Continuing Education Activity

Oppositional defiant disorder (ODD) is a type of childhood disruptive behavior disorder that primarily involves problems with the self-control of emotions and behaviors. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the main feature of ODD is a persistent pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness toward others. This activity describes the evaluation and management of oppositional defiant disorder and highlights the role of interprofessional treatment in managing patients with this condition.

Objectives:

• Describe the etiological risk factors of oppositional defiant disorder.
• Summarize the epidemiology of oppositional defiant disorder.
• Outline the diagnostic criteria of oppositional defiant disorder.
• Explain the importance of the interprofessional management of oppositional defiant disorder.

Introduction

Oppositional defiant disorder (ODD) is a type of childhood disruptive behavior disorder that primarily involves problems with the self-control of emotions and behaviors. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the main feature of ODD is a persistent pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness toward others.

Etiology

The exact etiology of oppositional defiant disorder (ODD) is complex and often results from an interplay between genetic, environmental, and psychosocial factors.

Genetics

It is estimated that heritability of ODD is around 50%, and there is a substantial genetic overlap with conduct disorder (CD).[1] Genetic effects also appear to underlie the association between ODD with ADHD and depressive disorder.[2] Gene-environment interactions also appear to be significant in the development of ODD. In one study, participants with a low activity level of the neurotransmitter-metabolizing enzyme monoamine oxidase A (MAO-A) and who were exposed to childhood abuse were found to be more likely to report conduct problems and hostility later in development.[3] Lastly, changes in cortisol levels, as well as neuroimaging findings (particularly of the prefrontal cortex, amygdala, and insula), appear to be involved.[4]

Environmental Factors

Childhood maltreatment and harsh, inconsistent parenting are commonly found in families of children with ODD.

Psychosocial Factors

Temperamental factors such as irritability, impulsivity, poor frustration, tolerance, and high levels of emotional reactivity are commonly associated with ODD. While not all children diagnosed with ODD show callous and unemotional traits, it has been shown that such traits are highly heritable and may be seen more frequently in a subset of children with more significant disruptive behaviors. In addition, peer rejection, deviant peer groups, poverty, neighborhood violence, and other unstable social or economic factors are known to exert significant negative effects on children’s behaviors and may contribute to the development of ODD.

Epidemiology

The prevalence of oppositional defiant disorder varies greatly, with an estimated range of 2% to 11%.[5] This variation is due in part to various factors, including varying informant sources (such as parent, child or teacher reports of symptoms), the timing of diagnosis (whether it is current or retrospective), and whether children meeting criteria for conduct disorder (CD) are included in epidemiologic studies. In addition, ODD is rarely diagnosed in older children and adolescents, in part due to overlap in normative discord between children and their parents.

ODD is more common in preadolescent males than in females (1.4:1); however, this male predominance is not found in adolescents or adults. Symptoms remain relatively stable between the ages of five and ten and are thought to decline afterward. The prevalence declines with increasing age.

Pathophysiology

Oppositional defiant disorder symptoms are commonly seen initially during preschool years and often precede symptoms of CD. In a large-scale study using retrospective age-of-onset reports, 92.4% of those who met ODD criteria also met criteria for at least one other mental disorder, including mood disorders (45.8%), anxiety disorders (62.3%), impulse control disorders (68.2%) and substance use disorders (47.2%).[6]

ODD is a strong risk factor for the development of CD in boys, with atypical family structure being an important factor. In contrast, ODD does not increase the risk of later development of CD in girls. However, ODD does increase the risk of continued ODD symptoms, depression, and anxiety.[2] The majority of children with ODD do not go on to develop CD despite the high rates of other comorbidities.

History and Physical

Diagnostic Criteria as per DSM- 5

At least four symptoms from the list below should have been present on most days for at least 6 months demonstrating a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness:

1. Often loses temper
2. Often touchy or easily annoyed
3. Often angry and resentful
4. Often argue with authority figures or, for children and adolescents, with adults
5. Often actively refuse or defy to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or misbehavior
8. The child has been spiteful or vindictive at least twice within the past 6 months                                                    

There should be evidence of impairment either in the form of distress (in the individual, family, peers, etc.) and/or negative impact on social, educational, occupational, or other important areas of functioning. The behaviors do not occur exclusively during substance use, psychotic, depressive, or bipolar disorder. The patients must not meet the criteria for disruptive mood dysregulation disorder.

Severity: ODD is considered mild if symptoms are confined to only one setting, moderate if at least two settings and severe if symptoms are present in three or more settings.

