Diagnoses

The American Academy of Child and Adolescent Psychiatry publishes an online Oppositional DefianceDisorder Resource Center, the first in a series designed to gather together information regarding common children's mental health problems. The site appears to be designed especially for parents, but also contains links to practice guidelines and other information that would be very helpful for primary care providers. As an AACAP resource, the information is carefully vetted, and computer-literate parents of children with ODD may very much appreciate being directed to the site by their primary care clinician. -Barry Sarvet, MD

Oppositional Defiance Disorder (ODD)

Introduction

Children with oppositional defiance disorder (ODD) have a persistant pattern of defiant and negative behavior that is severe enough to cause significant impairment in functioning at school, home, and/or in the community. It is considered an "externalizing" behavior disorder, meaning that their problems are manifest in the outside world. In other words, the problems are quite noticeable to others. This does not, however, imply that the child's problems are well-understood. In fact, children with oppositional defiance disorder often provoke expressions of resentment, frustration, exhaustion, and anger in caregivers, which may reinforce the behavior.

Children with ODD need to be carefully evaluated for ADHD and mood disorders. It's easy to imagine the pathway from untreated ADHD symptoms leading over time to the establishment of a pattern of negative interactions with caregivers. Alternatively, the angry, hopeless, and irritable symptoms of a child or adolescent with chronic depression may result in a similar pattern of behavior. Treating these underlying comorbidities is necessary but not sufficient. The behavior patterns of ODD are usually entrenched and require a focused behavioral treatment approach. Unchecked, ODD frequently leads to conduct disorder, delinquency, substance abuse disorders, and school failure.

Diagnostic criteria for Oppositional Defiance Disorder
A. A pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four (or more) of the following are present:

(1) Often loses temper
(2) Often argues with adults
(3) Often actively defies or refuses to comply with adults'requests or rules
(4) Often deliberately annoys people
(5) Often blames others for his or her mistakes or misbehavior
(6) Is often touchy or easily annoyed by others
(7) Is often angry and resentful
(8) Is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B.   The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C.   The behaviors do not occur exclusively during the course of a psychotic or mood disorder.

D.   Criteria are not met for conduct disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

*Diagnostic and Statistical Manual of Mental Disorders, fourth Edition

Clinical Guidelines:

AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder 46:1 (January 2007)

Screening rating scales, diagnosis, and evaluation

See AACAP Practice Parameter (Table 2) for a list of instruments to use in practice as diagnostic aids and tools for tracking progress.

A portion of the assessment of the child with ODD should take the form of a functional analysis of the child's behavior, including identification of the antecedents and consequences of the child's behavior and parent and others' behavior that may reinforce the child's problem behaviors (Mash and Terdal, 2001).

Parent information and handouts:

AACAP Facts for Families: Oppositional Defiance Disorder

American Academy of Child & Adolescent Psychiatry (AACAP) Oppositional Defiant Disorder Resource Center