Oppositional Defiant Disorder

Background

• Oppositional defiant disorder (ODD) is a common type of disruptive behavior disorder of childhood characterized by a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures that is not caused by underlying psychosis, substance use, or mood disorder.
• ODD behaviors typically begin in late preschool or early school years and are evident by age 8 years. They negatively impact social, academic, or occupational functioning.
• Comorbid conditions are common and may include attention deficit hyperactivity disorder, conduct disorder, anxiety disorders, depression, and substance abuse.

Evaluation

• Assessment involves a detailed history, the use of specific questionnaires and rating scales, and should include information from multiple sources such as preschool teachers, family, and history obtained from child directly.
• The diagnosis of oppositional defiant disorder (ODD) can be made using Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for types, duration, severity, and frequency of behaviors.
  • The pattern of behavior should be present for ≥ 6 months and be exhibited during an interaction with ≥ 1 nonsibling.
  • 4 or more criteria must be present in the areas of angry/irritable mood, argumentative/defiant behavior, and vindictiveness.
  • The behaviors must be more frequent and intense than the normative range for the child's developmental level, gender, and culture. General guidelines include behavior being present:
    • on most days in children < 5 years old (except vindictive criterion)
    • at least once weekly in children ≥ 5 years old (except vindictive criterion)
    • ≥ 2 times over 6 months for vindictive criterion at any age
  • The behavior must be associated with distress in the child or others in their immediate social context or impact negatively on social, educational, occupational, or other important area of functioning, and not be caused by another disorder.

Management

• Children with oppositional defiant disorder (ODD) are typically managed with caregiver-based outpatient counseling, such as:
  • parent training, usually in collaboration with the child
  • collaborative problem-solving interventions
• Medications may be considered for specific behaviors associated with ODD or in children with comorbid conditions.
  • They should only be used along with counseling as adjunctive and/or palliative treatment.
  • Begin treatment only after establishing a baseline of symptoms and if there is no improvement with psychosocial interventions after 2-3 months.
  • In children with comorbid ODD and attention deficit hyperactivity disorder (ADHD), methylphenidate, atomoxetine, and amphetamine/dextroamphetamine may be effective.
  • In children with ADHD with or without ODD:
    • Use stimulants such as methylphenidate (Ritalin), and amphetamine/dextroamphetamine (Adderall) for treatment of oppositional behavior or aggression (Strong recommendation).
    • Consider risperidone or valproate for treatment of aggression (Weak recommendation).
    • Consider atomoxetine, clonidine, or guanfacine for treatment of oppositional behavior (Weak recommendation).