Oppositional Defiant Disorder

What Is Oppositional Defiant Disorder?

40 percent of children with ADHD also show signs of oppositional defiant disorder, which disrupts daily home and school life with arguments, aggression, disobedience, and a lack of respect for authority.

A boy with ADHD plays with a toy sword.
A boy with ADHD plays with a toy sword.

Oppositional defiant disorder (ODD) is a behavioral disorder defined by chronic aggression, frequent outbursts, and a tendency to ignore requests and purposely irritate others. The condition impacts anywhere between 1 and 16 percent of children and adolescents in the general population, but is far more common among patients with ADHD. In fact, 4 out of every 10 children with ADHD also show signs of ODD.

Kids with ODD take insolent behavior to a level far beyond tantrums or disobeyed orders. An oppositional, defiant child will often lose his temper, argue with adults, actively defy requests or rules set by adults, deliberately annoy people, and blame others for misbehavior. He will engage in angry, violent, and disruptive conduct directed at the adults in his life – parents, teacher, physicians, and other authority figures. And he may seem to feel most comfortable in the midst of a conflict, which is upsetting and exhausting for everyone involved – even the child himself.

The symptoms of ODD may look different for girls and boys, in whom the condition is more common. Boys with ODD tend to be more physically aggressive and have explosions of anger while girls often lie, refuse to cooperate, and otherwise express symptoms in indirect ways. ODD is usually diagnosed in early childhood; some patients outgrow the condition by age eight or nine.

Read on to learn more about ODD and how to turn around problem behavior with treatment, which typically includes therapy – both individual and family – and sometimes medication. Consult with a physician if you recognize the symptoms below in your child, and seek help immediately for violent or self-harming behavior that could be dangerous.

Symptoms of ODD

All children defy their parents and lash out from time to time. To merit an ODD diagnosis, however, a patient must exhibit a consistent pattern of negative, hostile, and defiant behavior that lasts at least six months. The most common symptoms include:

  • Physical aggression
  • Verbal abuse
  • Explosions of anger
  • Deliberately annoying others
  • Vindictive behavior
  • Frequent arguments
  • Defiance of rules and laws

Types of ODD

Physicians typically see two types of ODD.

Childhood onset is present from an early age, and can make children very difficult to raise. Early intervention and treatment can effectively address symptoms of ODD and prevent it from progressing into a more serious condition like conduct disorder.

Adolescent-onset ODD begins out of the blue in the middle- and high-school years. Once-loving children become impossible to live with. Home and school become places of almost constant conflict.

Adults can have oppositional defiant disorder, too. The condition may persist for a lifetime just as often as it spontaneously disappears. In about 40 percent of cases, adults with ODD become progressively worse and end up developing antisocial personality disorder.

Even when the condition doesn’t worsen, ODD in adults can cause problems in relationships, marriage, and work. Rates of substance abuse, divorce, and employment problems are higher in this population. Therapy and medication are the treatment strategies used most often with adults who have ODD.

ODD and ADHD

Surveys estimate that 5 percent of the general population has ODD, while up to 40 percent of children with ADHD may have the condition. Experts cannot definitely say why ODD and ADHD so commonly overlap, but some believe the comorbidity is tied to ADHD-related impulsivity.

“Many ADHD kids who are diagnosed with ODD are showing oppositional characteristics by default,” says Houston-based child psychologist Carol Brady, Ph.D. “They misbehave not because they’re intentionally oppositional, but because they can’t control their impulses.”

ODD is sometimes a way for kids to cope with the frustration and emotional pain of having ADHD. “Understanding why ODD is found so frequently in children with ADHD is to understand the two dimensions of the disorder — the emotional and social components,” says Dr. Russell A. Barkley. “Frustration, impatience, and anger are part of the emotional component. Arguing and outright defiance are part of the social aspect. For people with ADHD, emotions are expressed quickly.” Flexibility, adaptability, and problem solving – all skills that help regulate emotions – are severely lacking in most people with ADHD.

Diagnosing ODD

The exact cause of ODD is unknown, though many professionals trace it back to a combination of psychological, social, and biological factors. ODD symptoms are often linked to prenatal smoke exposure, toxin exposure, or poor nutrition. ODD is more common in people who have relatives with ODD, ADHD, conduct disorder (CD), bipolar disorder, or substance abuse problems, though researchers have not pinpointed a specific gene responsible. Traumatic life events, like childhood abuse, can trigger ODD for some people.

Parents and teachers are often the first to identify oppositional behavior in children. Then, the next step is to visit a child psychiatrist or other qualified mental health professional. To diagnose ODD accurately, a physician will perform an evaluation to rule out anxiety, depression, and bipolar disorder, which can all cause ODD-like behaviors. These behaviors are only “symptoms” of ODD if they occur more commonly than is normal for individuals of the same age and developmental level, and if they cause clinically significant impairment in social, academic, or occupational functioning.

An evaluating physician may compile a detailed behavior history from parents, teachers, and clinical observation. Talking to as many people as possible about how and where the behavior occurs can help the doctor determine which behaviors are impacting different areas of the child’s life. It also helps to determine if the child is responding to a stressful situation, or if you’re dealing with an ongoing behavioral issue. The physician may use rating scales and questionnaires to make a complete assessment. Diagnosis is time consuming because multiple sources of information must be assessed.

A person with ODD seldom takes responsibility for her behavior and the effect it has on everyone around them. She sees “the problem” lying with anyone but herself. It usually takes a highly qualified physician to determine whether problems at school, work, or home trace back to ODD.

The strain of dealing with ODD affects the entire family, and may strain marital relationships. Fortunately, effective therapies exist for reigning in even the most defiant child or adult. Changing behaviors is not easy, but it can be done – typically with the help of specialized psychotherapy, family training programs, and a physician to supervise treatment.

Treatment Options for ODD

Before tackling oppositional defiant symptoms, a patient or parent must be certain that related conditions – including ADHD, anxiety, depression and bipolar disorder – are under control. Each one of these can cause oppositional behavior and can exacerbate ODD symptoms. “When we reduce hyperactivity, impulsiveness, and inattention, perhaps through medication, we see simultaneous improvement in oppositional behavior,” says Ross W. Greene, Ph.D.

Treatment for ODD includes psychotherapy and medication.

Behavior therapy and family/parent training programs are the treatment of choice for ODD. These programs teach loved ones strategies for dealing with upsetting behavior; suggest positive alternative behaviors to replace defiant ones; and establish guidelines for setting clear expectations, consequences, and rewards for behavior. Treatment is most effective when started early in life.

In those rare cases where a patient doesn’t respond to therapy, medication is sometimes used to “re-wire” ODD behaviors. No medications are FDA-approved for treatment of ODD in the U.S., but clinical experience suggests that most children and adolescents with ODD improve rapidly with a low dose of atypical neuroleptics – arippirazole (Abilify) and risperidone (Risperidal), for example. Medication is most effective when paired with therapy programs.

People with mild ODD may report improved symptoms after taking omega-3 fatty acids to regulate mood and emotions, vitamin E to help absorb omega-3s, melatonin to help normalize sleep patterns, or zinc to help neutralize hyperactivity and impulsivity. These alternative therapies are not empirically proven to improve symptoms, however many patients find it helps to devise a holistic treatment plan with their physicians.

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