What is ODD?
Oppositional Defiant Disorder (ODD) is a condition in which a child displays a continuing pattern of uncooperative, defiant, and hostile behaviour toward people in authority. This should not be confused with typical age-appropriate challenging and defiant behaviour that occurs once in a while (terrible two’s, early teens). The behaviour observed with ODD typically disrupts the child’s normal daily function, including relationships, learning and activities within the family and the school.
Causes and Risk Factors
The exact cause of ODD is not known, however, there are various theories that biological, genetic, and environmental factors play a role[1].
Biological: Some studies suggest that abnormalities in or injuries to certain parts of the brain can lead to behavioural disorders. In addition, ODD has been linked to special chemicals in the brain called neurotransmitters, and these neurotransmitters help the nerve cells in the brain communicate with each other. If these chemicals are out of balance, or not working properly, messages might not make it through the brain correctly leading to some symptoms.
Genetic: ODD might be inherited. It is important to note that many children and teenagers with ODD have close family members with mental disorders, including mood disorders, personality disorders and anxiety disorders.
Environment: Factors such as chaotic family life, a family history of mental disorders and substance abuse, abuse and inconsistent discipline by parents may be a cause of contributing factors.
Developmental: There are theories suggesting that the problem starts when children are toddlers. Children or teens may have had trouble learning to become independent from a parent or others with whom they were emotionally attached. Their behaviour may be normal developmental issues that are now lasting beyond the toddler years.
Learned: Negative symptoms of ODD may be learned attitudes. They mirror the effects of negative reinforcement methods used by parents and other people in authority positions. The use of negative reinforcement increases the prevalence of ODD behaviour. That is because these behaviours allow for a child to get what they want, namely attention and the reaction of the adult.
Things that may put a child at risk for developing ODD are:
Temperament à Difficulty regulating emotions, being highly emotionally reactive to situations or having difficulty tolerating frustration.
Parenting issues à A child who experiences abuse or neglect, harsh and inconsistent discipline, a lack of parental supervision, family discord or fighting.
Environment à ODD can be strengthened and reinforced by attention from peers and inconsistent discipline from other authority figures such as teachers.
Prevention of ODD:
Even though it may not be possible to prevent ODD, recognising and acting on the symptoms when they appear may minimise the distress to the child and the family, and may prevent further problems associated with the disorder.
Providing a nurturing, supportive and consistent home environment, with a balance of love and discipline might help reduce symptoms and prevent episodes of defiant behaviour.
Co-occurring Disorders:
- ADHD
- Depression
- Anxiety
- Bipolar Disorder
- Conduct Disorder
- Learning and communication difficulties
ODD can lead to various other problems:
- Poor school and work performance
- Antisocial behaviour
- Impulse control problems
- Substance use disorder
- Suicide
The prevalence of Oppositional Defiant Disorder (ODD) in Attention Deficit and Hyperactivity Disorder (ADHD):
Up to 60% of individuals with ADHD also have ODD[1]. These individuals show a considerably worse prognosis compared with individuals with either ADHD or ODD. Therefore, early identification of the risk factors for comorbid ADHD and ODD is essential to contribute to the development of early preventive interventions[2]. Individuals with both ADHD and ODD have a higher risk to develop anxiety and depressive disorders, conduct disorder and even antisocial personality disorder later in life[3].
Reported overlapping risk factors for ODD and ADHD include maternal smoking during pregnancy[4], a family history of ADHD and/or ODD[5], and higher levels of family conflict[6]. Specific risk factors for ODD, compared with ADHD, include deviant peer attachment, harsh or inconsistent parenting, low levels of parental affection, and exposure to family violence[7].
Treatment Options for ODD:
It is recommended that parents receive continual professional support and guidance on how to assist children with ODD.
- Play Therapy or Psychotherapy for a child with ODD
- Setting clear boundaries in all contexts
- Implementing clear morning and evening routines
- Implementing effective commands for behaviour modification.
Urquiza, Zebell, Timmer, McGrath and Whitten (2011) discuss tips on communication and giving effective commandments:
1. Be Specific with Your Commands
Avoid being vague with commandments. It is important to tell the child exactly what you want them to do. Providing them with specific commands will likely result in getting the desired behaviour. Instead of saying, “Now behave in the store,” a parent could say:
• “Please hold onto the shopping cart.”
2. Every Command Positively Stated
Avoid using words like “No – Don’t – Stop – Quit – or Not”. These words may cause immediate resistance in children. Instead, provide a command that tells the child what to do rather than what not to do.
For example, instead of saying “Stop jumping on the bed”, or “quit it”, a positively stated command would be to instruct the child as to what you want them to do.
