Oppositional defiant disorder

Oppositional defiant disorder
Specialty	Psychiatry, clinical psychology

Oppositional defiant disorder (ODD) is a childhood disorder described by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as an ongoing pattern of anger-guided disobedience, hostility, and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior. Children suffering from this disorder may appear very stubborn and often angry. A diagnosis of ODD cannot be given if the child presents with conduct disorder (CD).

Behavioral features

Common features of oppositional defiant disorder (ODD) include excessive, often persistent anger, frequent temper tantrums or angry outbursts, as well as disregard for authority. Children and adolescents with ODD often purposely annoy others, blame others for their own mistakes, and are easily disrupted. Parents often observe more rigid and irritable behaviors than in siblings. In addition, these young people may appear resentful of others, and when someone does something they don't like they prefer revenge over more sensitive solutions.

For a child or adolescent to qualify for a diagnosis of ODD, these behaviors must cause considerable distress for the family and/or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations. These behaviors must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Signs and symptoms

Some signs and symptoms that must be perpetuated for longer than 6 months and must be considered beyond normal child behavior to fit the diagnosis are:

The child must exhibit 4 out of the 8 signs and symptoms listed below in order to meet the DSM-IV-TR diagnostic threshold for oppositional defiant disorder

• Actively refuses to comply with majority's requests or consensus-supported rules

• Performs actions deliberately to annoy others

• Angry and resentful of others

• Argues often

• Blames others for his or her own mistakes

• Often loses temper

• Spiteful or seeks revenge

• Touchy or easily annoyed

Generally, these patterns of behavior will lead to problems at school and other social venues.

Causes

The cause of ODD is unknown.

Children of alcoholic parents, or whose parents have "been in trouble with the law" run an 18% chance of developing ODD, beginning very early in age.

Prognosis

ODD has an estimated lifetime prevalence of 10.2% (11.2% for males, 9.2% for females). According to a 1992 article, if left untreated, about 52% of children with ODD will continue to meet the DSM-IV criteria up to three years later, and about half of those 52% will progress into conduct disorder. In many cases, CD progresses into antisocial personality disorder. This strong correlation between strong defiance in childhood and adulthood may suggest similar mechanisms for hostility towards established authority by children and by adults.

Psychosocial treatments

One of the key factors in the development and maintenance of the negative behaviors associated with ODD symptoms is reinforcement, whether intentional or not, of the unwanted behaviors. The most effective way of treating disruptive behavior disorders is behavioral therapies. Behavioral therapy for children and adolescents focuses primarily on how to prevent problematic thoughts or behaviors from accidentally getting reinforced unknowingly within a young person's environment.

Positive reinforcement often unintentionally contributes to an increase in the frequency of ODD behaviors. Behavior therapies can be applied to a wide range of psychological symptoms among children, adolescents, and adults with ODD. Behavior therapists encourage children and adolescents to try new behaviors and not to allow unwanted reinforcement to dictate the ways in which they act. Furthermore, therapists may work with parents to discontinue ways in which they are unintentionally reinforcing unwanted behaviors. An example of how positive reinforcement can occur is when the patient is rewarded with attention when performing ODD behaviors. Attention is reinforcing itself and the reinforcing attention could be accidentally given, ironically, when trying to create a negative consequence to their behavior. Positive Punishment occurs when the patient is inadvertently punished by aversive stimuli for not performing the ODD behaviors (of revenge, dis-cooperation, and frequent anger). These aversive stimuli that punish patients for not performing ODD behaviors can include: humiliation, isolation, not being told the reason of rules (e.g. being told "the reason you should is because I said so"), not having opinions taken seriously, as well as "being pushed around."

Researchers have found that the use of positive reinforcement and praise for appropriate behaviors are two key elements in effective interventions. If the majority of interactions with the child are focused around correcting their negative behaviors, a cycle of negative interactions is created, where the child expects attention after misbehaving. On the contrary, positive reinforcement and praise not only builds a child's self-esteem but also serves to strengthen the bond between a child and their caregiver. To accomplish this the positive reinforcement should occur immediately after a child has exhibited an appropriate behavior. The behaviors outlined for the child to be reinforced should be easy to evaluate and have very clear and easy to understand instructions. The type of reinforcement used should always depend on the child and should be developed together with both the family and the therapist.

Other approaches to the treatment of ODD include parent training programs, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents. There are several preventative programs which have had a positive effect on those who are at high risk for ODD. Both home visitation and programs such as Head Start have shown some effectiveness in preschool children. Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD. For adolescents at risk for ODD, cognitive interventions, vocational training, and academic tutoring have shown preventative effectiveness.

An approach developed by Russell Barkley uses a parent training model and begins by focusing on positive approaches to increase compliant behaviours.

Non-profit organizations such as the Mayo Clinic and the American Academy of Child and Adolescent Psychiatry (AACAP) provide information and resource centers to the public through their respective websites regarding ODD, including tests and diagnosis, treatments and drugs, as well as advice on preparation for an initial meeting with a physician regarding concerns.

Issues to address in the DSM-5

Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder has included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when CD is present. According to Dickstein, the latest DSM attempts to:

“redefine ODD by emphasizing a ‘persistent pattern of angry and irritable mood along with vindictive behavior,’ rather than DSM-IV's focus exclusively on ‘negativistic, hostile, and defiant behavior.’ Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is 'angry/irritable mood' —defined as ‘loses temper, is touchy/easily annoyed by others, and is angry/resentful.’ This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD”.

Controversy

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.

See also

• Antisocial personality disorder
• Attention deficit hyperactivity disorder (ADHD)
• Conduct disorder
• Counterdependency
• Parent Management Training
• Passive-aggressive behavior

External links

• What is ODD? – Society for Clinical Child and Adolescent Psychology (SCCAP)
• Oppositional defiant disorder (ODD) – Mayo Clinic
• ODD Resource Center – American Academy of Child and Adolescent Psychiatry