disorder is a rewards-based behavior modification program designed to make the child’s behaviors more socially appropriate. Many children can benefit from group-based therapy that builds social skills.

Sometimes drugs used to treat depressive or anxiety disorders (see Table: Drugs for Long-Term Treatment of Anxiety and Related Disorders) may be beneficial.

Key Points

  • In oppositional defiant disorder, children typically lose their temper frequently, defy adults, disregard rules, and deliberately annoy other people.

  • Initially, use a rewards-based behavior modification program to make the child’s behaviors more socially appropriate; sometimes drugs used to treat depressive and anxiety disorders can help.