Advances in the Treatment of
Oppositional Defiant Disorder: Part 1
Advances in the Treatment of Oppositional Defiant Disorder: Part 1

Oppositional Defiant Disorder (ODD) is among the most commonly diagnosed mental health
conditions in childhood. It is defined by a recurrent pattern of developmentally inappropriate
levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures.1  
This behavior must be present for more than six months and must not be caused by psychosis
or a mood disorder, and the behavior must negatively impact the youngster's social, academic,
or occupational functioning.

Kids with ODD have substantially impaired relationships with moms and dads, educators, and
friends. These kids are not only impaired in comparison with their friends, scoring more than
two standard deviations below the mean on rating scales for social adjustment, but they also
show greater social impairment than do kids with bipolar disorder, major depression, and
multiple anxiety disorders.6When compared with ODD, only Conduct Disorder (CD) and
pervasive developmental disorder had non-statistical differences in social adjustment.6

ODD is more common in males than females, but the data are inconsistent.7 Some investigators propose that
different criteria be used with females, who tend to exhibit aggression more covertly.5 Females may use verbal,
rather than physical, aggression, often excluding others or spreading rumors about another youngster. ODD is more
common among kids in low-income households and is typically diagnosed in late preschool to early elementary
school with symptoms often appearing two or three years earlier. Cross-sectional epidemiologic studies show a
gradually increasing prevalence of ODD as kids age.4

Etiology—

Investigators agree there is no single cause or even greatest single risk factor for ODD. Rather, it is best
understood in the context of a bio-psychosocial model in which a youngster's biologic vulnerabilities and protective
factors interact complexly with the protective and harmful aspects of his or her environment to determine the
likelihood of developing this disorder.5

Recent theories conceptualize kids with ODD as possessing deficits in a discrete skill set that lead to oppositional
behavior.6 An apparently noncompliant youngster who “explodes” in response to a parental demand may lack the
cognitive or emotional skills required to comply with the adult's request. For example, a youngster may not have
developed the skill of affective modulation, and tends to emotionally overreact, losing his or her capacity to reason.
A youngster may possess deficits in his or her executive cognitive skills (e.g., working memory, ability to change
tasks, organized problem solving). These deficits undermine the youngster's ability to comply with adult demands.
Such skill deficits are components of the transactional conceptualization of ODD, which emphasizes the interaction
of the kids and moms and dads, and the context of the behavior. An important feature of this model is the relative
predictability of the context (e.g., bath time, dinnertime) and the parent and youngster behaviors that precipitate a
youngster's meltdown.

Neuro-biologic theories have been explored in the etiology of aggression. Neurotransmitters such as serotonin,
norepinephrine, and dopamine have been investigated in their role with aggression. No single neurotransmitter or
neurologic pathway has been identified as the root cause. ODD is clearly familial, but research has yet to determine
what role genetics play because studies on the genetics of the disorder have produced inconsistent results.5
Smoking during pregnancy and malnutrition during pregnancy have been associated with the development of ODD,
although causality has not been firmly established.8

Natural History—

The natural history of ODD is not completely understood. The majority of individuals who are diagnosed with the
disorder in childhood will later develop a stable pattern of ODD behavior, an affective disorder, or ODD with
coexisting attention-deficit/hyperactivity disorder or affective disorders. Some kids persist with ODD without
coexisting conditions. Kids who were diagnosed with ODD at a young age (e.g., preschool, early elementary school)
may later transition to a diagnosis of attention-deficit/hyperactivity disorder, anxiety, or depression.9 In general,
earlier and more severe ODD is associated with a poorer long-term prognosis.9

Coexisting Conditions—

Coexisting conditions are common in kids with ODD, particularly attention-deficit/hyperactivity disorder and mood
disorders. The extent and nature of their coexistence is not precisely defined. The most comprehensive study of
kids with attention-deficit/hyperactivity disorder is the Multimodal Treatment Study of Kids with attention-
deficit/hyperactivity disorder. In this study, investigators found that 40 percent of kids with attention-
deficit/hyperactivity disorder also meet diagnostic criteria for ODD.10 Kids who have both disorders tend to be more
aggressive, have more persistent behavioral problems, experience more rejection from friends, and more severely
underachieve academically.5

