As a parent, you don't have to go it alone in trying to manage a youngster with oppositional defiant disorder. Doctors, counselors and youngster development experts can help.
Treatment of ODD involves therapy, special types of training to help build positive family interactions, and possibly medications to treat related mental health conditions.
It's not unusual for kids -- especially those in their "terrible twos" and early teens -- to defy authority every now and then. They may express their defiance by arguing, disobeying, or talking back to their moms and dads, teachers, or other adults. When this behavior lasts longer than six months and is excessive compared to what is usual for the youngster's age, it may mean that the youngster has a type of behavior disorder called oppositional defiant disorder (ODD).
ODD is a condition in which a youngster displays an ongoing pattern of uncooperative, defiant, hostile, and annoying behavior toward people in authority. The youngster's behavior often disrupts the youngster's normal daily activities, including activities within the family and at school.
Many kids and teens with ODD also have other behavioral problems, such as attention-deficit/hyperactivity disorder, learning disabilities, mood disorders (such as depression), and anxiety disorders. Some kids with ODD go on to develop a more serious behavior disorder called conduct disorder.
It may be tough at times to recognize the difference between a strong-willed or emotional youngster and one with oppositional defiant disorder. Certainly there's a range between the usual independence-seeking behavior of kids and oppositional defiant disorder. It's normal to exhibit oppositional behaviors at certain stages of a youngster's development.
However, your youngster's issue may be ODD if your youngster's oppositional behaviors:
• Are clearly disruptive to the family and home or school environment
• Are persistent
• Have lasted at least six months
The following are behaviors associated with ODD:
• Hostility directed toward authority figures
These behaviors might cause your youngster to regularly and consistently show these signs and symptoms:
• Academic problems
• Acting touchy and easily annoyed
• Aggressiveness toward peers
• Anger and resentment
• Argumentativeness with adults
• Blaming others for mistakes or misbehavior
• Deliberate annoyance of other people
• Difficulty maintaining friendships
• Refusal to comply with adult requests or rules
• Spiteful or vindictive behavior
• Temper tantrums
Related mental health issues—
Oppositional defiant disorder often occurs along with other behavioral or mental health problems such as:
• Attention-deficit/hyperactivity disorder (ADHD)
The symptoms of ODD may be difficult to distinguish from those of other behavioral or mental health problems.
It's important to diagnose and treat any co-occurring illnesses because they can create or worsen irritability and defiance if left untreated. Additionally, it's important to identify and treat any related substance abuse and dependence. Substance abuse and dependence in kids or adolescents is often associated with irritability and changes in the youngster's usual personality.
There's no clear cause underpinning oppositional defiant disorder. Contributing causes are likely a combination of inherited and environmental factors, including:
• A youngster's natural disposition
• Abuse or neglect
• An imbalance of certain brain chemicals, such as serotonin
• Inconsistent or harsh discipline
• Lack of supervision
• Limitations or developmental delays in a youngster's ability to process thoughts and feelings
The exact cause of ODD is not known, but it is believed that a combination of biological, genetic, and environmental factors may contribute to the condition.
• Biological: Some studies suggest that defects in or injuries to certain areas of the brain can lead to serious behavioral problems in kids. In addition, ODD has been linked to abnormal amounts of special chemicals in the brain called neurotransmitters. Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals are out of balance or not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses. Further, many kids and teenagers with ODD also have other mental illnesses, such as ADHD, learning disorders, depression, or an anxiety disorder, which may contribute to their behavior problems.
• Environmental: Factors such as a dysfunctional family life, a family history of mental illnesses and/or substance abuse, and inconsistent discipline by parents may contribute to the development of behavior disorders.
• Genetics: Many kids and teenagers with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited.
A number of factors play a role in the development of oppositional defiant disorder. ODD is a complex problem involving a variety of influences, circumstances and genetic components. No single factor causes ODD.
