By Mayo Clinic Staff
Even the best-behaved children can be difficult and challenging at times. But if your child or teen has a frequent and persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward you and other authority figures, he or she may have oppositional defiant disorder (ODD).
As a parent, you don't have to go it alone in trying to manage a child with ODD. Doctors, counselors and child development experts can help.
Treatment of ODD involves therapy, training to help build positive family interactions and skills to manage behaviors, and possibly medications to treat related mental health conditions.
Sometimes it's difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It's normal to exhibit oppositional behavior at certain stages of a child's development.
Signs of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. These behaviors cause significant impairment with family, social activities, school and work.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing ODD. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
DSM-5 criteria for diagnosis of ODD show a pattern of behavior that:
- Includes at least four symptoms from any of these categories — angry and irritable mood; argumentative and defiant behavior; or vindictiveness
- Occurs with at least one individual who is not a sibling
- Causes significant problems at work, school or home
- Occurs on its own, rather than as part of the course of another mental health problem, such as a substance use disorder, depression or bipolar disorder
- Lasts at least six months
DSM-5 criteria for diagnosis of ODD include both emotional and behavioral symptoms.
Angry and irritable mood:
- Often loses temper
- Is often touchy or easily annoyed by others
- Is often angry and resentful
Argumentative and defiant behavior:
- Often argues with adults or people in authority
- Often actively defies or refuses to comply with adults' requests or rules
- Often deliberately annoys people
- Often blames others for his or her mistakes or misbehavior
- Is often spiteful or vindictive
- Has shown spiteful or vindictive behavior at least twice in the past six months
These behaviors must be displayed more often than is typical for your child's peers. For children younger than 5 years, the behavior must occur on most days for a period of at least six months. For individuals 5 years or older, the behavior must occur at least once a week for at least six months.
ODD can vary in severity:
- Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
- Moderate. Some symptoms occur in at least two settings.
- Severe. Some symptoms occur in three or more settings.
For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends.
When to see a doctor
Your child isn't likely to see his or her behavior as a problem. Instead, your child will probably believe that unreasonable demands are being placed on him or her. But if your child has signs and symptoms common to ODD that are more frequent than is typical for his or her peers, make an appointment with your child's doctor.
If you're concerned about your child's behavior or your own ability to parent a challenging child, seek help from your doctor, a child psychologist or a child behavioral expert. Your primary care doctor or your child's pediatrician can refer you to the appropriate professional.
There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including:
- Genetics — a child's natural disposition or temperament and possibly neurobiological differences in the way nerves and the brain function
- Environment — problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect
Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include:
- Temperament — a child who has a temperament that includes difficulty regulating emotions, such as being highly emotionally reactive to situations or having trouble tolerating frustration
- Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of parental supervision
- Other family issues — a child who lives with parent or family discord or has a parent with a mental health or substance use disorder
Children with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, at work with supervisors and other authority figures, and may struggle to make and keep friends and relationships.
ODD may lead to problems such as:
- Poor school and work performance
- Antisocial behavior
- Impulse control problems
- Substance use disorder
Many children with ODD also have other mental health conditions, such as:
- Attention-deficit/hyperactivity disorder (ADHD)
- Conduct disorder
- Learning and communication disorders
Treating these other mental health conditions may help improve ODD symptoms. And it may be difficult to treat ODD if these other conditions are not evaluated and treated appropriately.
You may start by seeing your child's doctor. After an initial evaluation, your doctor may refer you to a mental health professional who can help make a diagnosis and create the appropriate treatment plan for your child.
What you can do
Before your appointment, make a list of:
- Signs and symptoms your child has been experiencing, and for how long.
- Your family's key personal information, including factors that you suspect may have contributed to changes in your child's behavior. Include any stressors that your child or close family members recently experienced, particularly with regard to parental separation or divorce and differences in expectations and parenting styles.
- Your child's key medical information, including other physical or mental health conditions with which your child has been diagnosed.
- Any medication, vitamins and other supplements your child is taking, including the dose.
- Questions to ask the doctor so that you can make the most of your appointment.
When possible, both parents should be present with the child. Or, take a trusted family member or friend along. Someone who accompanies you may remember something that you missed or forgot.
Questions to ask the doctor at your child's initial appointment include:
- What do you believe is causing my child's symptoms?
- Are there any other possible causes?
- How will you determine the diagnosis?
- Should my child see a mental health provider?
Questions to ask if your child is referred to a mental health provider include:
- Does my child have oppositional defiant disorder?
- Is this condition likely temporary or long lasting?
- What factors do you think might be contributing to my child's problem?
- What treatment approach do you recommend?
- Is it possible for my child to grow out of this condition?
- Does my child need to be screened for any other mental health problems?
- Is my child at increased risk of any long-term complications from this condition?
- Do you recommend any changes at home or school to encourage my child's recovery?
- Should I tell my child's teachers about this diagnosis?
- What else can my family and I do to help my child?
- Do you recommend family therapy?
- What can we, the parents, do to cope and sustain our ability to help our child?
Don't hesitate to ask additional questions during your appointment.
What to expect from your doctor
Be ready to answer your doctor's questions. That way you'll have more time to go over any points you want to talk about in-depth. Your doctor may ask:
- What are your concerns about your child's behavior?
- When did you first notice these problems?
