Oppositional Defiant Disorder in Children and Adolescents

Children with ODD are often verbally aggressive toward authority figures and peers. Some of the common behaviors children with ODD exhibit include:

• Claims not to care about losing privileges as a consequence to negative behavior
• Ignores directives
• Manipulate adults against each other (e.g., parent and teacher)
• Refuses to go to "time out"
• Resistance to directions
• Stubbornness
• Tests limits
• Unwillingness to compromise or negotiate with adults or peers

Oppositional defiant disorder often precedes the development of conduct disorder, especially for those with the childhood-onset type of conduct disorder. However, many children and adolescents with oppositional defiant disorder do not subsequently develop conduct disorder. Children with ODD may have difficulty with interpersonal relationships, particularly with their parents, teachers, and peers. There is an increased risk for the development of anxiety disorders and major depressive disorders, even in the absence of conduct disorder. Children whose profile is predominantly defiant, argumentative, and vindictive symptoms carry most of the risk for conduct disorder, whereas angry and/or irritable profiles carry most of the risk for emotional disorders. Children and adolescents with oppositional defiant disorder are at increased risk for a number of problems in adjustment as adults, including antisocial behavior, impulse-control problems, substance abuse, anxiety, and depression. Coexisting conditions include attention-deficit/hyperactivity disorder and mood disorders.

Children with high levels of emotional reactivity and poor frustration tolerance may have problems related to emotional regulation. This emotional profile is common in children with ODD. Parents of children with ODD have been shown to exhibit less effective problem solving skills and negative parenting styles (e.g, uninvolved, rejecting, harsh). Thus, ODD could be a child’s response to the parent-child interaction. Neurobiological markers such as skin conductance reactivity, lower heart rate, reduced basal cortisol reactivity and abnormalities in the prefrontal cortex and amygdala have been investigated in their role with ODD. No single neurotransmitter or neurologic pathway has been identified as the root cause. Oppositional defiant disorder appears to be familial, but research has yet to determine what role genetics play because studies on the genetics of the disorder have produced inconsistent result.

First Line Treatments

• Individual Parent Management Training: Training for parents to help them better handle disruptive behavior. Parents are trained in how to effectively utilize reinforcement, punishment, and consequences to reduce disruptive behavior and increase prosocial and compliant behavior.

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• Individual Cognitive-Behavioral Therapy: An intervention that combines cognitive and behavioral learning principles to shape and encourages desired behaviors. Clients are encouraged to change the way of thinking or acting out their problems and replace them with proactive solutions.
• Parent-Child Interaction Therapy: emphasizes improvements in the relationship between the parent and child and offers tools to help manage behaviors that are disruptive
• Problem-Solving Skills Training:  facilitates problem solving, rather than to teach and motivate children to comply with parental demands
• Group Assertiveness Training: Group therapy on learning to expresses oneself in a direct and honest manner in interpersonal situations, while simultaneously respecting the rights and dignity of others
• Treatment Foster Care: is out-of-home care by foster parents with specialized training to care for children with behavioral and emotional needs
• Multi-Systemic Therapy: community-based intervention that explicitly attempts to intervene in multiple real-life settings (e.g., home, school)
• Psychopharmacologic Interventions: may result in the improvement of oppositional behavior. Medication for youth with ODD should be used in conjunction with other interventions.
• Stimulants such as methylphenidate, atomoxetine and amphetamine/dextroamphetamine
• Mood stabilizers, such as divalporex sodium and lithium carbonate
• Typical antipsychotics, such as haloperidol
• Atypical antipsychotics, such as risperidone

Third Line Treatments

When patients do not respond adequately to the first- and second-line treatments described above, other strategies might include:

• Group Cognitive Behavioral Therapy
• Group Parent Management Training