Oppositional defiant disorder (ODD)

Even the best-behaved children can be difficult and challenging at times. But oppositional defiant disorder (ODD) includes a frequent and ongoing pattern of anger, irritability, arguing and defiance toward parents and other authority figures. ODD also includes being spiteful and seeking revenge, a behavior called vindictiveness.

These emotional and behavioral issues cause serious problems with family life, social activities, school and work. But as a parent, you don't have to try to manage a child with ODD alone. Your health care provider, a mental health professional and a child development expert can help.

Treatment of ODD involves learning skills to help build positive family interactions and to manage problem behaviors. Other therapy, and possibly medicines, may be needed to treat related mental health conditions.

Sometimes it's difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It's common for children to show oppositional behavior at certain stages of development.

Symptoms of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. Oppositional and defiant behaviors are frequent and ongoing. They cause severe problems with relationships, social activities, school and work, for both the child and the family.

Emotional and behavioral symptoms of ODD generally last at least six months. They include angry and irritable mood, argumentative and defiant behavior, and hurtful and revengeful behavior.

Angry and irritable mood

• Often and easily loses temper.
• Is frequently touchy and easily annoyed by others.
• Is often angry and resentful.

Argumentative and defiant behavior

• Often argues with adults or people in authority.
• Often actively defies or refuses to follow adults' requests or rules.
• Often annoys or upsets people on purpose.
• Often blames others for their own mistakes or misbehavior.

Hurtful and revengeful behavior

• Says mean and hateful things when upset.
• Tries to hurt the feelings of others and seeks revenge, also called being vindictive.
• Has shown vindictive behavior at least twice in the past six months.

Severity

ODD can be mild, moderate or severe:

• Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
• Moderate. Some symptoms occur in at least two settings.
• Severe. Some symptoms occur in three or more settings.

For some children, symptoms may first be seen only at home. But with time, problem behavior also may happen in other settings, such as school, social activities and with friends.

When to see a doctor

Your child isn't likely to see their own behavior as a problem. Instead, your child will probably complain about unreasonable demands or blame others for problems.

If you think your child may have ODD or other problem behavior, or you're concerned about your ability to parent a challenging child, seek help from a child psychologist or a child psychiatrist with expertise in behavior problems. Ask your child's pediatrician or other health care provider for a referral to a mental health provider.

There's no known clear cause of oppositional defiant disorder. Causes may include a combination of genetic and environmental factors:

• Genetics. A child's natural personality or character — also called temperament — may contribute to developing ODD. Differences in the way nerves and the brain function also may play a role.
• Environment. Problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect may contribute to developing ODD.

Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include:

• Temperament — a child who has a temperament that includes difficulty managing emotions, such as reacting with strong emotions to situations or having trouble tolerating frustration.
• Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of proper supervision.
• Other family issues — a child who lives with parent or family relationships that are unstable or has a parent with a mental health condition or substance use disorder.
• Environment — problem behaviors that are reinforced through attention from peers and inconsistent discipline from other authority figures, such as teachers.

Children and teenagers with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, and at work with supervisors and other authority figures. Children and teens with ODD may struggle to make and keep friends and relationships.

ODD also may lead to other problems, such as:

• Poor school and work performance.
• Antisocial behavior.
• Legal problems.
• Impulse control problems.
• Substance use disorder.
• Suicide.

Many children and teens with ODD also have other mental health conditions, such as:

• Attention-deficit/hyperactivity disorder (ADHD).
• Conduct disorder.
• Depression.
• Anxiety disorders.
• Learning and communication disorders.

Treating these other mental health conditions may help reduce ODD symptoms. It may be difficult to treat ODD if these other conditions are not evaluated and treated appropriately.

There's no sure way to prevent oppositional defiant disorder. But positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that ODD can be managed, the better.

Treatment can help restore your child's self-esteem and rebuild a positive relationship between you and your child. Your child's relationships with other important adults in their life — such as teachers and care providers — also will benefit from early treatment.

To determine whether your child has oppositional defiant disorder, a mental health provider does a thorough psychological exam. ODD often occurs along with other behavioral or mental health problems. So it may be difficult to tell which symptoms are from ODD and which ones are linked to other problems.

Your child's exam will likely include an assessment of:

• Overall health.
• How often the behaviors occur and how severe they are.
• Emotions and behavior in different settings and relationships.
• Family situations and interactions.
• Strategies that have been helpful ― or not helpful ― in managing problem behaviors.
• Issues experienced by the child and the family due to the problem behaviors.
• Other possible mental health, learning or communication problems.

Treatment for oppositional defiant disorder primarily involves family-based interventions. But treatment may include other types of talk therapy and training for your child — as well as for parents. Treatment often lasts several months or longer. It's important to also treat any other problems, such as a mental health condition or learning disorder, because they can cause or worsen ODD symptoms if left untreated.

Medicines alone generally aren't used for ODD unless your child also has another mental health condition. If your child also has other conditions, such as ADHD, anxiety disorders or depression, medicines may help improve these symptoms.

