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Oppositional Defiant Disorder (ODD)

Ahmed Zayed, MD
angry child

Oppositional defiant disorder (ODD) is a type of behavior disorder indicated by a persistent pattern of angry or irritable mood and defiant behavior. The condition usually affects children or teens. 

The main symptoms of ODD are aggressive, irritable, defiant, and vindictive behavior. Patients with ODD are reluctant to obey parents or other authority figures. They may also purposely be aggressive toward their peers. 

The exact causes of ODD are unknown, but environment and genetics could be to blame. A child with this disorder doesn’t know how to process their emotions adequately or cope with certain situations. As a result, they act out.

Males are more likely to develop ODD in childhood than females, but this difference goes away in adolescence. 

Early ODD treatment is necessary to prevent complications that affect a patient and their family. Oppositional defiant disorder treatments revolve around therapy options that enable children to communicate and express their emotions more effectively. Since parenting approaches also contribute to the development and severity of ODD, a lot of treatment plans are parent-centric.

What is Oppositional Defiant Disorder (ODD)?


Oppositional defiant disorder (ODD) is a form of behavior disorder wherein a child or adolescent exhibits a persistent or frequent pattern of irritability, anger, vindictiveness, and defiance toward parents or problems with authority figures.

This disorder has been recognized by the American Psychiatric Association for several decades. It first appeared in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3) in 1987. Before that, DSM-3 used the term oppositional disorder (OD) in its original version published in 1980.

It’s useful to mention the current DSM, i.e. DSM-5, also includes oppositional defiant disorder as well as criteria for diagnosis. 

Oppositional defiant disorder is a type of childhood disruptive behavior disorder that usually includes problems with self-control regarding emotions and behaviors.

aggressive man holding womans hand

What are the symptoms of Oppositional Defiant Disorder (ODD)?


The main symptoms of oppositional defiant disorder are angry or irritable mood, argumentative or defiant behavior, and vindictiveness. A person with this disorder loses temper tantrums and is restless or easily annoyed. They may also deliberately annoy others, refuse to comply with rules or authority figures, and blame others for their mistakes. 

This disorder has a major impact on a person’s daily life. After all, a person with ODD lacks the coping skills necessary to respond adequately to a given request, challenge, or task. As a result, they tend to act out by expressing their frustration negatively or in a hostile manner. Behavioral problems and angry outbursts also jeopardize their work, school, and even family relationships and dynamics. In turn, patients with ODD may take their defiant behavior to the extreme

The exact symptoms and their severity vary from one person to another. Generally speaking, the severity of symptoms is observed through the settings in which they are manifested. A patient with ODD can manifest their symptoms at home, school, or work, with their peers, just to name a few.


"The main symptoms of oppositional defiant disorder are angry or irritable mood, argumentative or defiant behavior, and vindictiveness."


 

When symptoms are confined to one setting or situation only, they’re considered mild. Moderate symptoms are present in at least two settings. Symptoms present in a minimum of three settings indicate severe ODD, according to DSM-5. 

The disorder may manifest itself slightly differently across different age groups.

For example, children with ODD have frequent temper tantrums and argue a lot with adults, according to Cedars Sinai. A child with ODD may also refuse to do what an adult asks or questions and refuse to follow the rules. They may also deliberately do something to annoy other children and adults or blame others for their misbehavior. 

Children with oppositional defiant disorder often have an angry attitude and speak unkindly or harshly. Also, they tend to be vindictive or seek revenge.

Adolescents with ODD also display angry outbursts, and they tend to be argumentative and uncooperative. Moreover, teens with this disorder are purposely antagonistic and hostile. They are also irritable, defiant, spiteful, stubborn, vindictive, and verbally aggressive. Oppositional defiant disorder in adults also exhibits these symptoms.

Angry man

What are the causes of Oppositional Defiant Disorder (ODD)?