Possible risk factors include:
• Being abused or neglected
• Exposure to violence
• Family instability such as occurs with divorce, multiple moves, or changing schools or youngster care providers frequently
• Financial problems in the family
• Harsh or inconsistent discipline
• Having a parent with a mood or substance abuse disorder
• Having moms and dads with a severely troubled marriage
• Lack of positive parental involvement
• Lack of supervision
• Moms and dads with a history of ADHD, oppositional defiant disorder or conduct problems
Stressful changes that disrupt a youngster's sense of consistency — such as divorce or moving — increase the risk of disruptive behavior. However, though these changes may help explain disrespectful or oppositional behavior, they don't excuse it. If you're concerned about your youngster's behavior or trouble adjusting to life changes, talk with your doctor.
Many kids with oppositional defiant disorder have other treatable conditions, such as:
• Attention-deficit/hyperactivity disorder (ADHD)
• Learning and communication disorders
If these conditions are left untreated, managing ODD can be very difficult for the parents, and frustrating for the affected youngster. Kids with oppositional defiant disorder may have trouble in school with teachers and other authority figures and may struggle to make and keep friends.
ODD may be a precursor to other, more severe problems such as conduct disorder, substance abuse and severe delinquency.
Preparing for a Dr. appointment—
If your kid has signs and symptoms common to oppositional defiant disorder, make an appointment with your kid's doctor. After an initial evaluation, your doctor may refer you to a mental health professional, who can help make a diagnosis and create the right treatment plan for your kid.
Here's some information to help you prepare for your appointment, and what to expect from your doctor.
What you can do:
• Make a list of your kid's key medical information, including other physical or mental health conditions with which your kid has been diagnosed. Also write down the names of any medications, including over-the-counter medications, your kid is taking.
• Take a trusted family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor in advance so that you can make the most of your appointment.
• Write down the signs and symptoms your kid has been experiencing, and for how long.
• Write down your family's key personal information, including factors that you suspect may have contributed to changes in your kid's behavior. Make a list of stressors that your kid or close family members have recently experienced and share it with the doctor.
Questions to ask the doctor at your kid's initial appointment include:
• Are there any other possible causes?
• How will you determine the diagnosis?
• Should my kid see a mental health provider?
• What do you believe is causing my kid's symptoms?
Questions to ask if your kid is referred to a mental health provider include:
• Do you recommend any changes at home or school to encourage my kid's recovery?
• Do you recommend family therapy?
• Does my kid have oppositional defiant disorder?
• Is my kid at increased risk of any long-term complications from this condition?
• Is this condition likely temporary or chronic?
• Should I tell my kid's teachers about this diagnosis?
• Should my kid be screened for any other mental health problems?
• What else can I and my family do to help my kid?
• What factors do you think might be contributing to my kid's problem?
• What treatment approach do you recommend?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor—
Being ready to answer your doctor's questions may reserve time to go over any points you want to talk about in-depth. You should be prepared to answer the following questions from your doctor:
• Do any particular situations seem to trigger negative or defiant behavior in your kid?
• Has your kid been diagnosed with any other medical conditions, including mental health conditions?
• Have your kid's teachers or other caregivers reported similar symptoms in your kid?
• How do you typically discipline your kid?
• How have you been handling your kid's disruptive behavior?
• How often over the last six months has your kid argued with adults or defied or refused adults' requests?
• How often over the last six months has your kid been angry or lost his or her temper?
• How often over the last six months has your kid been spiteful or vindictive, or blamed others for his or her own mistakes?
• How often over the last six months has your kid been touchy, easily annoyed or deliberately annoying to others?
• How would you describe your kid's home and family life?
• What are your kid's symptoms?
• When did you first notice these symptoms?