In one community study of kids with ODD, 14 percent had coexisting attention-deficit/hyperactivity disorder, 14
percent had anxiety, and 9 percent had a depressive disorder.7 The authors of another study found that kids with
ODD were twice as likely to have severe major depression or bipolar disorder compared with a reference group.6,11
Specific data are lacking, but expert consensus is that learning disabilities and language disorders also commonly
coexist with ODD.5

ODD has commonly been regarded as a subset and precursor of the more serious CD, in part because most kids
with CD have a history of ODD. Approximately one third of kids with ODD subsequently develop CD, 40 percent of
whom will develop antisocial personality disorder in adulthood.12Kids with coexisting ODD and attention-
deficit/hyperactivity disorder are particularly likely to develop CD.

Among other features, aggression toward other people and animals, a disregard for the rights of others, and the
theft or destruction of others' property characterize CD.1 The DSM-IV precludes diagnosing a youngster with both
ODD and CD. When a diagnosis of CD is made, the diagnosis of ODD must be dropped if strict adherence to the
DSM-IV is sought. Some investigators conceptualize CD and ODD less as separate disorders, but rather as differing
primarily in the severity of their disruptive behavior. Other investigators consider the two as entirely separate
disorders. There is little disagreement that CD is more serious and is a poor outcome for kids previously diagnosed
with ODD.

Case Study—

Kylie is a 6-year-old girl whose father asked their family doctor to see her because of his increasing concern about
her temper tantrums in the home. The father indicated that Kylie often becomes enraged and argumentative with
him, refusing to follow rules or take direction. In particular, he reports difficulty getting her to transition from playing
with her toys to coming to the dinner table. After Kylie ignored her father’s repeated prompts, he became frustrated
and told her that she had lost her dessert privilege. Kylie became aggressive and destructive, breaking her toys and
smashing food and water from the dinner table into the carpet. Her father described similar scenarios at bedtime,
bath time, and when getting dressed in the morning. He described her as irritable in these situations and he felt she
was deliberately ignoring or trying to annoy him.

Diagnosis—

Tools such as the National Initiative for Child’s Healthcare Quality (NICHQ) Vanderbilt Assessment Scale,13
designed for the primary care evaluation of kids with suspected or diagnosed attention-deficit/hyperactivity disorder,
contain questions that aid in the identification of ODD. Use of this or similar instruments, such as the SNAP-IV
Teacher and Parent Rating Scale for kids with attention-deficit/hyperactivity disorder,14 may allow enhanced
detection of ODD as well as other psychological concerns. Screening tools such as the Pediatric Symptom Checklist
are not specific for ODD, but can screen for cognitive, emotional, or behavioral problems, thereby identifying kids
who require additional investigation.15  

The initial step in diagnosis is to determine whether or not the behavior is, in fact, abnormal. A certain amount of
oppositional behavior is normal in childhood. ODD is only distinguishable by the duration and degree of the
behavior. Doctors should carefully explore the possibility that the youngster's oppositional behavior is caused by
physical or sexual abuse, or neglect. Given the wide range of normal oppositional behavior during the preschool
years, caution should be exercised in diagnosing this disorder in the preschool-age youngster.5 Assessment of the
youngster with a potential diagnosis of ODD depends on establishing a therapeutic alliance with both the youngster
and family. The assessment should include information gathered from multiple sources (e.g., preschool, educators)
as well as history obtained from the youngster directly.

To satisfy DSM-IV criteria for ODD, a youngster must frequently demonstrate behavior from at least four of nine
criteria. The behavior must be considerably more frequent than is typically observed in individuals of comparable
age and developmental level and must cause clinically significant impairment in social, academic, or occupational
functioning.1

When the diagnosis is unclear, clients should be referred to a psychologist or psychiatrist trained in the assessment
of kids with behavioral disorders. For kids in elementary school, a doctor's written request should facilitate a school-
based evaluation by an appropriate professional. Evaluation of preschool kids can most often be prompted by a
telephone call to a county's Child Find or similar program. When available, a developmental-behavioral doctor can
be an ideal beginning point of an assessment. Structured psychological interviews (such as the National Institute of
Mental Health's Diagnostic Interview Schedule for Kids [DISC] version 2.3), typically administered by a psychologist,
can be used for formal diagnosis. When these services are unavailable, doctors may wish to use a brief series of
questions that investigators have shown to possess 90 percent sensitivity and 94 percent specificity for identifying
ODD.