The exact causes of the oppositional defiant disorder are still unknown. That said, a combination of inherited and environmental factors could be to blame, according to Mayo Clinic

In some cases, a child’s temperament is due to neurological differences i.e., their brain and nerves function differently. Environmental factors that contribute to the development of ODD include problems with parenting such as harsh or inconsistent discipline, lack of supervision, and neglect or abuse.

A series of issues could contribute to the onset of the oppositional defiant disorder. These primarily include developmental stages and learned behaviors such as the negative and toxic environment

Some children don’t learn to be independent of their parents (or both), which makes them more likely to develop ODD due to attachment issues. This happens because all children go through emotional phases. They grow and develop emotionally by successfully resolving those stages. But, attachment issues could prevent some children from processing their emotions adequately. As a result, a child becomes a defiant person.

man talking to a child

What are the risk factors for Oppositional Defiant Disorder (ODD)?


Risk factors for oppositional defiant disorder are listed below.

  • Gender: before the adolescent years, boys are more likely to develop ODD than girls. The difference diminishes by adolescence 
  • Temperament: a child with temperament including difficulty regulating emotions is at a higher risk of oppositional defiant disorder
  • Family discord: children brought up in a hostile, aggressive, and dysfunctional environment may develop behavioral issues and become more likely to get ODD
  • Parenting problems: the style of parenting may influence the child’s risk of ODD. Both overly strict and neglectful parenting can contribute to the development of this disorder
  • Exposure to violence and substance abuse: children that spend a lot of time in unhealthy and negative environments that include violence and substance abuse are more likely to develop ODD
  • Family history: like many other mental health disorders, ODD is more common in patients with a family history of mental illness
  • Presence of other conditions: ADHD and other mental health conditions could also pave the way to ODD

Although all children can develop oppositional defiant disorder, some are at a higher risk than others. Risk factors for ODD usually revolve around:

  1. Unhealthy or dysfunctional environment 
  2. Problematic parenting styles (lack of supervision or being too strict)
  3. Exposure to negative behaviors and activities 

How Is Oppositional Defiant Disorder (ODD) diagnosed?


Oppositional defiant disorder is diagnosed if a patient meets the criteria described in DSM-5. These criteria include a pattern of irritable or angry moods, spiteful reactions or vindictiveness, and argumentative or defiant behavior. To be diagnosed with ODD, these behaviors must last at least six months. Additionally, they also need to involve at least one person who is not a patient’s sibling.

When making a diagnosis, a doctor considers a patient’s age, the intensity of symptoms, and their frequency.

Pediatricians may refer a child with symptoms of ODD to a child psychiatrist or mental health expert who will diagnose the condition and recommend an adequate treatment plan.

crying child

It’s useful to bear in mind that ODD may occur along with other mental health and behavioral problems, which is why its symptoms may be tricky to distinguish from those associated with other disorders.

In order to rule out other conditions, the healthcare professional will evaluate a child’s overall health, intensity or frequency of behaviors, and family interactions and situations. 

They may also assess a child’s behavior and emotions across multiple relationships and settings, strategies that have been helpful or unhelpful in managing aggressive behaviors, and the presence of disorders involving communication with others, learning, and mental health.

Once the oppositional defiant disorder is diagnosed, the healthcare professional recommends the most suitable treatment plan.

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When does Oppositional Defiant Disorder (ODD) begin?


Oppositional defiant disorder begins between the ages of six and eight in most cases. The symptoms can occur as early as two or three years old. 

The BMJ Open published a study that looked into the incidence of ODD in Spanish children from ages three to nine. The study found that the probability of developing ODD is higher in the preschool period and reduces at the beginning of childhood, then increases again when approaching puberty at the ages of eight or nine. The prevalence of ODD was between 6% and 7% between the ages of three and eight, and it jumped to 8.8% by the age of nine.

The same study also revealed the early ODD diagnosis age was related to worse mental health outcomes.

child holding his face with his hands

What is the prevalence of oppositional defiant disorder?