Tests and diagnosis—
To be diagnosed with oppositional defiant disorder, a youngster must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
Criteria for oppositional defiant disorder to be diagnosed include a pattern of behavior that lasts at least six months and includes at least four of the following:
• Is often angry and resentful
• Is often spiteful or vindictive
• Is often touchy or easily annoyed by others
• Often actively defies or refuses to comply with adults' requests or rules
• Often argues with adults
• Often blames others for his or her mistakes or misbehavior
• Often deliberately annoys people
• Often loses temper
These behaviors must be displayed more often than is typical for your youngster's peers.
In addition, to be diagnosed with oppositional defiant disorder, a youngster's disruptive behavior:
• Must cause significant problems at work, school or home
• Must not meet the diagnostic criteria for conduct disorder or, if the affected person is older than age 18, antisocial personality disorder
• Must occur on its own, rather than as part of the course of another mental health problem, such as depression or bipolar disorder
It can be difficult for doctors to sort and exclude other associated disorders — for example, attention-deficit/hyperactivity disorder versus oppositional defiant disorder. These two disorders are commonly diagnosed together.
As with adults, mental illnesses in kids are diagnosed based on signs and symptoms that suggest a particular illness like ODD. If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical exam. Although there are no lab tests to specifically diagnose ODD, the doctor may use various tests -- such as X-rays and blood tests -- to rule out physical illness or medication side effects as the cause of the symptoms. The doctor also will look for signs of other conditions that often occur along with ODD, such as ADHD and depression.
If the doctor cannot find a physical cause for the symptoms, he or she may refer the youngster to a youngster and adolescent psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses in kids and teens. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a youngster for a mental illness. The doctor bases his or her diagnosis on reports of the youngster's symptoms and his or her observation of the youngster's attitude and behavior. The doctor often must rely on reports from the youngster's moms and dads, teachers, and other adults because kids often have trouble explaining their problems or understanding their symptoms.
Treatments and drugs—
Treating oppositional defiant disorder generally involves several types of psychotherapy and training for your youngster — as well as for you and your co-parent. If your youngster has co-existing conditions, particularly ADHD, medications may help significantly improve symptoms.
The cornerstones of treatment for ODD usually include:
• Cognitive problem solving training. This type of therapy is aimed at helping your youngster identify and change through patterns that are leading to behavior problems. Research shows that an approach called collaborative problem solving — in which you and your youngster work together to come up with solutions that work for both of you — is highly effective at improving ODD-related problems.
• Individual and family therapy. Individual counseling for your youngster may help him or her learn to manage anger and express his or her feelings more healthfully. Family counseling may help improve your communication and relationships, and help members of your family learn how to work together.
• Medication. While there is no medication formally approved to treat ODD, various drugs may be used to treat some of its distressing symptoms, as well as any other mental illnesses that may be present, such as ADHD or depression.
• Parent training. A mental health provider with experience treating ODD may help you develop skills that will allow you to parent in a way that's more positive and less frustrating for you and your youngster. In some cases, your youngster may participate in this type of training with you, so that everyone in your family develops shared goals for how to handle problems.
• Parent-child interaction therapy (PCIT). During PCIT, therapists coach moms and dads while they interact with their kids. In one approach, the therapist sits behind a one-way mirror and, using an "ear bug" audio device, guides moms and dads through strategies that reinforce their kid's positive behavior. Research has shown that as a result of PCIT, moms and dads learn more-effective parenting techniques, the behavior problems of kids decrease, and the quality of the parent-youngster relationship improves.
• Psychotherapy. Psychotherapy (a type of counseling) is aimed at helping the youngster develop more effective ways to express and control anger. A type of therapy called cognitive-behavioral therapy aims to reshape the youngster's thinking (cognition) to improve behavior. Family therapy may be used to help improve family interactions and communication among family members. A specialized therapy technique called parent management training (PMT) teaches moms and dads ways to positively alter their youngster's behavior.
• Social skills training. Your youngster also might benefit from therapy that will help him or her learn how to interact more positively and effectively with peers.
