Oppositional Defiant Disorder (ODD)
Updated: Aug 31, 2021
Throughout the course of their development, children and adolescents undergo a process of individuation, discovering and asserting who and what they are to be in the world. Parents set limits; to keep children safe, to mould their behaviour, and to encourage their personal and social growth. Children, by design, test parents’ limits. A child or adolescent who is occasionally oppositional and defiant, even spectacularly so, does not necessarily have a disorder that needs treatment.
So how can you tell when a child’s defiant behaviour has risen to the point of needing specialised care? And how can you tell when defiant behaviour is a primary part of their temperament or a symptom of some other problem(s) that may have been missed?
What’s Oppositional Defiant Disorder (ODD)
ODD is a pattern of hostile, defiant, and disobedient behaviours directed at authority figures. The problem is not just one of regulating emotion, instead the person with ODD engages in behaviour that consistently brings him or her into conflict with social norms. Children and adolescents are often referred for evaluation when problems with spiteful, negativistic, and hostile behaviour, including verbal and physical threats, are severe enough to disrupt their academic and/or social functioning. Children and adolescents with ODD are not just occasionally defiant. The diagnosis is only warranted when there is a persistent and near constant pattern of angry and defiant behaviours (lasting at least 6 months) directed towards parents and other authority figures.
Prevalence of ODD
The lifetime prevalence of ODD is approximately 10% with a slightly higher rate among males than females. There appears to be consistent gender differences in the expression of ODD symptoms. While boys with ODD are more likely to express anger with verbal and sometimes physical outbursts, girls are more likely to show their defiance indirectly by being dishonest or uncooperative. However, these are just trends. Both genders can display varied symptoms. ODD usually presents first in childhood. Children and adolescents who receive an ODD diagnosis are at risk for going on to develop a number of other disorders some of which will cause problems that extend into adulthood. Early identification and intervention is extremely important to mitigate the significant impairment and dysfunction that can occur.
DSM V criteria for Oppositional Defiant Disorder
A. A pattern of angry/irritable mood, argumentative/defiant behavior, 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:
Often loses temper
Is often touchy or easily annoyed
Is often angry and resentful
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
6.Often deliberately annoys others
7.Often blames others for his or her mistakes or misbehavior Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
B. The disturbance in behavior 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 behavior 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.
Note: The persistence and frequency of these behaviours should be used to distinguish a behaviour that is within normal limits from a behaviour that is symptomatic. 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 provide guidance on 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.
The Important Role of the Child and Adolescent Psychiatrist
When seeking help for a child or adolescent with disruptive behaviour, most parents end up in the offices of their primary care providers. After only a brief encounter, they may receive a diagnosis such as Oppositional Defiant Disorder, Conduct Disorder, Bipolar Disorder, or other labels. An initial visit to a paediatrician or general practitioner (GP) is appropriate to rule out any physical health issues. It is important to make sure the child has been meeting all of their developmental milestones appropriately, and that there are not obvious, genetic, neurological, or cognitive problems. But beyond that, the diagnosis of ODD should be avoided until a specialist evaluation has been completed.
Labelling a child with ODD carries with it a significant amount of stigma which itself can be detrimental to the child’s academic and social functioning. Often teachers, other parents, and other adults can subtly change expectations of a child or adolescent who they know has been labeled as “oppositional.” Sometimes labels can become self fulfilling, in that the expectations and attention of others (even though well-meaning or subconscious) can reinforce the very behaviour that is problematic. In addition to the stigma of the label, an inappropriate diagnosis could lead to exposure to lengthy, intrusive, and ultimately ineffective treatment.
There is a complex interplay between developmental stages and symptom presentation. A Child and Adolescent Psychiatrist has specific training to take into account the interaction between a child’s social and emotional temperament, their developmental stage, and the presenting symptoms. Making the diagnosis of Oppositional Defiant Disorder is a complex process and many children and adolescents receive the label inappropriately. Child and Adolescent Psychiatrists are skilled at considering other possible problems and diagnoses before the label of ODD is applied. There is significant symptom overlap between ODD and other disorders, so a thorough differential diagnosis must be considered.
The specially trained Child and Adolescent Psychiatrist will also be able to synthesise information from various sources in order to get a fuller understanding of the child, their family and school functioning, and other factors that might contribute. If ODD is the appropriate diagnosis, a Child and Adolescent Psychiatrist will be able to make specific treatment recommendations, avoid inappropriate or harmful interventions, and provide invaluable education and insight to the child and the adults around them.
The Assessment & Diagnosis
It is important that the assessment of ODD examines information from a number of different sources including parents, teachers, and other authority figures. It is not uncommon for the child to display no obvious ODD symptoms during the actual assessment with the Child and Adolescent Psychiatrist. It will be essential then, to gather details about when and how the symptoms do occur. If the child’s disruptive behaviour is directed more at peers or if the child reacts negatively only to certain adults or to parents, other causes should be explored. A determination should be made as to the child’s involvement in bullying, either as a victim or perpetrator. A thorough evaluation will include information from as many sources as possible. Clinical rating scales filled out by parents, teachers, and clinicians can also be helpful.
The assessment will also consider any physical health problems, family history, genetic predisposition and other factors. ODD should really only be considered after other more obvious or common causes of disruptive behaviours are explored. Other causes include Childhood Trauma including developmental trauma disorder.
Professionals involved in the care of individuals with ODD symptoms face a diagnostic and treatment challenge. Significant symptoms overlap with other diagnoses, as well as typical developmental tasks and challenges can contribute to misdiagnosis and unfortunate labelling and stigma. Trauma, especially chronic exposure, is an often overlooked cause of disruptive behaviours in childhood. It is essential that anyone doing an assessment for ODD symptoms ask both the child, their family and other adults in their lives, about current and past trauma exposure. Child and Adolescent Psychiatrists are specially trained to synthesise all of the diagnostic information, to consider other possible causes of the problem behaviour, and to suggest appropriate treatment options. Whenever possible, consultation with a Child and Adolescent Psychiatrist (Paediatric Psychiatrist) should be sought.