Oppositional Defiant Disorder or “O.D.D."

The following answers are from excerptsof the writings of Dr. Lowenstein, M.D., Dr. Carosso, Psy.D., latest research findings, the DSM-IV, and WebMD (writings from Dr. Douglas Tynan, Ph.D. http://www.emedicine.com/ped/topic279 1.htm)

What is Oppositional Defiant Disorder or “O.D.D.”?

Diagnostic Criteria, as per the DSM-IV, consists of the following:

1. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
  - often loses 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 or her mistakes or misbehavior
  - is often touchy or easily annoyed by others
  - is often angry and resentful
  - is often spiteful or vindictive.
2. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
3. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
4. 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.

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

The Diagnostic and Statistical Manual, Fourth Edition, (DSM IV) of the American Psychiatric Association defines oppositional defiant disorder (ODD) as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. Behaviors included in the definition include the following: losing one's temper; arguing with adults; actively defying requests; refusing to follow rules; deliberately annoying other people; blaming others for one's own mistakes or misbehavior; being touchy, easily annoyed or angered, resentful, spiteful, or vindictive.

When is ODD usually diagnosed?

ODD is usually diagnosed when a child has a persistent or consistent pattern of disobedience and hostility toward parents, teachers, or other adults. The primary behavioral difficulty is the consistent pattern of refusing to follow commands or requests by adults. Children with ODD are often easily annoyed; they repeatedly lose their temper, argue with adults, refuse to comply with rules and directions, and blame others for their mistakes. Stubbornness and testing limits are common, even in early childhood.

The criteria for ODD are met only when the problem behaviors occur more frequently in the child than in other children of the same age and developmental level.

These behaviors cause significant difficulties with family and friends, and the oppositional behaviors are the same both at home and in school. Sometimes, ODD may be a precursor of a conduct disorder. ODD is not diagnosed if the problematic behaviors occur exclusively with a mood or psychotic disorder.

What are the prevalence rates?

The base prevalence rates for ODD are estimated to be 6-10% in surveys of nonclinical, nonreferred samples of parents' reports. In more stringent population samples, rates are lower when impairment criteria are stricter and when the information is obtained from both parents and teachers, rather than from parents only. Before puberty,the condition is more common in boys; after puberty, rates are nearly equal in boys and girls. ODD, and other conduct problems, is the single greatest reason for referrals to outpatient and inpatient mental health settings for children accounting for half or more of all referrals.

Please discuss “co-morbidity” (ODD occurring with other mental health problems, such as with ADHD):

ODD is complicated by relatively high rates of comorbid (e.g. two or more disorders occurring together) disruptive,
behavior disorders. Some symptoms of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder overlap. Researchers have postulated that, in some children, ODD may be the developmental precursor of conduct disorder. Comorbidity of ODD with ADHD has been reported to occur in 50-65% of affected children.

In some children, ODD commonly occurs with anxiety disorders and depressive disorders. Cross-sectional surveys have revealed the comorbidity of ODD with a mood disorder in about 35% of cases, with rates of comorbidity increasing with patient age. High rates of comorbidity are also found among ODDs, learning disorders, and academic difficulties. Given these findings, children with significant oppositional and defiant behaviors often require multidisciplinary assessment, and they may need components of mental health care, case management, and educational intervention to improve.

What type of pattern tends to develop between a parent and a child who is very oppositional?

In toddlers, temperamental factors, such as irritability, impulsivity, and intensity of reactions to negative stimuli, may contribute to the development of later oppositionality. The interactions of a child who has a difficult temperament and irritable behavior with parents who may react harshly, punitively, and inconsistently, can lead to a coercive, negative cycle of behavior in the family. In this pattern, the child's defiant behavior tends to intensify the parents' harsh reactions. The parents respond to misbehavior with threats of punishment that are inconsistently applied. When the parent punishes the child, the child learns to respond to threats. When the parent fails to punish the child, the child learns that he or she does not have to comply. Research indicates that these patterns are established early, in the child's preschool years; left untreated, pattern development accelerates, and patterns worsen.

Does the disorder change over time?

