110 Oppositional Defiant Disorder (313.81)

• Classifed as an externalizing disorder

DSM-IV-TR criteria

• A pattern of negativism, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
  • (1) often loses temper
  • (2) often argues with adults
  • (3) often actively defies or refuses to comply with adults’ requests or rules
  • (4) often deliberately annoys people
  • (5) often blames others for his or her mistakes or misbehavior
  • (6) is often touchy or easily annoyed by others
  • (7) is often angry and resentful
  • (8) is often spiteful or vindictive
    • Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
    • More diagnostic information can be found on the following link from the American Academy of Child & Adolescent Psychiatry: AACAP
• The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. http://www.wikispaces.com/_/ad4b0f60/i/c.gif
• The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
• Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
• Recurrent pattern of negativeistic, defiant, disobedient, and hostile behavior towards authority figures.
• Occurs ouside of normal developmental levels and lead to impairment in functioning.

Peers

Children with oppositional defiant disorder (ODD) have substantially impaired relationships with parents, teachers, and peers. These children are not only impaired in comparison with their peers, scoring more than two standard deviations below the mean on rating scales for social adjustment, but they also show greater social impairment than do children with bipolar disorder, major depression, and multiple anxiety disorders. When compared with oppositional defiant disorder, only conduct disorder and pervasive developmental disorder had nonstatistical differences in social adjustments.

Associated features

Oppositional Defiant Disorder (ODD) is characterized by hostile and defiant behaviors, such as negativity, defiance, hostility, frequent outbursts of rage, an excessive need to argue and swear, avoidance, and disobedience that begin by age six and is followed by Conduct Disorder (CD) that has an early onset around age nine. Those who develop CD in adolescence have problems that persist through adolescence, but are not seen in adulthood. These children seem to be most comfortable when pushing the boundaries of familiar territory.

According to the DSM-TR-IV, Oppositional Defiant Disorder (ODD) is more common in households where the child’s upbringing has been very inconsistent or even neglectful and tends to shift into the school environment. The child’s caregiver might also change often during their life. Children with Oppositional Defiant Disorder (ODD) might also have Attention-Deficit/ Hyperactivity Disorder (ADHD) or other Learning Disorders (LD) and Communication Disorders. Males in their preschool years tend to have higher motor activity or a more problematic temperament. During school years children with Oppositional Defiant Disorder (ODD) may have lower self-esteem and low frustration tolerance. They may also swear and use alcohol, tobacco, or illegal drugs. They may often invoke conflict with teachers, parents, and even peers. Difficulty maintaining friendships and academic problems are also seen quite frequently with this disorder.

ODD usually begins in the child’s home and often carries over to familiar adults in the child’s life such as his/her parents. With these adults they will push the boundaries and test their limits. Children with ODD may present either a low self-concept or an inflated self-esteem. They often engage their parents or caregivers in fights that may escalate into emotional turmoil on both child and parents which can lead parents to start a negative style of parenting that often only serves to perpetuate the problem. ODD behaviors may not be evident in the school or community and are not likely to be evident in the clinical interview.

It occurs outside of normal development levels and leads to impairment in functioning.

Child vs. adult presentation

Oppositional behavior is common in preschool children and adolescents, therefore, the caution should be determined for an adequate diagnosis. The number of symptoms tends to increase with age. Children tend to display disruptive and aggressive behaviors for longer than 6 months. There is a pattern of ongoing defiant, uncooperative, and hostile behaviors. Children usually have frequent temper tantrums, deliberate attempts to upset or annoy people especially adults, and they seek revenge often. If the Oppositional Defiant Disorder (ODD) does not progress into Antisocial Personality Disorder (ASPD), then the problems continue through adolescence, but will not be seen in adulthood. Research has demonstrated that children, who have Oppositional Defiant Disorder (ODD), especially at an early age, are more likely to develop Antisocial Personality Disorder (ASPD), psychopathy, or other serious mental illness when they reach adulthood.

Gender and cultural differences in presentation

Before puberty, males seem to have Oppositional Defiant Disorder (ODD) more often than females. It is a 4:1 agverage ratio that males have ODD more than girls. After puberty, the rates will equal out. Symptoms for both genders are very similar, except that males will sometimes be more confrontational or have more persistent symptoms. The presentation of ODD symptoms may be seen differently across cultures.

Epidemiology

Oppositional Defiant Disorder (ODD) seems to be more common in families where at least one parent has had a history of Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Mood Disorder, Attention Deficit/Hyperactivity Disorder (ADHD), Substance-Related Disorder, or Antisocial Personality Disorder. Also, some studies have shown that children that have mothers with Depressive Disorder are more likely to have oppositional behavior. It is unknown as to how much the mother’s depression results from or causes the child’s oppositional behavior.

