Oppositional Defiant Disorder

Consider the standards used to diagnose oppositional defiant disorder (ODD), and you may think they could describe any kid on a bad day -- and almost any teenager almost every day: They argue with adults, deliberately annoy people, defy rules, and have high fits of temper. All these activities are all-too-familiar to parents. The distinction lies in the frequency and intensity of the behavior.

For most children, episodes of oppositional behavior are like the raisins in the oatmeal cookie -- undeniably present, but not the main event. For a child with ODD, there are so many raisins that it's hard to see the cookie. In fact, the American Academy of Child and Adolescent Psychiatry cautions that problematic behavior "counts" toward a diagnosis of ODD only if it stands out in comparison to what is normal in a child of a given age.

A kid with ODD doesn't just talk back to his teacher, for instance; he seems unable to keep himself from doing it no matter how damaging the consequences. He may deliberately provoke confrontations by disobeying instructions or refusing to cooperate with others. Making things more frustrating for parents and teachers, he may not perceive that he's being disruptive or aggressive, instead blaming other people ("He started it!") or complaining that too much is being demanded of him . Topping it off, he may be vindictive, seeming to positively enjoy making things unpleasant for others.

So think of a 2-year-old who giggles when her mother tells her not to play with the nightlight, and whose response is to reach quickly for the electrical socket again. That's normal. Then imagine a 6-year-old who wakes up early each day and turns the television to the earsplitting level he knows will wake his father. He screams at his mother that he hates the pancakes he pleaded for and then has a tantrum the instant he loses his parent's attention. This happens all day, every day; and he is so overbearing with other children that no one wants to play with him. That child may have ODD.

How common is ODD?

While estimates different, according to the American Academy of Child and Adolescent Psychiatry, between one and 16 percent of children and adolescents have it. Boys and girls are both vulnerable. Making diagnosis trickier, ODD frequently comes packaged with another problem, such as attention-deficit/hyperactivity disorder (ADHD), depression, or a learning disability. Experts say as many as 35 percent of all kids with ADHD also have ODD.

How can you tell if your child has ODD?

If you're a parent, chances are that you've had days when every word out of your child's mouth has seemed a deliberate attempt to drive you round the bend. The crucial question: Is your child like that only on bad days, or every day? One parent described her ODD child as seeming "like he woke up on the wrong side of the bed every single day." Another said, "It sometimes seems like he hates anyone who tells him what to do."

Lonnie Warner's* son Christopher was diagnosed with ODD when he was in first grade. The boy's problems were noticeable, but not troublesome until he turned 13. Arguments with his parents were unbearable. "If you said the sky was blue, he'd say, 'Well, no it isn't.' It went on and on. You'd get so frustrated, you'd want to punch him, but of course you couldn't," she says.

The American Academy of Child and Adolescent Psychiatry defines ODD as "an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngster's day to day functioning." To assess whether your child might have ODD, think about whether, compared to other kids of the same age, he has exhibited the following behaviors frequently over the past six months:

• Arguing excessively with adults
• Frequent temper tantrums
• Active defiance
• Refusing to comply with requests or follow rules
• Deliberately attempting to annoy or upset people
• Blaming others for misbehavior and mistakes
• Being "touchy" or easily annoyed by others
• Seeking revenge

Generally, signs of ODD appear before the age of 8. (Indeed, parents often report that from a very young age, a child with the disorder was more rigid and demanding than his siblings.) But kids can be diagnosed with ODD through adolescence. Of course, in preteens and teens it becomes increasingly hard to separate ODD from normal adolescent rebellion, says psychologist Bryan Loney, PhD, an assistant professor at Florida State University. The key is the intensity of the rebellion and the amount of hostility involved: "You have to have a sound knowledge of what's normal for kids at each age and compare the child's behavior to that of his peers," Loney says.

What causes ODD?

Experts don't yet have an answer, but they know that several factors can play a role. Neurological damage is one possible cause: Those who have suffered a traumatic brain injury can develop aggression, hostility, and other symptoms of ODD.

But injury is not behind most cases of ODD. The disorder seems to run in some families; one study showed that sons of fathers who'd had ODD were more likely than other kids to have ODD themselves. That finding leaves open the nature/nurture question, since a father who'd had the disorder may model oppositional behaviors for his child, or may have passed on a genetic vulnerability to the condition, or both.

There is some evidence that ODD has a biological basis: In a recent study, children with ODD had an unusual pattern of frontal brain activity. And researchers are investigating whether low levels of the brain chemical serotonin contribute to the disorder.

At the same time, it's clear that difficult children can provoke strong reactions from their parents, strong enough to throw family dynamics out of whack. So ODD may also be a matter of a child's natural temperament combined with how his family responds to it.

How is ODD treated?