Developmentally, the presenting problems change with the child's age. For example, younger children are more likely to engage in oppositional and defiant behavior, whereas older children are more likely to engage in more covert behavior such as stealing.

By the time they are school aged, children with patterns of oppositional behavior tend to express their defiance with teachers and other adults, and they exhibit aggression toward their peers. As children with ODD progress in school, they experience increasing peer rejection due to their poor social skills and aggression. These children may be more likely to misinterpret their peers' behavior as hostile, and they lack the skills to solve social conflicts. In problem situations, children with ODD are more likely to resort to aggressive physical actions rather than verbal responses. Children with ODD and poor social skills often do not recognize their role in peer conflicts; they blame their peers (eg, "He made me hit him.") and usually fail to take responsibility for their own actions.

What are the hallmark symptoms?

The following three classes of behavior are hallmarks of both oppositional and conduct problems:

1. noncompliance with commands;
2. emotional overreaction to life events, no matter how small; and
3. failure to take responsibility for one's own actions.

Should I be concerned about where my child is placed at school?

When behavioral difficulties are present beginning in the preschool period, teachers and families may overlook
significant deficiencies in the child's learning and academic performance. When many children with behavioral problems and academic problems are placed in the same classroom, the risk for continued behavioral and academic problems increases. ODD behavior may escalate and result in serious antisocial actions that, when sufficiently frequent and severe, become criteria to change the diagnosis to conduct disorder. Milder forms of ODD in some children spontaneously remit over time. More severe forms of ODD, in which many symptoms are present in the toddler years and continually worsen after the child is aged 5 years, may evolve into conduct disorder in older children and adolescents.

What are the treatment options?

Given the high probability that ODD is a comorbid condition with attention disorders, learning disorders, and conduct disturbances, an evaluation for these disorders is indicated for comprehensive treatment. Pharmacologic treatment (eg, stimulant medication) for ADHD may be beneficial once this is diagnosed. Children with oppositional behavior in the school setting should undergo necessary screening testing in school to evaluate for possible learning disabilities. With the multifaceted nature of associated problems in ODD, comprehensive treatment may include medication, parenting and family therapy, and consultation with the school staff. If children with ODD are found to have ADHD as well, appropriate treatment of ADHD may help them to restore their focus and attention and decrease their impulsivity; such treatment may enable their social and behavioral interventions to be more effective.

Please tell me about Parent Training or Parent Management Training (PMT).

Parent management training (PMT) is recommended for families of children with ODD because it has been demonstrated to affect negative interactions that repeatedly occur between the children and their parents. PMT consists of procedures with which parents are trained to change their own behaviors and thereby alter their child's problem behavior in the home. PMT is based on 35 years of well-developed research showing that oppositional and defiant patterns arise from maladaptive parent-child interactions that start in early childhood. These patterns develop when parents inadvertently reinforce disruptive and deviant behaviors in a child by giving those behaviors a significant amount of negative attention. At the same time, as would be expected, the parents, who are often exhausted by the struggle to obtain compliance with simple requests, usually fail to provide positive attention such that the parents have infrequent positive interactions with their children. The pattern of negative interactions evolves quickly as the result of repeated, ineffective, emotionally expressed commands and comments; ineffective harsh punishments; and insufficient attention and modeling of appropriate behaviors.

PMT alters the pattern by encouraging the parent to pay attention to pro-social behavior and to use effective, brief, nonaversive punishments. Treatment is conducted primarily with the parents; the therapist, through outpatient or in-home wraparound services provided by C.P.C., demonstrates specific procedures to modify parental interactions with their child. Parents are first trained to simply have periods of positive play interaction with their child. They then receive further training to identify the child's positive behaviors and to reinforce these behaviors. At that point, parents are trained in the use of brief negative consequences for misbehavior. Treatment sessions provide the parents with opportunities to practice and refine the techniques.

Follow-up studies of operational PMT techniques in which parents successfully modified their behavior showed continued improvements for years after the treatment was finished. Treatment effects have been stronger with younger children, especially in those with less severe problems. Recent research suggests that less severe problems, rather than a younger patient age, is predictive of treatment success. Approximately 65% of families show significant clinical benefit from welldesigned parent management programs.