- Have your child's teachers or other caregivers reported similar behaviors in your child?
- How often over the last six months has your child been spiteful or vindictive, or blamed others for his or her own mistakes?
- How often over the last six months has your child been easily annoyed or deliberately annoying to others?
- How often over the last six months has your child argued with adults or defied or refused adults' requests?
- How often over the last six months has your child been visibly angry or lost his or her temper?
- In what settings does your child demonstrate these behaviors?
- Do any particular situations seem to trigger negative or defiant behavior in your child?
- How have you been handling your child's disruptive behavior?
- How do you typically discipline your child?
- How would you describe your child's home and family life?
- What stresses has the family been dealing with?
- Has your child been diagnosed with any other medical conditions, including mental health conditions?
To determine whether your child has oppositional defiant disorder, the mental health provider can do a comprehensive psychological evaluation. This evaluation will likely include an assessment of:
- Your child's overall health
- The frequency and intensity of your child's behaviors
- Your child's behavior across multiple settings and relationships
- The presence of other mental health, learning or communication disorders
Related mental health issues
Because ODD often occurs along with other behavioral or mental health problems, symptoms of ODD may be difficult to distinguish from those related to other problems. It's important to diagnose and treat any co-occurring problems because they can create or worsen ODD symptoms if left untreated.
Treating oppositional defiant disorder generally involves several types of psychotherapy and training for your child — as well as for parents. Treatment often lasts several months or longer.
Medications alone generally aren't used for ODD unless another disorder co-exists. If your child has co-existing conditions, particularly ADHD, medications may help significantly improve symptoms.
The cornerstones of treatment for ODD usually include:
- Parent training. A mental health provider with experience treating ODD may help you develop parenting skills that are more positive and less frustrating for you and your child. In some cases, your child may participate in this type of training with you, so that everyone in your family develops shared goals for how to handle problems.
- Parent-child interaction therapy (PCIT). During PCIT, therapists coach parents while they interact with their children. In one approach, the therapist sits behind a one-way mirror and, using an "ear bug" audio device, guides parents through strategies that reinforce their children's positive behavior. As a result, parents learn more-effective parenting techniques, the quality of the parent-child relationship improves and problem behaviors decrease.
- Individual and family therapy. Individual counseling for your child may help him or her learn to manage anger and express feelings in a healthier way. Family counseling may help improve your communication and relationships, and help members of your family learn how to work together.
- Cognitive problem-solving training. This type of therapy is aimed at helping your child identify and change thought patterns that lead to behavior problems. Collaborative problem-solving — in which you and your child work together to come up with solutions that work for both of you — can help improve ODD-related problems.
- Social skills training. Your child also might benefit from therapy that will help him or her learn how to interact more positively and effectively with peers.
As part of parent training, you may learn how to manage your child's behavior by:
- Giving clear instructions and following through with appropriate consequences when needed
- Recognizing and praising your child's good behaviors and positive characteristics to promote desired behaviors
Although some parenting techniques may seem like common sense, learning to use them in the face of opposition isn't easy, especially if there are other stressors at home. Learning these skills will require consistent practice and patience.
Most important in treatment is for you to show consistent, unconditional love and acceptance of your child — even during difficult and disruptive situations. Don't be too hard on yourself. This process can be tough for even the most patient parents.
At home, you can begin chipping away at problem behaviors of oppositional defiant disorder by practicing these strategies:
- Recognize and praise your child's positive behaviors. Be as specific as possible, such as, "I really liked the way you helped pick up your toys tonight."
- Model the behavior you want your child to have.
- Pick your battles and avoid power struggles. Almost everything can turn into a power struggle, if you let it.
- Set limits and enforce consistent reasonable consequences.
- Set up a routine by developing a consistent daily schedule for your child. Asking your child to help develop that routine may be beneficial.
- Build in time together by developing a consistent weekly schedule that involves you and your child spending time together.
- Work with your partner or others in your household to ensure consistent and appropriate discipline procedures. Enlist support from teachers, coaches and other adults who spend time with your child.
- Assign a household chore that's essential and that won't get done unless the child does it. Initially, it's important to set your child up for success with tasks that are relatively easy to achieve and gradually blend in more important and challenging expectations. Give clear, easy-to-follow instructions.
- Be prepared for challenges early on. At first, your child probably won't be cooperative or appreciate your changed response to his or her behavior. Expect behavior to temporarily worsen in the face of new expectations. This is called an "extinction burst" by behavior therapists. Remaining consistent in the face of increasingly challenging behavior is the key to success at this early stage.
With perseverance and consistency, the initial hard work often pays off with improved behavior and relationships.
Being the parent of a child with oppositional defiant disorder isn't easy. Counseling for you can provide you with an outlet for your frustrations and concerns. In turn, this can lead to better outcomes for your child because you'll be more prepared to deal with problem behaviors.
Maintaining your health through relaxation, supportive relationships, and effective communication of your concerns and needs are important elements during treatment of ODD.
There's no guaranteed way to prevent oppositional defiant disorder. However, positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that ODD can be managed, the better.
Treatment can help restore your child's self-esteem and rebuild a positive relationship between you and your child. Your child's relationships with other important adults in his or her life — such as teachers, community supports and care providers — also will benefit from early treatment.
Feb. 06, 2015
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