Evaluation

Oppositional problems may be assessed in a child as young as five years of age, though the majority of children usually present at school-age. Children and adolescents who are suspected of having oppositional defiant disorder should have a thorough psychiatric evaluation with multiple informants (parents, siblings, friends, teachers, etc.) and, if possible, in multiple settings. A complete academic assessment, in conjunction with intelligence testing, should be done to uncover any learning disorders or intellectual problems. It is also important to identify modifiable risk factors (e.g., bullying or poor school performance) that might contribute to oppositional behaviors. ODD has high comorbidity with ADHD and anxiety disorders (e.g., OCD and ADHD), and the clinician needs to diagnose and treat any comorbid disorders.

There are multiple assessment tools available to assist the clinician in identifying ODD, including:

The Child Behaviour Checklist

Conners Child Behaviour Checklist

The Behaviour Assessment for Children (BASC - 2)

Strength and Difficulties Questionnaire (SDQ)

The Child and Adolescent Psychiatric Assessment

The Development and Well-Being Assessment (DAWBA)

The Disruptive Behaviour Diagnostic Observation Schedule

Treatment / Management

Treatment of oppositional defiant disorder is multimodal and should involve the patient, family, school, and community. Identifying and treating comorbidities (like ADHD, depression, and anxiety) and modifiable risk factors (such as bullying and learning difficulties) should be done. Treatment may also vary based on whether oppositional behavior primarily occurs in specific contexts or if the behavior is pervasive and thus requires more intensive treatment.

Treatment modalities include parent management training, school-based interventions, individual child therapy, and family therapy. Additionally, identification of attachment security, parent-child relationships, and specific cognitive beliefs held by parents regarding child-rearing may be further explored to provide a framework for the modalities listed below.

Lastly, the identification of comorbidities is an important aspect of treatment in oppositional defiant disorder. ODD, in particular, has been demonstrated to be part of the developmental history of several mental disorders in young adults and additionally has been shown to predict depression and anxiety later in life consistently.[6] Concurrent mental disorders worsen the prognosis of ODD and should be treated appropriately to minimize disruptive behaviors in multiple settings.

Parent Management Training (PMT)

PMT is based on the principles of social learning theory and is the main treatment for oppositional behaviors. The guiding principle in PMT is the use of operant conditioning (using the role of positive reinforcement in changing behaviors) to decrease unwanted behaviors and promote prosocial behaviors.[7] Such behaviors may be identified during treatment and subsequently modified in both parties. Methods include teaching parents to identify problem behaviors as well as positive interactions and to apply punishment or reinforcement as appropriate. These techniques may be used to increase the frequency of positive behaviors and interactions while diminishing antisocial or otherwise oppositional behaviors. Functional family therapy or brief strategic family therapy can also be supplemented to identify factors in the home that may contribute or exacerbate aggressive behaviors such as those seen in ODD.

Two notable parent management training programs are Webster-Stratton’s “Incredible Years” and the Triple P program. The former entails 13 to 16 two-hour weekly sessions during which parents are shown videos of correct and incorrect ways of child management, and are then asked to rehearse different approaches and complete weekly activities at home, with progress reported via telephone. The latter program comprises multiple levels of intervention, including advice and training programs, in addition to coping and support skills for both parent and child. Both parent management training programs have been shown to decrease conduct problems in multiple contexts and family backgrounds significantly.

School-based Interventions

Supportive interventions to improve school performance, peer relationships, and problem-solving skills are particularly useful in the treatment of ODD. This may include education and specific tools for the teacher to improve classroom behavior, techniques to prevent oppositional behavior or the escalation of such behavior, and other methods that facilitate adherence to classroom rules and acceptable social norms.

Individual therapy:

Cognitive-behavioral therapy (CBT) based anger management training is useful in treating anger problems. In older children, problem-solving skills training and perspective-taking are also CBT components that may alleviate aggressive behaviors.[8]The Coping Power program is an anger management program that has multiple formats and consists of an additional component of parent involvement along with periodic home visits.

Pharmacologic Therapy

As psychosocial interventions are the first-line treatment for children with ODD, pharmacologic agents are typically reserved for cases in which aggressive and disruptive behaviors cannot be managed by the above treatment modalities alone. Treatment of comorbidities is paramount and should be the first option considered, and the potential burden of side effects carefully considered. In cases of severe comorbid emotional dysregulation or severe aggression, an atypical antipsychotic may be added. Risperidone has the best evidence for control of aggressive behaviors, followed by aripiprazole.[9] While quetiapine has been observed to alleviate aggression, its wider range of side effects makes it a less favorable choice versus other atypical antipsychotics. If aggression continues to be unmanaged, a mood stabilizer may be considered after thorough evaluation, though evidence for the use of lithium, carbamazepine, and lamotrigine is not robust at the time of this writing.