Regardless of the child's age, intervention early in the developing pattern of oppositional behavior is likely to be more effective than waiting for the child to grow out of it. These children can benefit from group treatment. The process of modeling behaviors and reactions within group settings creates a real-life adaptation process. In younger children, combined treatment in which parents attend a PMT group while the children go to a social skills group has consistently resulted in the best outcome. Concerns exist regarding the efficacy of group treatment of adolescents with oppositional behaviors. Group therapy for adolescents with ODD is most beneficial when it is structured and focused on developing the skills of listening, empathy, and effective problem solving.

ODD and other conduct problems, can be intractable. Despite advances in treatment, many children continue to have long-term negative behaviors. PMT requires parental cooperation and effort for success.

I’ve had some mental health problems of my own; can that have an impact on my child’s behavior?

Existing psychiatric conditions in the parents can be a major obstacle to effective treatment. Depression in a parent, particularly the mother, can prevent successful intervention with the child and become worse if the child's
behavior is out of control. Substance abuse and other more severe psychiatric conditions can adversely affect parenting skills, and these conditions are particularly problematic for the parents of a child with ODD. Consequently, it is vital that parents receive treatment of their own mental health issues, as needed. In that regard, C.P.C. offers such parent to help the entire family.

I heard that offering praise is more important than punishment for treating children with ODD?

Yes, that is true. It is vital to provide high levels of reinforcement for compliance and pro-social behavior, and meaningful consequences for being oppositional. While redirecting misbehavior, keep statements brief and rely on fair, firm and consistent limitsetting based in logical consequences. Remain calm and mention the child’s strengths and accomplishments (“I know you can do a nice job cleaning your room because you’ve done it before… this is not
your best effort but we can work together to make it better…”). Rely more on praise and reinforcement than punishment (10/1 ratio: ten comments offering praise and reinforcement (“I like the way you cleaned-up, nice job…”) for every one negative comment or reprimand.

A consistent daily routine is also advised during which unfavored tasks (clean-up) are completed before favored activities (watching television).

What should I focus on in terms of social skill development?

Skills that will need to be emphasized include (Attwood & Gray) Entry: how to join-in with a group of children and how to welcome a child who wants to join-in; Assistance: recognizing when and how to provide and accept help from others; Compliments: providing compliments at appropriate times and knowing how to respond to a friend’s compliment; Criticism: knowing when criticism is appropriate and inappropriate, how it is given and the ability to tolerate criticism; Accepting Suggestions: incorporating the ideas of others in the activity; Reciprocity and Sharing: a “back and forth” sharing of conversation and resources (toys…); Conflict Resolution: working through disagreements with compromise, accepting opinion of others; Monitoring and Listening: learning to observe peer’s body language and monitor their contribution to the activity. Monitor one’s own body language to reflect interest in peer and activity; Empathy: recognizing when appropriate comments and actions are required in response to peer’s circumstances and the feelings of others; Avoiding and Ending: teach the appropriate comments and behavior to maintain, end, or avoid an interaction.

Also emphasize the potential benefits of associating with peers who a good influence as opposed to those who are not. Encourage opportunities for involvement with such peers and reinforce that choices in that regard can result in increased privileges.

Use social stories, role playing, and rehearsal of social situations.

Utilization of feedback, i.e. videotape or audio recording may also be helpful.

Introduce child to peers, or structure social opportunities, with peers who have similar interests.

Explain why a particular behavior is necessary; don’t assume an understanding of the reasoning behind the pro-social behavior.

I learn better by being shown something and then doing it myself, as opposed to only having something being explained to me. Is that typical? Is that also true for my child?

Yes, that is a great point. It is important for professionals, when teaching problem-solving and task completion, to rely on “experiential” approaches (literally walking the child through the activity) as opposed to explaining and using only “words.” The same is true for teaching parents new strategies; rely on actual “hands-on” and experiential strategies as opposed to only teaching in a didactic manner.

Please describe ‘token economy systems’.

