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Oppositional Defiant Disorder

Björn Kadesjö gives an overview of the diagnosis Oppositional Defiant Disorder, including a definition, causes and treatment.

Definition

Oppositional Defiant Disorder (ODD) is a diagnostic term for children and adolescents who exhibit a pattern of negative, hostile and oppositional/defiant behaviour. These are children and adolescents who quickly get angry, object to and argue against the demands of adults, easily end up in arguments and fights and blame others for their own failures. The objections are initially usually directed at the parents but may eventually also come to characterise interactions with other adults and friends.

In the diagnostic manual DSM 5, the diagnostic criteria are grouped into the following categories:

• angry or irritated mood with the criteria: often loses his/her temper, is often easily irritated, is often angry and embittered
• defiant or eccentric behaviour with the criteria: often argues with adults, often actively defies or refuses to submit to the demands or rules of adults, often intentionally angers others, often blames others for own mistakes or bad conduct
 vindictiveness with the criteria: is often vindictive or mean

The symptomatology of ODD thus consists of both emotional symptoms and behavioural symptoms. In order for the diagnosis oppositional defiant disorder to be used, the types of behaviour listed above need to have become a pattern in the child’s interaction with their environment. They also need to have been both ongoing for an extended period of time (over 6 months) and clearly influenced the child in their everyday life.

Author

Björn Kadesjö

Causes

The children who develop oppositional defiant disorder have often, even from a very young age, been demanding, prone to screaming, and difficult to console. Many have a temperament that temperament researchers would refer to as “difficult to manage”. When adults in a child’s environment lack the energy to deal with that child’s demanding behaviour, there is a risk that the adult will simply give up whatever demands they have given the child just to get some peace and quiet, which results in the child subconsciously learning that objecting allows him/her to avoid demands. The risk of developing this kind of vicious cycle is especially great if the parents or child’s preschool teachers and teachers themselves are having difficulties coping with the pressures of their own everyday lives.

“Coercion theory”, a theory on coercive interactions, describes how such vicious cycles occur and serves an important role in counselling parents and teachers regarding children exhibiting oppositional/defiant behaviour. It provides the basis for several parent training programmes such as “De otroliga åren”, COPE and Komet.

As stated above, many children who grow up with adults lacking the energy to deal with their demanding behaviour, may develop oppositional/defiant behaviours, but, that being said, the risk of such a development occurring is a great deal higher for children who have ADHD. Around half of children with ADHD, especially if they exhibit obvious features of impulsivity and overactivity, develop oppositional defiant disorder. The impulsivity makes them find it difficult to hold in their reactions upon facing demands, and leads them to quickly react by objecting and distancing themselves. If, in addition, the child has developmental disorders concerning language, intellect or motor control, the strain increases and makes it possible for negative patterns to develop in the interaction between parents and children. This is amplified by the fact that these are children who often fail and perceive themselves as misunderstood, and therefore are angry and disappointed at their unsympathetic environment.

Boys/girls

ODD is more common among boys than among girls, just as ADHD with hyperactivity/impulsivity is more common among boys.

Often associated traits

Oppositional defiant disorder is often one of the problems present in conduct disorder, or in other cases simply precedes a conduct disorder diagnosis. Oppositional defiant disorder occurs in children and adolescents with Tourette’s syndrome or autism spectrum disorder. At the same time, behavioural problems in individuals with these diagnoses might be mistaken for ODD. A central aspect to note is that it is not rare for children and adolescents with ODD to exhibit depressive moods and anxiety problems as significant components of their overarching problems.

Treatment

Help for children and adolescents with ODD needs to be grounded in two approaches. Firstly, parents and teaching staff need an understanding of the child/youth so that demands, confrontation and pedagogic planning are adjusted according to his or her situation. This usually requires an assessment of the child’s cognitive abilities, as well as determining whether they have specific difficulties like ADHD or emotional problems like anxiety or depression. If the patient has other diagnoses, these also require their respective treatments. Secondly, one must develop strategies to be able to deal with the child’s/youth’s demanding behaviour in such a manner that the problems are not exacerbated. In addition to knowledge, this also requires a great deal of energy, which in turn means that the child’s social situation must be mapped out, and that the parents may require help in everyday life.