Oppositional Defiant Disorder (ODD)

Understanding oppositional defiant disorder (ODD)

Oppositional Defiant Disorder (ODD) is a behavior disorder primarily affecting children and adolescents. The symptoms include having an angry or irritable mood, disobedience, defiance, and vindictive behavior.^[1]

The signs of ODD are usually apparent by the age of eight, although they can start significantly earlier.

It’s hard to know the exact prevalence of ODD, with some groups potentially being overdiagnosed whilst others are underdiagnosed. Estimates typically fall between 1-16% of children.^[2]

ODD can cause significant problems for children; they have difficulty building strong social connections, are considered antisocial, and can be excluded from school. It is also difficult for their parents, families, and wider caregivers, who are faced with challenging behavior daily.

Although the symptoms will often reduce and even disappear over time, a significant minority of ODD patients will go on to develop other, more serious, conditions including conduct disorder.^[3] Treatment should be sought as early as possible to reduce this risk. These treatments typically involve the whole family.

Symptoms of ODD

According to DSM-5, there are three categories of ODD symptoms. ^[6]

Angry or irritable mood

• Often losing their temper or having temper tantrums
• Often being touchy or easily annoyed
• Often being angry or resentful

Argumentative or defiant behavior 

• Often argues with authority figures or adults
• Often refuses to comply with requests from authority figures or with rules, may actively defy these
• Often deliberately annoys others
• Often blames others for their mistakes or behavior

Vindictiveness

• Being spiteful or vindictive

For a diagnosis of ODD to be given, these behaviors must be directed at someone other than a sibling.

Causes of ODD

ODD is a complicated, and sometimes hard to define, disorder. This can make it difficult to find the precise causes. As with many aspects of mental health, there are probably genetic, environmental, and biological components that work together to create the symptoms.

It is difficult to estimate the genetic component of ODD, given that children with similar genetics will often also share a family and home environment. Some estimates have placed the heritability of ODD as high as 61%, however.^[7]

There are some suggestions that children with ODD may have a reduced brain response to rewards.^[8] If true, this could mean that these children require more praise or rewards than other children to have the same effect.

Approximately 40% of children diagnosed with ADHD also meet the diagnostic criteria for ODD.^[9] This supports the idea that there is a genetic and/or neurochemical factor influencing these behaviors. There are also similarities between the conditions, so an accurate diagnosis is important for proper, effective treatment.

ODD is also often seen in children with learning disabilities.^[10] In these children, ODD may be a coping mechanism for when they are asked to perform tasks they don’t understand or when they are unable to comply.

ODD is seen more commonly in children who have had challenging experiences in their childhood. Risk factors include:

• Experiencing abuse or neglect
• Having family members with substance use disorders or mood disorders
• Being exposed to violence
• Having a lack of adult supervision and care
• Family instability
• Financial difficulties within the family

There are also specific character traits associated with children with ODD. They are typically both quick to anger and slow to calm down. They may score highly on measures of negativity and pessimism.

In addition to the factors listed above, ODD is thought to include aspects of learned behavior.^[11] Children who develop ODD may use their behavior as a way to gain attention from adults or caregivers or because they have learned that such behavior is effective.

ODD diagnosis

Diagnosis of ODD is usually carried out by a child psychologist or psychiatrist.^[6] This will often involve talking to parents and other caregivers, the child themselves, and potentially siblings, school staff, and others who have witnessed the child’s behavior.

There are no diagnostic tools designed specifically to help with the diagnosis of ODD but other common childhood diagnostic tools can help medical practitioners gather enough evidence to be sure of their diagnosis.

At least four of the eight symptoms listed above must have been present for at least six months and be considered outside of what is developmentally normal. This includes both the severity and the frequency of the behavior. For example, temper tantrums would be normal for very young children but highly unusual in older adolescents. Similarly, children under five may become very angry several days a week while once a week is seen as frequent for older children.

Some of these symptoms may appear slightly differently in girls compared with boys, especially around vindictiveness and angry outbursts. Where boys may be more physically aggressive, girls start rumors about other children or ostracize them instead.

Clinicians will need to be sure that these symptoms aren’t caused by another condition, such as an undiagnosed learning disorder, or a more serious condition such as disruptive mood dysregulation disorder (DMDD).

ODD is typically diagnosed as mild, moderate, or severe. This doesn’t refer to the severity of the symptoms themselves. Instead, mild ODD is when the symptoms are only seen in one situation (typically at home). For moderate cases, it would be seen in two situations, for example at school as well as at home. If the symptoms occur in three or more situations, it is considered severe.

ODD prevention

Where children have several risk factors for ODD, for example, if they have experienced abuse or have been diagnosed with ADHD, it can be helpful for parents to seek support designed to prevent ODD.

ODD prevention focuses on giving parents tools designed to prevent their children from developing the learned behaviors of ODD. This typically includes positive reinforcement and support in creating a stable home environment.

For at-risk children, therapy can also offer a path to help them healthily deal with their emotions.

Even where ODD cannot be fully prevented, these techniques may improve the prognosis for at-risk children.

ODD treatment

The symptoms of ODD can sometimes diminish over time, but this is not guaranteed. Seeking treatment can help manage behaviors in the short term and reduce the risks that it will become more serious over time.

Support for parents of children with ODD

Being a parent of a child with ODD is challenging. Their behavior can create an unstable and chaotic home life and you may experience significant stigma and shame.

Self-care is especially important for parents of children with ODD. Therapy can help you deal with your feelings and stress, which will help to build a more stable basis from which you can address your child’s behavior.

Taking time out for yourself, even during high-stress situations can be extremely beneficial. Pausing a confrontation can model healthier communication strategies for your child.

Reach out to healthcare workers and school staff. ODD is a common condition and they might have advice, guidance, and support to offer.