A token economy system, consisting of a point or sticker chart, is very helpful. Daily/Weekly responsibilities (included as tasks on the chart) can include: cleaning room, taking care of belongings, helping to launder, fold, and/or put away clothes, doing family chores in timely manner, completing homework, and proper grooming and dressing.

What about exercise and diet?

A consistent exercise regimen can be very helpful including involvement in sports/gross-motor activities and/or a specific aerobic exercise regimen It would likely be helpful to implement avegetables, void of excessive additives,
caffeine, and refined sugars.

How do I manage negative-attention-seeking?

Ignore attention-seeking behavior, walkaway and take time-out to gather thoughts. If you’re followed by your child so it’s difficult to “escape”, express that you won’t argue and offer a designated time-out area to cool down.

My child always want to watch TV before chores, what should I do?

Enforce what is known as the “Premack Principle”: First you do this (un-favored activity) and then you can do that
(favored activity). Example: “First pickup your stuff in the living room and then you can watch television.”

Is Time-Out helpful?

Time-out is a traditional and often-times helpful technique. Use of a timer may be helpful. Time-out can be preceded by use of the 1-2-3 Magic System (please see C.P.C. professional for full description of the 1-2-3 Magic Program).

Is my voice tone important?

Yes, it is. Model an appropriate tone of voice (calm and reassuring) and offer praise when you hear an appropriate tone of voice.

What do I do if my child becomes aggressive?

When faced with aggression, refer to the pre-established Crisis Plan (professional from C.P.C. will develop, with you, a comprehensive Crisis Plan addressing aggressive behavior) that may include immediate time-out with gentle physical prompts if not compliant in going to the time-out area. After time-out, review posted house rules. After a period being calm, ask what could have been done to express feelings rather than being physically aggressive or destroying property. For property destruction, after presenting as calm, direct to clean-up area and “pay back” what was destroyed by doing extra chores. Utilized logical consequences such as losing, for a pre-established period of time, a valued item that was thrown or broken.

My child, who is diagnosed with O.D.D., always fights with his sister. What can I do?

Try not to take sides or figure out “who started it” both of which is futile. Instead, encourage your kids to problem solve on their own. Anything short of bodily injury and destruction of property can be considered minor. The goal is for your children to realize that name-calling, and related minor nuisances, is to be managed by “brushing it off” and not becoming defensive or angry, which only adds fuel to the conflict. Moreover, parent intervention too, ironically, tends to only add fuel to sibling’s bickering especially if you “take sides.” Rather, limit intervention to giving the child the“words” to help problem-solve and/or “divide and conquer” (separate the siblings) if the children are unable to resolve in timely manner. If a punishment is necessary, implement the consequence equally on both kids.

My child is always being teased and rejected. What do you suggest?

To address bullying or child being teased, teach your child any number of simple and easy-to-use diffusing strategies to avoid worsening the situation. In that regard, it tends to be counter-productive for child to become defensive or argumentative when teased but, rather, it’s often best for child to respond to the teasing in an unemotional, nonchalant, and agreeable manner. A sense of humor also tends to be quite helpful. Clearly, the child becoming emotional and upset only ‘adds fuel to the fire.’ It can ‘take the wind out of the sails’ of the teaser if there is no subsequent argument or emotionality from the would-be “victim” of the teasing. It will also be important to work with school staff to ensure that, while they protect all students from physical danger, they do not take sides when faced with accusations of minor teasing. In that regard, taking sides and punishing only worsens the subsequent teasing given that, after being punished, the “bully” tends to seek revenge on the “victim.” However, if the minor teasing is managed effectively by the child and teacher, the situation can be easily diffused and future teasing averted. Please contact the C.P.C. office for more information about specific techniques and/or review the resources listed below.

My child is really tough during the bedtime routine, what can I do?

Utilize two minute warning prior to beginning of bedtime routine.

Keep the lights dim as bedtime approaches. Maintain a quite environment by turning the television down, or off. Create an environment, as bedtime approaches, of quiet, peacefulness, and that things are “winding down.”

Use a visual schedule to emphasize routine. Utilize a favored activity as the last activity prior to going to sleep and reinforce adherence to the routine prior to going to sleep. However, the activity should be relaxing, not stimulating.