As part of parent training, you may learn how to:
• Avoid power struggles
• Establish a schedule for the family that includes specific meals that will be eaten at home together, and specific activities one or both moms and dads will do with the youngster
• Give effective timeouts
• Limit consequences to those that can be consistently reinforced and if possible, last for a limited amount of time
• Offer acceptable choices to your youngster, giving him or her a certain amount of control
• Recognize and praise your youngster's good behaviors and positive characteristics
• Remain calm and unemotional in the face of opposition
Although some parent management techniques may seem like common sense, learning to use them in the face of opposition isn't easy, especially if there are other stressors at home. Learning these skills will require consistent practice and patience.
Most important in treatment is for you to show consistent, unconditional love and acceptance of your youngster — even during difficult and disruptive situations. Don't be too hard on yourself. This process can be tough for even the most patient moms and dads.
Treatment for ODD is determined based on many factors, including the youngster's age, the severity of symptoms, and the youngster's ability to participate in and tolerate specific therapies.
Lifestyle and home remedies—
At home, you can begin chipping away at problem behaviors by practicing the following:
• Assign your youngster a household chore that's essential and that won't get done unless the youngster does it. Initially, it's important to set your youngster up for success with tasks that are relatively easy to achieve and gradually blend in more important and challenging expectations.
• Build in time together. Develop a consistent weekly schedule that involves moms and dads and youngster being together.
• Model the behavior you want your youngster to have.
• Pick your battles. Avoid power struggles. Almost everything can turn into a power struggle — if you let it.
• Recognize and praise your youngster's positive behaviors. Be as specific as possible, such as, "I really liked the way you helped pick up your toys tonight."
• Set limits and enforce consistent reasonable consequences.
• Set up a routine. Develop a consistent daily schedule for your youngster. Asking your youngster to help develop that routine may be beneficial.
• Work with your partner or others in your household to ensure consistent and appropriate discipline procedures.
At first, your youngster is not likely to be cooperative or to appreciate your changed response to his or her behavior. Expect that you'll have setbacks and relapses, and be prepared with a plan to manage those times. In fact, behavior often temporarily worsens when new limits and expectations are set. However, with perseverance and consistency, the initial hard work often pays off with improved behavior and relationships.
Teaching Students with ODD—
Getting a reaction out of others is the chief hobby of kids with ODD. They like to see you get mad. They try to provoke reactions in people and are often successful in creating power struggles. Therefore it is important to have a plan and try not to show any emotion when reacting to them. If you react too emotionally, you may make big mistakes in dealing with this youngster. Plan in advance what to do when this child engages in certain behaviors and be prepared to follow through calmly.
• Address concerns privately. This will help to avoid power struggles as well as an audience for a potential power struggle.
• Always listen to this child. Let him/her talk. Don't interrupt until he/she finishes.
• Ask moms and dads what works at home.
• Avoid all power struggles with this child. They will get you nowhere. Thus, try to avoid verbal exchanges. State your position clearly and concisely and choose your battles wisely.
• Avoid making comments or bringing up situations that may be a source of argument for them.
• Decide which behaviors you are going to ignore. Most kids with ODD are doing too many things you dislike to include all of them in a behavior management plan. Thus, target only a few important behaviors, rather than trying to fix everything.
• Do not take the defiance personally. Remember, you are the outlet and not the cause for the defiance- unless you are shouting, arguing or attempting to handle the child with sarcasm.
• Establish a rapport with the ODD youngster. If this youngster perceives you as reasonable and fair, you'll be able to work more effectively with him or her.
• Give the ODD child some classroom responsibilities. This will help him/her to feel apart of the class and some sense of controlled power. If he/she abuses the situation, the classroom responsibilities can be earned privileges.
• In the private conference be caring but honest. Tell the child calmly what it is that is causing problems as far as you are concerned. Be sure you listen as well. In this process, insist upon one rule- that you both be respectful.
