Ask the Expert: What is Oppositional Defiant Disorder?
Q: Over this past school year, my 6-year-old daughter has been increasingly defiant at home and having difficulties behaving at school. She argues constantly, does not listen to my husband or me and seems to purposefully provoke me. Everything is a power struggle for her, from what she eats for breakfast to the clothes she wears. Last week we were called by her school to pick her up because she would not listen to the teacher and was unable to calm down after her tantrum. My mother thinks she has something called Oppositional Defiant Disorder. What is this, and how do you treat it?
A: Children can exhibit more defiant behavior at different stages of development. It’s not uncommon, for example, to see a 2- or 3-year-old having multiple tantrums and difficulty modulating emotions. Such challenging behavior may reappear during early adolescence, when testing limits is a natural phase of development. However, when children persistently demonstrate disregard for respecting authority figures and rules, it is wise to examine your child’s current situation and the potential need for prompt intervention.
What you describe above is classically known in the mental health community as “disruptive behavior.” In fact, there is a continuum of such behaviors, beginning with more impulsive, often non-intentional disruptive behavior on one side of the continuum (such as ADHD) and a serious violation of rules and rights of others on the other (such as Conduct Disorder). In the middle resides a condition known as Oppositional Defiant Disorder (ODD), a condition that according to the American Academy of Child and Adolescent Psychiatrists (ACCAP), affects between 1 and 16 percent of youth. In fact, this disorder is the most common reason for a referral for psychiatric intervention. ODD occurs more commonly before puberty, and boys are more affected at this stage. As children become teenagers the percentage of girls with ODD increases and is closer to that of boys. Most commonly, kids with ODD present in the preschool and school-age years, when rules are first introduced outside the home and expectations to conform to rules are part of everyday life. Oppositional Defiant Disorder is defined by the DSM IV (a diagnostic and statistical manual that mental health professionals use to classify and define mental disorders) “as a pattern of negativistic, hostile and defiant behavior that lasts at least six months.” During that time, at least four of the following behaviors occur:
• Loses temper
• Argues with adults
• Disobeys rules
• Deliberately annoys others
• Blames others
• Is touchy or easily annoyed
• Is angry and resentful
• Is spiteful and vindictive
Another key feature of the disorder is that such symptoms are not developmentally appropriate (as would be in a 2- or 3-year-old, for example) and cause significant interference in a child’s social, academic or occupational functioning. These symptoms are not part of an underlying mood disorder or psychosis.
Most kids with ODD demonstrate hostile and negative behavior at home initially and direct their anger and provocation toward one adult. After time, such behavior begins to occur outside the home such as in school, and in extracurricular activities.
Parents of children who have ODD often question why their child has such a condition, especially when other siblings may show “model” behavior. While there has not yet been a specific cause defined for ODD, heredity, temperament and parental responses to the child’s behavior play a role. Exposure during the fetal stage to nicotine and toxins has been correlated to the incidence of ODD. According to reports by ACCAP, low levels of serotonin, neurepinephrhine, dopamine, cortisol and testosterone have been found to play a role in the emergence of ODD.
Parents of kids with ODD often feel lost and fraught with guilt that they somehow “caused” the problem. While it is true that inconsistent parenting, poor supervision and abuse play a role, other contributors such as a child’s unique learning style, social skills and language difficulties, play a role as well. And, for some children, learned behavior and poor attachment to parents are contributing factors.
When children present for treatment to a mental health professional, it’s important to look for the presence of other diagnoses that may affect how a child behaves and responds to treatment. Interestingly, studies show that between 30 and 40 percent of children who have ODD may also carry a diagnosis of ADHD. Depression and anxiety disorders also are commonly associated with ODD. Left undiagnosed and untreated, as many as one third of children with ODD may progress to a more serious condition, conduct disorder, when there is a serious violation of rules, aggression to people or animals, destruction of property and theft.
The cornerstone of treatment, according to the practice parameters for child psychiatrists, involves a multimodal treatment plan, including: parent training, family and individual therapy. For the preschool child with ODD, emphasis is placed on parent training and effective discipline strategies. For the school-age child, family therapy and school-based programs involving teachers are effective. For adolescents with ODD, individual therapy has been shown to have some impact, as well as family therapy to help with communication skills and pro-social behavior. When behavior is unmanageable to the point that the safety of others is a concern, a more restrictive therapeutic environment can be helpful.
As your child is still quite young, emphasis should be placed on establishing effective means of discipline and avoiding power struggles. The negative attention children receive from such acting-out behavior is, in fact, a huge reinforcement of unwanted behavior. Helping parents learn to reduce such positively reinforcing behavior and increasing attention for more appropriate behavior is critical for treating ODD effectively. The clinician can help provide support to assist with patience and resolve to stay consistent with responses to highly provocative behavior. The basics for managing the school-age and preschool-age child with ODD include:
• Rewarding appropriate behavior
• Ignoring negative behavior
• Demonstrating consistent discipline at home and away from home, and having predictable consequences for unacceptable and dangerous behavior
A nurturing, yet authoritative, parenting style has been shown to be the most effective in helping youngsters with ODD change their behavior to more adaptive responses. Lastly, at the present time, medications are used cautiously and primarily as adjunctive measures for children who might also have underlying treatable conditions such as depression, anxiety or ADHD. A careful discussion of the risks, benefits and alternatives of treatment regarding medications for ODD is always important before beginning such treatment.
In the end, giving your daughter’s behavior a name is one of several starting points to getting her behavior back on track. Children with ODD are difficult to engage in treatment, and for many parents, difficult to be around. Get support from your providers, friends and family and keep an open dialogue with your child. Your persistence to parent effectively, unconditional love and time will eventually help lead your child to the positive behavior you are hoping for.
A board-certified child psychiatrist and mother of four in Charlotte. 704-540-1488.