At the end of the routine, refuse to attend to questioning or stalling.

Utilize a time bank with an earlier bedtime the following night if the routine is not followed.

If child frequently leaves bedroom after going to bed, may help to provide up to three “passes” that can be used per night to leave bedroom and ask parent for something such as a drink of water (research has shown that this technique often results in only one or none of the passes being used and the child more readily staying in bed)

SOME HELPFUL RESOURCES THAT CAN BE FOUND AT YOUR LOCAL C.P.C. LIBRARY:

To address attention-deficit/hyperactivity:

Childswork-Childsplay
(www.childswork.com): quality
resource for counseling games and
books for children
Various workbooks including: The “Putting On The Breaks” Activity Book For Young People With ADHD; and The Best of “Brakes” (Quinn & Stern)
Getting a Grip on ADD: A Kid’s Guide to Understanding and Coping with Attention Disorders (Frank and Smith)
ADD/ADHD Behavior Change Resource Kit (Flick) Improving relationship between parent and child
How To Talk So Kids Will Listen and Listen So Kids Will Talk (Faber & Mazlish) Addressing Teenagers’ Issues
STEP (Systematic Training for Effective Parenting): Parenting Teenagers (Dinkmeyer and McKay)
Parents, Teens, and Boundaries: How to Draw the Line (Bluestein)
Brief Adolescent Therapy Homework Planner (Jongsma, Peterson, and McInnis) To address behavioral issues (noncompliance, defiance, develop parenting skills)
STEP (Systematic Training for Effective Parenting): Parenting Young Children Under the age of six (Dinkmeyer and McKay)
1-2-3 Magic System (Phelan) How to Behave So Your Child Will Too (Sal Severe)
Parenting with Love and Logic (Fay and Cline)
Skills Training for Children with Behavioral Disorders (Bloomguist)
Defiant Children: A Clinician’s Manual for Assessment and Parent Training (Barkley)

Address problems with Mood, Anxiety,and Fears

- - The Bipolar Child (Popolos & Popolos)
  - Bipolar Disorders: A Guide toHelping Children and Adolescents (Waltz)
  - Tell Me Something Happy Before I Go to Sleep (Dunbar and Gliori)
  - Nightlight: A Story for Children Afraid of the Dark (Gutro and Boyle)
  - Fear’s, Doubt’s, Blues and Pouts: Stories of Handling Fear, Worry, Sadness and Anger (Wright)
  - The Complete Depression Treatment and Homework Planner (Jongsma)
  - Handbook of Anger Management (Potter-Efron)
  - Helping Your Anxious Child: A Step-by-Step Guide for Parents (Parpe)
  - The Anxiety and Phobia Workbook (Bourne)
  - The Boy Who Couldn’t Stop Washing (The Experience and
  - Treatment of Obsessive- Compulsive Disorder (Rapoport)
  - The Coping Skills Workbook: Teaches Kids Nine Essential Skills to Help Deal with Real-Life Crisis (Schab)
  - Feeling Good Handbook (Burns)
  - The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms (Williams & Puijula)
  - Treating Self-Injury: A Practical Guide (Walsh, Barent)

Developing friendships

- - Good Friends are Hard to Find: Help Your Child Find, Make and Keep Friends (Wetmore)
  - Social Stories and More Social Stories (Gray)
  - The New Social Story Book, Illustrated Edition (Gray)

Information about medication

Straight Talk About Psychiatric Medications For Kids (Wilens)
Medications for School-Age Children: Effects on Learning and Behavior (Brown and Sawyer)

Sleep problems

Solve your Child’s Sleep Problems (Ferber)

Toileting

Toilet Training Autistic Individuals in 21 Days: A Guide to Effectively Potty Training Individuals on the Autistic Spectrum (Steven, J)

Dealing with Bullies (Avoid being the "Victim")

Bullies to Buddies: How to Turn Your Enemies into Friends (Kalman,I)
www.Bullies2Buddies.com

Sibling issues:

Siblings Without Rivalry (Faber & Mazlish)

For Additional Internet Resources on many childhood disorders visit our Parent Resource Page by clicking here.