In Part 1 of this 2 part series, we will discuss what Oppositional Defiant Disorder (ODD) is and how to diagnosis and treat it. The second part of this series will discuss in more detail the differential diagnosis for ODD and begin the discussion about if the diagnosis is over used in clinical practice.
Oppositional Defiant Disorder (ODD) is a diagnosis in the DSM V. It is a disruptive behavior disorder characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness lasting for at least 6 months. The prevalence of ODD is 3.3% across multiple cultures. It is diagnosed more commonly for males than females. ODD is a risk factor for future development of conduct disorder in the adolescent years and antisocial personality disorder (ASPD) in adulthood. Most children who are diagnosed with ODD do not go to develop conduct disorder or ASPD. The etiology of ODD is thought to be multifactorial, including biologic, genetic and environmental factors. Biologic factors include parental nicotine use, prenatal deficiencies and developmental delays. Environmental factors include poor attachment, unresponsive parents, strict parenting and excessive punishment by parents. Newer studies have shown that parents’ behavior is causal rather than a reaction to the child’s symptoms. Poverty is a known risk factor and social support is a known protective factor.
Many children who have oppositional and defiant behavior have other psychiatric diagnoses that can help explain those behaviors. It is therefore very important to assess a differential diagnosis prior to making a diagnosis of ODD. Children with depression and mood disorders can present with irritability, defiance and argumentativeness during the mood episodes but they would not exhibit those symptoms during periods of normal mood. Children with anxiety disorders can exhibit oppositionality as part of their fear and anxiety, which is different than for a child with ODD who acts oppositional against figures of authority. Children with Disruptive Mood Dysregulation Disorder (DMDD) can exhibit chronic negative mood and temper outbursts like children with ODD but the anger outbursts are more severe with DMDD so if a child qualifies for a diagnosis of DMDD, they should not also be diagnosed with ODD. Children with ADHD can present with difficulty following directions, talking back and noncompliance as part of their ADHD diagnosis without being diagnosed with co-morbid ODD. Children who have experienced trauma can present with aggression and defiance. Children on the autism spectrum have a hard time showing empathy and can come across as displaying intentional defiance and oppositionality. Children on the autism spectrum or with intellectual disabilities or learning disabilities should not be diagnosed with ODD unless their oppositional behaviors are beyond what it typically seen for other children with similar disabilities.
There is not a screening tool specifically for ODD, but many of the screening tools for ADHD have multiple questions about ODD symptoms, which can be helpful in identifying that there might be a concern. These include the Conners, Vanderbilt and SANDAP.
https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf
The first line treatment for ODD is behavioral therapy, focused primarily on the parents and the parent-child dyad. It is important that the therapy involve parent management therapy and collaborative problem solving. Behavioral strategies, when generalized consistently into the home and school, can be very effective. Behavioral strategies can be challenging for some parents, who might be used to a certain parenting style and/or for families where the child with “ODD” plays a role of maintaining homeostasis for the family.
While medication is not first line treatment for ODD, it can be helpful for co-morbid conditions like ADHD, mood disorders and anxiety disorders. It is important to make sure that children and parents do not have an expectation that a medication intervention is going to have a significant role in treating noncompliance, defiance and oppositionality. Case studies have shown that stimulant and non-stimulant medications given to children with ADHD have some benefit for the oppositional behaviors related to the child’s ADHD. Other studies have shown that antidepressant medications given to children with depressive and anxiety disorders have some benefit for the related oppositional behaviors. Antipsychotic medication and mood stabilizers can be helpful for aggression but are not indicated and first line for ODD. They really should be considered a last resort treatment option.
Here is a link to a useful handout that can be given to parents that answers some basic questions about ODD:
Next week’s e-weekly will involve a discussion on the role of an ODD diagnosis and concerns about the overuse of the diagnosis and negative sequelae related to that concern.