If your child has been diagnosed with ODD, he should have a comprehensive psychological evaluation. This is useful especially if he hasn't had one already, and to see if he has another condition that requires treatment, such as ADHD. Determining whether his symptoms are caused by other disorders will make it easier for you to manage your child's oppositional symptoms.

The treatment plan for ODD may include both psychotherapy and cognitive-behavior therapy. Psychotherapy can help your child get in touch with his feelings and manage his anger, while cognitive-behavioral therapy can teach him how to solve problems and work through conflicts without resorting to destructive behavior. Your family may also be referred to family therapy to help improve communication.

Your child's therapist may also suggest that you and your spouse enroll in a parent-training program designed to help you manage your child's difficult behavior. While your first reaction may be one of indignation, many parents of kids with ODD have found such classes a source of great support.

Warner and her husband went through six months of communication training with their son, Christopher, in order to minimize the arguments. Eventually, they were able to get through the day without a major argument, and when the teen did want to argue, they would just let the argument run its course, Warner says. "Eventually he'd go into his room and you could hear him arguing eloquently with himself."

It can be a huge relief to realize that your child is indeed unusually difficult (It's not your imagination!), and enormously helpful to learn special parenting techniques. One type of parent training is called parent-child interaction therapy (PCIT) and combines teaching, modeling, and role-playing. The training teaches effective ways to respond to your child, by selectively ignoring inappropriate behavior, and by giving rewards and using punishment. Perhaps most important, you'll learn how to give directions to your child in ways that are less likely to push his oppositional buttons.

If your child's therapist thinks your child could benefit from medication, he'll refer you to a psychiatrist or physician who can evaluate your child's need for them and write a prescription. There are several drugs known to help children control aggression, but they are usually prescribed only if your child is becoming physically violent toward others.

You may also want to find a support group for parents of children with behavioral problems. It can be reassuring to hear from other adults who are struggling with what has been described as one of the most difficult challenges a parent can face.

What happens if my child goes without being treated for ODD?

Many children with ODD can go on to lead happy and fulfilling lives, especially if they receive comprehensive treatment for the condition. Unfortunately, though, some children with ODD can go on to develop a conduct disorder, exhibiting the kind of behavior that is commonly seen as "bad" or delinquent.

What things can I do to encourage my child to behave?

The American Academy of Child and Adolescent Psychiatry has some useful suggestions to keep in mind when dealing with a child who has ODD.

• Watch for moments when your child is cooperative or flexible and reward him with praise and positive reinforcement.
• Set up reasonable, age-appropriate limits with consequences that can be enforced consistently.
• Choose your battles. Since your ODD child simply cannot avoid power struggles, prioritize what you want him to do. If you give him a time-out in his room and he argues about it, don't add time for the arguing. Just say, "The time out will start when you go to your room."
• Take a time-out yourself if you're about to lose your cool and escalate the confrontation. This not only saves you from a pitched battle, it models an important technique for your child. If your child also offers to take a time-out from overreacting, be supportive. This is an important step!
• Don't let your ODD child take up all your time and energy. Find other outlets so you're not focusing solely on him; allow yourself opportunity to exercise and time for other activities that lower your stress level. Babysitters are an absolute must for the parents of a child with ODD!
• Seek support from teachers, coaches, friends, and your spouse so you don't feel isolated.

Finally, don't give up hope. Your child may be hard to manage today, that's for sure. But that doesn't mean he'll be unmanageable forever.

* Name has been changed.

References

Interview with Bryan Loney, PhD, assistant professor of psychology, Florida State University

Oppositional Defiant Disorder, Internet Mental Health, Phillip Long, MD http://www.mentalhealth.com/dis1/p21-ch05.html

American Academy of Child and Adolescent Psychiatry. Facts for Families: Children With Oppositional Defiant Disorder. 2009. http://www.aacap.org/cs/root/facts_for_families/children_with_oppositional_defiant_disorder

Oppositional Children Differ from Healthy Children in Frontal Brain Activation, Lioba Baving, Journal of Abnormal Child Psychology, June 2000 http://www.findarticles.com/cf_0/m0902/3_28/63910744/p1/article.jhtml

Oppositional Defiant and Conduct Disorder: A Review of the Past 10 Years, Part I, Rolf Loeber, Journal of the American Academy of Child and Adolescent Psychiatry, 39(12):1468-1484 http://www.findarticles.com/cf_0/m2250/12_39/68648571/p1/article.jhtml?term=oppositional+defiant+disorder+Loeber

New York - Presbyterian Hospital, Fact Sheet: Oppositional Defiant Disorder (ODD) http://smhp.psych.ucla.edu/qf/behaviorprob_qt/ODD.pdf

American Academy of Pediatrics, HealthyChildren.org. Understanding ADHD. http://www.healthychildren.org/English/health-issues/conditions/adhd/pages/Understanding-ADHD.aspx