Rates of 2% to 16% have been reported.

Symptoms usually become evident before eight years of age and not later than early adolescence. Oppositional symptoms often emerge at home but may emerge elsewhere as well over time. Onset is usually gradual, over months or years. Oppositional Defiant Disorder (ODD) may be a precursor to Conduct Disorder (CD).

Etiology

• There are many different theories that try to explain both Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD):
  • A psychodynamic oriented therapist would interpret the aggressive and defiant behaviors of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) as manifestations of a deeply-seated feeling of lack of parental love, the inability to trust, and an absence of empathy. This is related to the Psychodynamic disorders.
  • Behavioral Theories suggest that the defiant behaviors are caused by the defiant behavior not being punished and good behavior being reinforced. The parents repeatedly giving into demands is a reinforcement of the bad behavior.
  • Cognitive Theories suggest that the child feels hostility in their lives, and they responded to it with their own hostility.
  • Family Patterns, Attachment, and Parenting a Family System Clinician would say that the child’s aggression is their way of attempting to control the balance of power because of the parents inconsistent, or extreme boundaries and limit setting.
  • There is also evidence of low levels of DBH (which converts dopamine to noradrenaline) may produce higher thresholds for sensation-seeking behaviors in some children.

Empirically supported treatments

Problem-Solving – Skills-Training programs teach children to solve problems in a logical and predictable manner. The second, The Coping Power, promotes anger control. The down side to both is the time with Problem-Solving – Skills-Training being a 20 session program and The Coping Power being even longer at 33 sessions. There is also research being done in parenting training to help parents improve skills in targeting behaviors that should be changed and developing a reward program to reduce unwanted behaviors while increasing the wanted ones.

Parent Management Training (PMT) can allow the parents learn to develop and implement structured contingency management programs at home. It can improve interactions between the parents and child, change antecedents to problem behaviors, improve the parent’s monitoring skills of the child’s behavior, and give them more effective discipline strategies. A few examples of the techniques suggested towards parents during this training, are to acknowledge and praise children when they perform positive behaviors, establish schedules and stick to them, maintain effective timeouts, and try to circumvent corrivalry.

Individuals raising children with Oppositional Defiant Disorder (ODD) must find ways to accomplish thier daily routines and errands dispite the behavior of thier children. Without the perspective of being a parent of a child with ODD it can be difficult to understand the challenges they face. See video http://www.youtube.com/watch?v=c-KC9tkn0_Y

Recent studies demonstrate that certain medications can help with Oppositional Defiant Disorder (ODD). The research is preliminary, but the studies show that under certain circumstances medical treatments may help.

In one study, Ritalin (**methylphenidate** hydrochloride) was used to treat children with both ADHD and ODD. Researchers found that when treated with Ritalin, 90% of the children no longer had the ODD. However, this was a poorly executed study. The researchers dropped a number of children from the study because they were too defiant to take their medication as scheduled. Still, even if these children are included as treatment failures, the study still showed a 75% success rate with Ritalin (Kane, 2010). For children that are over 6 years old take Ritalin starting out with 5mg tablets twice a day. It should be taken in the morning before breakfast and in the afternoon before dinner to avoid stomach problems. If necessary, your child’s healthcare provider may slowly increase the dosage up to Ritalin 60 mg per day. For adults with narcolepsy, the total dosage of Ritalin per day is usually 20 mg to 30 mg (divided into two or three doses). Some people may need less Ritalin, while others may need as much as 60 mg per day.

As with any medicine, side effects are possible with **Ritalin** (**methylphenidate** hydrochloride). However, not everyone who takes the drug will experience side effects. In fact, most people tolerate it quite well. If side effects do occur, in most cases, they are minor, meaning they require no treatment or are easily treated by you or your healthcare provider. Common Side Effects of Ritalin has been studied thoroughly in clinical trials, with many people having been evaluated. In these studies, side effects occurring in a group of people taking the drug are documented and compared to side effects that occurred in a similar group of people not taking the medicine. This way, it is possible to see what side effects occur, how often they appear, and how they compare to the group not taking the medicine. Based on these studies, the most common Ritalin side effects include: nervousness, **Insomnia**, loss of appetite, nausea, dizziness, headache, drowsiness, abdominal pain (stomach pain), and weight loss (see **Ritalin and Weight Loss**). Ritalin can also temporarily stunt the growth of children. This slowing down of growth is usually small (less than an inch and less than two pounds), and children usually catch up to their normal growth rate with time.

DON’T FORGET: A diagnosis of ODD must occur before the age of 18, and symptoms must not be better accounted for by either conduct disorder or anitsocial personality disorder.