• Make this child a part of any plan to change behavior. If you don't, you'll become the enemy.
• Never raise your voice or argue with this child. Regardless of the situation do not get into a "yes you will" contest. Silence is a better response.
• Praise childs when they respond positively.
• Provide consistency, structure, and clear consequences for the child’s behavior.
• When decisions are needed, give two choices or options. State them briefly and clearly. Childs with ODD are more likely to complete or perform tasks that they have chosen. This also empowers them to make other decisions.
• When you see an ODD youngster getting frustrated or angry, ask if a calming down period would help. But don't force it on him/her. Rather than sending the child down to the office for this cooling down period, it may be better to establish an isolated “calming down” place in the classroom so he/she can more readily re-engaged in classroom activity following the cooling down period.
Instructional Strategies and Classroom Accommodations for the ODD Child—
• Establish clear classroom rules. Be clear about what is nonnegotiable.
• Post the daily schedule so the child will know what to expect.
• Make sure academic work is at the appropriate level. When work is too hard, childs become frustrated. When it is too easy, they become bored. Both reactions lead to problems in the classroom.
• Pace instruction. When the child with ODD completes a designated amount of a non-preferred activity, reinforce his/her cooperation by allowing him/her to do something they prefer or find more enjoyable or less difficult.
• Systematically teach social skills, including anger management, conflict resolution and how to be assertive in an appropriate manner. Discuss strategies that the child may use to calm him/ or herself down when they feel their anger escalating. Do this when the child is calm.
• Select materials that encourage child interaction. Childs with ODD need to learn to talk to their peers and to adults in an appropriate manner. All cooperative learning activities must be carefully structured, however.
• Minimize downtime and plan transitions carefully. Childs with ODD do best when kept busy.
• Allow the ODD child to redo assignments to improve their score or final grade.
Coping and support—
For yourself, counseling can provide an outlet for your own mental health concerns that could interfere with the successful treatment of your child's symptoms. If you're depressed or anxious, that could lead to disengagement from your child — and that can trigger or worsen oppositional behaviors.
Here are some tips:
• Learn ways to calm yourself. Keeping your own cool models the behavior you want from your child.
• Take time for yourself. Develop outside interests, get some exercise and spend some time away from your child to restore your energy.
• Be forgiving. Let go of things that you or your child did in the past. Start each day with a fresh outlook and a clean slate.
What Is the Outlook for Children With Oppositional Defiant Disorder?
If your child is showing signs of ODD, it is very important that you seek care from a qualified doctor immediately. Without treatment, children with ODD may experience rejection by classmates and other peers because of their poor social skills and aggressive and annoying behavior. In addition, a child with ODD has a greater chance of developing a more serious behavioral disorder called conduct disorder. When started early, treatment is usually very effective.
Can Oppositional Defiant Disorder Be Prevented?
Although it may not be possible to prevent ODD, recognizing and acting on symptoms when they first appear can minimize distress to the child and family, and prevent many of the problems associated with the illness. Family members also can learn steps to take if signs of relapse (return of symptoms) appear. In addition, providing a nurturing, supportive, and consistent home environment with a balance of love and discipline may help reduce symptoms and prevent episodes of defiant behavior.
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 or qualified mental health professional who can diagnose and treat ODD and any coexisting psychiatric condition.
According to The American Journal of Psychiatry, there are several sources of controversy around the diagnosis of ODD. One concerns the fact that the DSM-IV criteria differ slightly from those of the World Health Organization's criteria, as outlined in the ICD-10. Diagnosis of ODD is further complicated by the high occurrence of comorbidity with other disorders such as ADHD, though a 2002 study provided additional support for the validity of ODD as an entity distinct from Conduct disorder.
In another study, the utility of the DSM-IV criteria to diagnose preschoolers has been questioned because the criteria were developed using school-age children and adolescents. The authors concluded that the criteria could be used effectively when developmental level was factored into assessment.
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