Stimulants, including methylphenidate, are helpful in cases of comorbid ADHD, and non-stimulants such as atomoxetine, guanfacine, and clonidine also have beneficial effects. Clear treatment goals should be identified prior to the initiation of pharmacotherapy, and adverse effects should be discussed with the patient (if applicable) and family members and regularly assessed on follow-up. The use of pharmacologic agents in the acute setting should be evaluated on a case-by-case basis after careful consideration by the clinician.

Differential Diagnosis

Oppositional and defiant behaviors can be seen in many conditions, and it is important for the clinician to differentiate ODD from other disorders. In addition to those listed below, other conditions, including OCD and autism, should be considered as well, as these may also present with oppositional behaviors in the face of disrupted routines or obsessive-compulsive rituals.

Conduct Disorder

While both CD and ODD deal with conflicts with authority figures, behaviors in ODD are less severe than in conduct disorder and tend to involve primarily angry or argumentative behavior or behaviors that are intentionally annoying. In contrast, conduct disorder tends to be more severe and involves problems related to physical aggression, fire-setting, animal cruelty, truancy from school, property damage, or stealing. It is important to note that while children diagnosed with ODD are often diagnosed with CD later in life, not all individuals with CD have a prior diagnosis of ODD.[10] Conduct disorder and ODD share common genetic influences, though evidence suggests that the two should remain separate entities rather than represent a spectrum of one disorder. However, there continues to be inconsistency in the literature, with some studies suggesting that the genetic correlation between the two disorders may be sufficiently high to regard them as one construct.

Attention-deficit/Hyperactivity Disorder (ADHD)

The association between ODD and ADHD is well-studied in the literature. ADHD is a common childhood behavioral disorder that involves restless or fidgety behavior, inability to sustain focus on tasks or waiting for their turns, and problems with following rules in multiple settings. ADHD and ODD often co-exist, and the clinician needs to rule out ADHD as a primary reason for the oppositional/defiant behaviors. Furthermore, oppositionality is not uncommonly seen in ADHD as well as autism, in particular, when there is a change in routine or other sensory disruption.

Mood Disorders

Emotional dysregulation, negative affect, and irritability are commonly seen in mood disorders, including depression and bipolar disorders. Mood disorders are unsurprisingly common comorbidities alongside ODD, as oppositional individuals tend to exhibit problems with emotional regulation as well as a moody or irritable affect. In addition, ODD may represent a prodrome of mood disorders that may evolve later in life, and both disorders share similar risk factors (14). Concurrent mood disorders should, therefore, be identified early and treated appropriately during evaluation. Importantly a diagnosis of ODD should not be made if the symptoms are exclusively present during a mood disorder.

Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a childhood disorder characterized by frequent temper outbursts along with a persistently irritable mood in between outbursts. Criteria require that symptoms be present for at least twelve months, be present in multiple settings, and have an onset before the age of ten. While ODD and DMDD share symptoms of chronic irritable mood and temper outbursts, irritable mood in between outbursts persists in DMDD, and the severity of temper outbursts are more severe. According to the DSM-5, if an individual meets the criteria for both ODD and DMDD, a diagnosis of only DMDD should be given.

Prognosis

Individuals with oppositional defiant disorder can experience significant impairments in social, academic, and occupational life and also frequently experience conflicts with parents, teachers, and peers. Disruptive behaviors are also associated with increased costs to society and poor psychosocial adjustment in adulthood. Mild to moderate forms of ODD often improve with age, but more severe forms can evolve into conduct disorder in a subset of individuals. Low intellectual capabilities and lack of proper supervision indicate a poor prognosis, while adequate treatment of comorbidities (including ADHD or mood disorders), individual and/or family therapy, and positive parenting are associated with a good prognosis.

Complications

Mild to moderate forms of oppositional defiant disorder often get better with age, but the more severe form can evolve into conduct disorder.

Enhancing Healthcare Team Outcomes

Early diagnosis and treatment are crucial for individuals with oppositional defiant disorder, and help is available as mentioned above in the form of parent-management training, skills training, individual therapy, family therapy, and for comorbidities, pharmacologic therapy. Comorbidities should be carefully evaluated for and treated with evidence-based approaches. Treatment of ODD is often multimodal and involves the affected individual, families, teachers, and community-based mental health workers.