Neuro-imaging (e.g., functional magnetic resonance imaging, single-photon emission computed tomography,
electroencephalography) has a role in the research of aggressive behavior, but it has no clinical role in the
evaluation of kids with suspected ODD.

Non-pharmacologic Treatment—

Research supports outpatient psychological interventions for kids with ODD. Studies have demonstrated that parent
training is an effective means of reducing disruptive behavior.16Moms and dads often come to see their youngster's
behavior as deliberate and under the youngster's control, intentionally hurtful toward the parent, or as an attribute
of a disliked family member (e.g., an abusive partner).17 The difficult behavior and social disruption caused by kids
with ODD can have adverse effects on the mental health of their moms and dads.18 Parent training teaches moms
and dads to be more positive and less harsh in their discipline style. Media-based parent training (e.g., watching a
video) has been shown to be effective with results continuing one year after the intervention.19 In a randomized
study, investigators found that applying parent training to both the youngster and parent is superior to training
aimed solely at the parent, supporting the generally agreed-upon principle that therapies are more effective when
both parent and youngster are involved.20

Collaborative problem-solving interventions seek to facilitate joint problem solving, rather than to teach and motivate
kids to comply with parental demands. This model encourages moms and dads and kids to identify issues and to
use cognitive approaches to resolve the conflict to the mutual satisfaction of both parties. Collaborative problem
solving appears to be at least as effective as parent training.21

Pharmacologic Treatment—

Several studies have found that medicines used in the treatment of attention-deficit/hyperactivity disorder, such as
Ritalin, Strattera and Adderall, are effective in the treatment of attention-deficit/hyperactivity disorder with coexisting
ODD.22–24 According to these studies, stimulants reduced the symptoms of both attention-deficit/hyperactivity
disorder and ODD symptoms. There are also two small studies that show the effectiveness of clonidine in treating
kids with attention-deficit/hyperactivity disorder and ODD, either as mono-therapy or as augmentation to medical
therapy.25,26 Studies have not demonstrated that stimulants reduce the symptoms of ODD when attention-
deficit/hyperactivity disorder is absent.

Prevention—

There is evidence that programs for preschool kids (e.g., Head Start) reduce delinquency and, by inference, ODD.
13 In elementary school-age kids, the greatest evidence on prevention supports parent management strategies.
Researched programs include the Triple P-Positive Parenting Program and Incredible Years parenting series. Both
of these use self-directed, multimedia, parenting and family support strategies to prevent severe behavioral
problems in kids by enhancing the knowledge, skills, and confidence of moms and dads. These programs are most
appropriate for moms and dads whose kids appear to be at risk of developing emotional and/or behavioral
problems. School-based programs that focus on anti-bullying, antisocial behavior, or peer groups can also be
effective prevention approaches.27

Family doctors should suspect ODD when moms and dads report an excessively argumentative, defiant, and hostile
school-age youngster. ODD is common in kids with attention-deficit/hyperactivity disorder, and use of the validated
instruments mentioned in this article for the assessment and diagnosis of attention-deficit/hyperactivity disorder can
help doctors to identify ODD. Suspicion for ODD should be raised when known risk factors (e.g., family history of
ODD/CD, attention-deficit/hyperactivity disorder, low socioeconomic status) are present. Formal diagnosis may
require referral to a kid's psychiatrist.

Kids with ODD are best served by referral to a therapist who is skilled and knowledgeable in evidence-based
therapies for these kids, although finding such professionals can be challenging. A doctor's ability to locate
particular resources for a youngster will depend on the family's insurance, financial resources, and motivation, as
well as the availability of such resources in their community. There is no single best way to connect a youngster to
the best services for him or her, and it is often prudent to explore multiple avenues to find the optimal available
services. A doctor's knowledge of ODD, its typical symptoms, and best available treatments can allow the doctor to
serve as a patient advocate, to connect families with services, and to provide families with educational materials and
online resources.

Behavior Management for ODD Children and Teens: Parent Training Course
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