Oppositional Defiant Disorder

Oppositional defiant disorder is a recurring pattern of negative, hostile, disobedient, and defiant behavior in a child or adolescent, lasting for at least six months without serious violation of the basic rights of others.

Description

The behavior disturbances cause clinically significant problems in social, school, or work functioning. The course of oppositional defiant disorder varies among patients. In males, the disorder is more common among those who had problem temperaments or high motor activity in the preschool years. During the school years, patients may have low self-esteem, changing moods, and a low frustration tolerance. Patients may swear and use alcohol, tobacco, or illicit drugs at an early age. There are often conflicts with parents, teachers, and peers.

Children with this disorder show their negative and defiant behaviors by being persistently stubborn and resisting directions. They may be unwilling to compromise, give in, or negotiate with adults. Patients may deliberately or persistently test limits, ignore orders, argue, and fail to accept blame for misdeeds. Hostility is directed at adults or peers and is shown by verbal aggression or deliberately annoying others.

Causes and symptoms

Oppositional defiant disorder is more common in boys than girls and the disorder typically begins by age eight. Although the specific causes of the disorder are unknown, parents who are overly concerned with power and control may cause an eruption to occur. Symptoms often appear at home, but over time may appear in other settings as well. Usually the disorder occurs gradually over months or years. Several theories about the causes of oppositional defiant disorder are being investigated. Oppositional defiant disorder may be related to:

• the child's temperament and the family's response to that temperament
• an inherited predisposition to the disorder in some families
• a neurological cause, like a head injury
• a chemical imbalance in the brain (especially with the brain chemical serotonin)

Oppositional defiant disorder appears to be more common in families where at least one parent has a history of a mood disorder, conduct disorder, attention deficit/hyperactivity disorder, antisocial personality disorder, or a substance-related disorder. Additionally, some studies suggest that mothers with a depressive disorder are more likely to have children with oppositional behavior. However, it is unclear to what extent the mother's depression results from or causes oppositional behavior in children.

Symptoms include a pattern of negative, hostile, and defiant behavior lasting at least six months. During this time four or more specific behaviors must be present. These behaviors include the child who:

• often loses his/her temper
• often argues with adults
• often actively defies or refuses to comply with adults' requests or rules
• often deliberately annoys people
• often blames others for his/her mistakes or misbehavior
• is often touchy or easily annoyed by others
• is often angry and resentful
• is often spiteful or vindictive
• misbehaves
• swears or uses obscene language
• has a low opinion of him/herself

The diagnosis of oppositional defiant disorder is not made if the symptoms occur exclusively in psychotic or mood disorders. Criteria are not met for conduct disorder, and, if the child is 18 years old or older, criteria are not met for antisocial personality disorder. In other words, a child with oppositional defiant disorder does not show serious aggressive behaviors or exhibit the physical cruelty that is common in other disorders.

Additional problems may be present, including:

• learning problems
• a depressed mood
• hyperactivity (although attention deficit/hyperactivity disorder must be ruled out)
• substance abuse or dependence
• dramatic and erratic behavior

The patient with oppositional defiant disorder is moody, easily frustrated, and may abuse drugs.

Diagnosis

While psychological testing may be needed, the doctor must examine and talk with the child, talk with the parents, and review the medical history. Oppositional defiant disorder rarely travels alone. Children with attention/deficit hyperactive disorder will also have oppositional defiant disorder 50% of the time. Children with depression/anxiety will have oppositional defiant disorder 10–29% of the time. Because all of the features of this disorder are usually present in conduct disorder, oppositional defiant disorder is not diagnosed if the criteria are met for conduct disorder.

A diagnosis of oppositional defiant disorder should be considered only if the behaviors occur more frequently and have more serious consequences than is typically observed in other children of a similar developmental stage. Further, the behavior must lead to significant impairment in social, school, or work functioning.

Treatment

Treatment of oppositional defiant disorder usually consists of group, individual and/or family therapy, and education. Of these, individual therapy is the most common. Therapy can provide a consistent daily schedule, support, consistent rules, discipline, and limits. It can also help train patients to get along with others and modify behaviors. Therapy can occur in residential, day treatment, or medical settings. Additionally, having a healthy role model as an example is important for the patient.

Parent management training focuses on teaching the parents specific and more effective techniques for handling the child's opposition and defiance. Research has shown that parent management training is more effective than family therapy.

Whether involved in therapy or working on this disorder at home, the patient must work with his or her parents' guidance to make the fullest possible recovery. According to the New York Hospital/Cornell Medical Center, the patients must:

• use self timeouts
• identify what increases anxiety
• talk about feelings instead of acting on them
• find and use ways to calm themselves
• frequently remind themselves of their goals
• get involved in tasks and physical activities that provide a healthy outlet for energy
• learn how to talk with others
• develop a predictable, consistent, daily schedule of activity
• develop ways to obtain pleasure and feel good
• learn how to get along with other people
• find ways to limit stimulation
• learn to admit mistakes in a matter-of-fact way

Stimulant medication is used only when oppositional defiant disorder coexists with attention deficit/hyperactivity disorder. Currently no research is currently available on the use of other psychiatric medications in the treatment of oppositional defiant disorder.

Prognosis

The outcome varies. In some children the disorder evolves into a conduct disorder or a mood disorder. Later in life, oppositional defiant disorder can develop into passive aggressive personality disorder or antisocial personality disorder. Some children respond well to treatment and some do not. Generally, with treatment, reasonable adjustment in social settings and in the workplace can be made in adulthood.