• “Please sit on the couch.”
3. Developmentally Appropriate commands
It is important to give age-appropriate commands. Children can understand and do more as they get older. Therefore, our expectations for younger children should be different than for older children. Certain commands may be too difficult for young children
4. Individual Instructions rather than Compound Instructions
Focus on giving one instruction at a time rather than stringing several instructions together. Many younger children and children with attention problems have a difficult time remembering more than one or two instructions.
For example, the first command for cleaning up the room might be, “Please put your blocks back in the box” (praise compliance). Then, “Now please put your shoes in the cupboard” (praise compliance). Then, “Please finish by putting the books back on the shelf” (praise compliance).
5. Respectful and Polite
Start most instructions with the word “please”. This fosters respect, appropriate social skills, and good manners, and may increase the likelihood that children will listen to commands.
• “Please share the toy with your friend.”
6. Essential Commands
Parents spend more time giving commands – about everything! When a child hears too many commands, they are more likely to tune them out and shut down. This happens because they simply become overwhelmed with commands. Try to focus on essential commands.
7. Carefully Timed Explanations
Children often require a reason or rationale for complying with a command. Giving the reason before giving the command will reduce resistance or delay compliance. For example, you might say:
• “We are going to the store. Please put on your shoes.”
8. Keep your tone of voice neutral
Parents often say that they have to raise their voices to get their children to obey. Giving commands in a loud, stern voice can be stressful to parents, causing frustration and irritation. Give all commands in a neutral tone, avoiding angry, frustrated, pleading, or loud tones.
9. Predictable and Consistent Response Command
When a child follows a command, react with praise! Consistency is key, it teaches the child that your responses are predictable. When a child understands what they are supposed to do and know how you will respond, he/she is much calmer and happier. Therefore, when your child behaves appropriately, respond positively!
Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists the criteria for diagnosing Oppositional Defiant Disorder (ODD):
A. A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling:
Angry/Irritable Mood
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful
Argumentative/Defiant Behaviour
4. Often argues with authority figures or, for children and adolescents, with adults
5. Often actively defies or refuses to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or misbehaviour
Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
Note: The persistence and frequency of these behaviours should be used to distinguish a behaviour that is within normal limits from a symptomatic behaviour. For children younger than 5 years, the behaviour should occur on most days for a period of at least 6 months unless otherwise noted (Criterion AB). For individuals 5 years or older, the behaviour should occur at least once per week for at least 6 months. Unless otherwise noted (Criterion AB). While these frequency criteria guide a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviours are outside a range that is normative for the individual’s developmental level, gender, and culture.
B. The disturbance in behaviour is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues) or it impacts negatively on social, educational, occupational, or other important areas of functioning,
C. The behaviour does not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.
References:
[2] Connor DF, Doerfler LA. ADHD with comorbid oppositional defiant disorder or conduct disorder: discrete or nondistinct disruptive behavior disorders? J Atten Disord. 2008;12:126–134.
[3] Noordermeer, S. D. S., Luman, M., Weeda, W. D., Buitelaar, J. K., Richards, J. S., Hartman, C. A., Hoekstra, P. J., Franke, B., Heslenfeld, D. J., & Oosterlaan, J. (2017). Risk factors for comorbid oppositional defiant disorder in attention-deficit/hyperactivity disorder. Adolescent Psychiatry (Vol. 26, Issue 10, pp. 1155–1164). Springer Science and Business Media LLC.
[4] Loeber R, Burke JD, Lahey BB, Winters A, Zera M. Oppositional defiant and conduct disorder: a review of the past 10 years, part I. J Am Acad Child Adolesc Psychiatry. 2000;39:1468–1484.
[5] Nigg JT, Breslau N. Prenatal smoking exposure, low birth weight, and disruptive behavior disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:362–369.
[6] Boden JM, Fergusson DM, Horwood LJ. Risk factors for conduct disorder and oppositional/defiant disorder: evidence from a New Zealand birth cohort. J Am Acad Child Adolesc Psychiatry. 2010;49:1125–1133.
[7] Loeber R, Slot NW, Van der Laan P, Hoeve M. Tomorrow’s criminals. Farnham: Ashgate Publishing Limited; 2008
[8] Richards JS, Hartman CA, Franke B, Hoekstra PJ, Heslenfeld DJ, Oosterlaan J, Arias Vasquez A, Buitelaar JK. Differential susceptibility to maternal expressed emotion in children with ADHD and their siblings? Investigating plasticity genes, prosocial and antisocial behaviour. Eur Child Adolesc Psychiatry. 2015;24:209–217.
[9] American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: DSM-5. 5th edn. Washington, D.C.: American Psychiatric Publishing.
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