The prevalence of ODD ranges from 3% to 5%. At the same time, the prevalence of combined ODD and conduct disorder is 6.1%, according to Mental Disorders and Disabilities among Low-Income Children. Unfortunately, there is no population- or national-level data on the prevalence of ODD in the United States. Studies show that the average prevalence of ODD is around 3.3%. 

Research from the Journal of Child Psychology and Psychiatry, and Allied Disciplines reports that the lifetime prevalence of ODD is around 10.2%. The prevalence of ODD among males is 11.2% and 9.2% among females. Of individuals with lifetime oppositional defiant disorder, 92.4% meet the criteria for at least one other lifetime disorder such as those involving mood, anxiety, impulse control, and substance abuse.

National- and population-level statistics are necessary to determine the prevalence of ODD in order to raise awareness of this disorder and its true impact on a patient and their family or social circle.

Which children are at risk for ODD?


ODD is more common in boys than in girls. Additionally, the disorder is more common in children with certain mental health issues such as mood or anxiety disorders, conduct disorder, and attention deficit hyperactivity disorder (ADHD). 

The oppositional defiant disorder usually stops within three years of diagnosis, according to the American Academy of Child and Adolescent Psychiatry. Basically, there is no specific age at which ODD stops, but with proper treatment, the symptoms can resolve with time. 

The condition is generally diagnosed around early elementary school ages and stops being diagnosed after adolescence. By the age of 19, patients tend to have a well-established pattern of behavior. All this depends on an accurate diagnosis and an adequate treatment plan.

sad boy

What is the treatment for ODD in children?


Treatment for ODD in children revolves around therapy and family-based interventions primarily. The treatment options for ODD are listed below.

  • Parent training: includes working with a mental health professional to help parents develop skills for more consistent, positive, and less frustrating parenting. Sometimes children participate in parent training
  • Cognitive problem-solving training: helps children identify and change negative thought patterns that contribute to behavioral problems. This training works similarly to cognitive-behavioral therapy (CBT), which allows children to learn how to control anger and impulses. A major aspect of this approach is collaborative problem solving, wherein parents and children work together on solutions that work for everyone
  • Parent-child interaction therapy: involves the therapist coaching parents while they are interacting with children. The goal is to ensure parents adopt more effective parenting styles to decrease problematic behaviors
  • Peer group therapy: helps children be more flexible and allows them to improve their interaction with their peers
  • Individual and family therapy: enables children to learn how to express their feelings and manage their anger in a healthier manner. The goal of family therapy is to improve the relationship between children and parents or other family members

Early treatment for the opposition defiant disorder is crucial. When left untreated, the condition can cause various complications such as poor school performance, antisocial behaviors, and impulse control problems. Children with ODD could have difficulty at home with siblings and parents or in school with teachers and peers.

A major aspect of treatment for ODD includes managing co-occurring problems such as learning disorders. Medications are generally not used for the management of ODD unless a child has coexisting disorders such as ADHD, depression, or anxiety. In these cases, a healthcare professional could prescribe medications to manage symptoms of those conditions. 

The duration of treatment for ODD varies from one child to another, but it can last several months or longer.

What is the difference between ODD and ADHD?


The main difference between ODD and attention deficit hyperactivity disorder (ADHD) is that the latter condition makes children easily disorganized and distracted. On the other hand, ODD makes children defiant and angry. 

As Medicine Net explains, a child with ADHD may push another child impulsively and later regret their actions. At the same time, a child with ODD could push another kid deliberately and feel great about it. 

In other words, children with ADHD could disregard rules due to the inability to pay attention, whereas children with ODD can pay attention but choose not to adhere to rules or instructions

ADHD and ODD have some similarities, though. For example, the exact causes of both conditions are unknown, but genetics could play a role. Both conditions are more prevalent in males. Management of both ADHD and ODD involves therapy.

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