Treatment for ODD usually includes:

• Parenting skills training. A mental health professional with experience treating ODD can help you develop parenting skills that are more consistent, positive and less frustrating for you and your child. In some cases, your child may join you in this training, so everyone in your family develops a consistent approach and shared goals for how to handle problems. Involving other authority figures, such as teachers, in the training may be an important part of treatment.
• Parent-child interaction therapy (PCIT). During PCIT, a therapist coaches you while you interact with your child. In one approach, the therapist sits behind a one-way mirror. Using an "ear bug" audio device, the therapist guides you through strategies that reinforce your child's positive behavior. As a result, you can learn more-effective parenting techniques, improve the quality of your relationship with your child and reduce problem behaviors.
• Individual and family therapy. Individual therapy for your child may help them learn to manage anger and express feelings in a healthier way. Family therapy may help improve your communication and relationships and help your family members learn how to work together.
• Problem-solving training. Cognitive problem-solving therapy can help your child identify and change thought patterns that lead to behavior problems. In a type of therapy called collaborative problem-solving, you and your child work together to come up with solutions that work for both of you.
• Social skills training. Your child also may benefit from therapy that will help them be more flexible and learn how to interact in a more positive and effective way with peers.

As part of parent training, you may learn how to manage your child's behavior by:

• Giving clear instructions and following through with appropriate consequences when needed.
• Recognizing and praising your child's good behaviors and positive traits to encourage desired behaviors.

Although some parenting techniques may seem like common sense, learning to use them consistently in the face of opposition isn't easy. It's especially hard if there are other stressors at home. Learning these skills requires routine practice and patience.

Most importantly, during treatment, show consistent, unconditional love and acceptance of your child — even during difficult and disruptive situations. Don't be too hard on yourself. This process can be tough for even the most patient parents.

At home, you can work on improving problem behaviors of oppositional defiant disorder by practicing these strategies:

• Recognize and praise your child's positive behaviors as close to the time you see them as possible. Be as specific as possible. For example, "I really liked the way you helped pick up your toys tonight." Providing rewards for positive behavior also may help, especially with younger children.
• Model the behavior you want your child to have. Watching you interact well with others can help your child improve social skills.
• Pick your battles and avoid power struggles. Almost everything can turn into a power struggle if you let it.
• Set limits by giving clear instructions and using consistent reasonable consequences. Discuss setting these limits during times when you're not arguing with each other.
• Set up a routine by developing a regular daily schedule for your child. Ask your child to help develop that routine.
• Build in time together by planning a weekly schedule that includes you and your child doing things together.
• Work together with your partner or others in your household to ensure consistent and appropriate discipline procedures. Also ask for support from teachers, coaches and other adults who spend time with your child.
• Assign a household chore that's needed and that won't get done unless your child does it. At first, it's important to set your child up for success with tasks that are fairly easy to do well. Gradually blend in more-important and challenging jobs. Give clear, easy-to-follow instructions. Use this as an opportunity to reinforce positive behavior.
• Be prepared for challenges early on. At first, your child probably won't cooperate or appreciate your changed response to their behavior. Expect behavior to worsen at first after you tell them the new things you now expect. At this early stage, staying consistent even if the problem behavior worsens, is the key to success.

With regular and consistent effort, using these methods can result in improved behavior and relationships.

It's challenging to be the parent of a child with oppositional defiant disorder. Ask questions and tell your treatment team about your concerns and needs. Consider getting counseling for yourself and your family to learn coping strategies to help manage your own needs. Also seek and build supportive relationships and learn stress management skills to help get through difficult times.

Learning coping and support strategies can lead to better outcomes for you and your child because you'll be more prepared to deal with problem behaviors.

You may start by seeing your child's health care provider. Or you may choose to make an appointment directly with a mental health provider. A mental health provider can make a diagnosis and create a treatment plan that meets your child's needs.

When possible, both parents or caregivers should be present with the child. Or take a trusted family member or friend along to support you and help you remember information.

What you can do

Before your appointment, make a list of:

• Symptoms your child has been experiencing, and for how long.
• Key family information, including factors that you think may be linked to changes in your child's behavior. Include any stressors and changes in the family, such as parents' separation or divorce and differences in parenting styles, including what's expected from your child.
• Your child's school performance, including grades and areas where your child does well or poorly in school. Include any learning disorder assessments and any special education services.
• Issues that you, your family and your child have been experiencing because of the problem behavior.
• Your child's key medical information, including other physical or mental health conditions your child may have.
• Any medicines, vitamins, herbal products and other supplements your child is taking, including the doses.
• Questions to ask your health care provider or mental health provider to make the most of your appointment.

Some questions to ask your child's mental health provider include:

• What do you believe is causing my child's symptoms?
• Are there any other possible causes, such as other mental health conditions?
• Is this condition likely temporary or long lasting?
• What issues do you think might be contributing to my child's problem?
• What treatment approach do you recommend?
• Is my child at increased risk of any long-term complications from this condition?
• What changes do you suggest at home or school to improve my child's behavior?
• Should I tell my child's teachers about this diagnosis?
• What else can my family and I do to help my child?
• Do you recommend family therapy?

Feel free to ask other questions during your appointment.

What to expect from your doctor

Here are examples of questions that your mental health provider may ask.

• What are your concerns about your child's behavior?
• When did you first notice these problems?
• Have your child's teachers or other caregivers reported problem behaviors in your child?
• About how often over the last six months has your child had an angry and irritable mood, argued with or defied people in authority, or purposely hurt others' feelings?
• In what settings does your child show these behaviors?
• Do any specific situations seem to trigger problem behavior in your child?
• How have you been handling your child's problem behavior?
• How do you usually discipline your child?
• How would you describe your child's home and family life?
• What kinds of stress has your family been dealing with?
• Does your child have any other medical or mental health conditions?

Be ready to answer your mental health provider's questions. That way you'll have more time to go over any other information that's important to you.