Behavioural and Emotional Disorders
Oppositional Defiant Disorder (ODD)
What is Oppositional Defiant Disorder (ODD)?
Children show some acts of defiance and disobedience to authority occasionally. In fact, at certain developmental stages, it would be unusual if they never threw any tantrums or acted out - small amounts of this constitutes a healthy part of development!
However, when defiant behaviour persists in patterns of hostility and begins to occur in the form of age-inappropriateness, it could be classified as Oppositional Defiant Disorder.
Symptoms of ODD
ODD symptoms are classified into 3 dimensions in the DSM-5: angry or irritable mood, argumentative or defiant behaviour and vindictiveness, with examples of symptoms falling under each category seen in the table below.
Diagnosis
To be diagnosed with ODD (DSM-5 criteria), an individual must:
1) Show at least 4 symptoms from any of the categories mentioned earlier
2) Symptoms must be exhibited during interaction with at least one individual who is not a sibling
3) This pattern of behaviour should be observed for at least 6 months
4) Disturbance in behaviour
Ψ Is associated with distress in the individual or others in immediate social context (e.g., family, peer group, work colleagues), OR
Ψ It impacts negatively on social, education, occupation or other important areas of functioning
5) Behaviours do not occur exclusively during course of a psychotic, substance-use, depressive or bipolar disorder
6) Criteria are also not met for disruptive mood disorder
Severity levels of ODD
Ψ Mild: Symptoms are confined to only 1 setting (e.g. at home, at school, at work, with peers)
Ψ Moderate: Some symptoms are present in at least 2 settings
Ψ Severe: Some symptoms are present in 3 or more settings
A significant proportion of children with either ODD or Conduct Disorder (CD) have comorbid attention-deficit hyperactivity disorder (ADHD), anxiety, or depression.
Causes of ODD
Like many other disorders, there is no single, contributing cause towards ODD. It’s often a multitude of reasons, with a combination of psychological, biological, and environmental causes.
Genetic or biological factors contributing to the onset of ODD:
Ψ Malnutrition and maternal alcohol use during pregnancy are associated with increased risk.
Ψ Based on research findings, genetic or hereditary component accounts for the increased possibility of displaying unhealthy or maladaptive (psychopathological) behaviours.
Ψ In other words, a family history of such behaviour can explain why parents and children may both demonstrate maladaptive behaviours, just in different ways. Children may demonstrate behaviours like oppositional and conduct problems, difficult temperament, increased risk of developing antisocial and aggressive behaviour, inattention, hyperactivity-impulsivity and so on.
Environmental factors contributing to the presence of ODD:
Ψ Defiant behaviour may appear due to little internalisation of parent and societal standards. This may stem from insecure attachments, weak bonds with parents and other factors. Insecure attachments with parents may result in children associating with deviant peers, which explains for delinquency, and even defiant behaviour. Even when these children comply with parental requests, they may only do so due to perceived threats to their safety or freedom.
Ψ Harsh parenting can adversely impact a child’s emotion regulation abilities, resulting in expressed irritable or angry mood and in some cases, depressive symptoms as well.
Ψ Lax monitoring might be a good short-term solution to a child’s tantrums, but this creates a larger problem. By being permissive and lax on a child’s misbehaviour by giving them what they want, it enables their misbehaviour. In the long run, such parenting practices might result in a recurring pattern of defiant behaviour.
Managing ODD
Given the huge impact that ODD has on an individual and important people around them (e.g. family, friends, teachers), is there any way to reduce these symptoms?
Ideally, intervention should involve therapy for both the child and the parent or family. As families and parents play an important role in a child’s development, parents are often involved in the management plan. Parents either undergo parent management training (PMT) or parent-child interaction therapy (PCIT), depending on the age of their child.
Ψ Parent Management Training (PMT)
Aimed at teaching parents ways to change their child’s behaviour at home and in other settings. According to PMT, maladaptive parent-child interactions are viewed as the crux of the problem.
PMT aims to reduce ODD symptoms by improving parenting behaviour. It can be carried out in individual or group settings and is recommended for parents with children aged 12 and below. Parents are taught skills to improve parent-child interactions and parenting behaviour. This includes:
Ψ ways to monitor their children’s behaviour
Ψ to communicate clearly and effectively on rules and instructions
Ψ systematically provide rewards and minor forms of punishment, such as timeouts
Ψ Parent-Child Interaction Therapy (PCIT)
For parents with younger children (preschool and early school-aged children), PCIT integrates play therapy and operant behavioural therapy approaches to improve the parent-child relationship and manage disruptive behaviour problems.
Play therapy: parents are encouraged to let their child take the lead during play sessions instead of commanding or criticising them as this might result in oppositional behaviour instead. At the same time, parents are also taught ways to positively reinforce desired child behaviour (e.g. praising them, reflecting the child’s verbalisations, being enthusiastic).
Operant behaviour therapy has more emphasis placed on teaching parents how to manage disruptive behaviour. They are taught ways to be consistent in setting limits on their child’s behaviour, as well as apply direct consequences to shape child compliance and listening skills. They are also asked to use these skills as a therapist guides them on forming a contingency management program to decrease inappropriate behaviour and increase low-occurring, alternative appropriate behaviour. For instance, parents are guided on the brief removal of attention when their child displays disruptive behaviours.
Ψ Problem-solving skills training (PSST)
PSST can also be a good complement to parental and family interventions, particularly PMT. It is a form of cognitive-behavioural therapy focusing on cognitive deficiencies and distortions displayed by children and adolescents with conduct problems in interpersonal situations.
As PSST proposes that a child’s perceptions and interpretations of environmental events result in defiant and aggressive behaviour, therapy aims to correct the child’s unhelpful patterns of thinking. To achieve this, they are taught problem-solving steps to identify thoughts, feelings, and behaviours in problem social situations. The child then learns to interpret situations differently, identify self-statements and reactions, and alter their attributions about other children’s motivations. They also learn to be more sensitive to how other children feel, to anticipate others’ reactions, and to generate appropriate solutions to social problems.
However, considering that a significant proportion of ODD cases have also have other psychological disorders like ADHD, anxiety, or depression, therapy targeted at these conditions can be administered in tandem with intervention for ODD. CBT can be an option for ODD cases with ADHD, anxiety, or depression. Stimulants can be administered for ODD-ADHD comorbid cases too. Children who are struggling with extreme emotional dysregulation might also benefit from Dialectical Behavioural Therapy.
Prognosis
The prognosis of ODD depends on various factors, such as the age of onset and quality of parent-child relationships.
Individuals who are on the early-onset pathway of ODD typically develop ODD behaviours before preschool and may continue into adolescence. Those belonging to the early-onset group have a poorer prognosis, and some develop conduct disorder (CD) and/or antisocial personality disorder (APD) in the later parts of their lives.
Individuals who are on the late-onset pathway of ODD develop such behaviours during adolescence, but there is little oppositional behaviour during early childhood. This stage of onset is often associated with family stresses (e.g. divorce), which disrupts the monitoring of the child’s activities and family management practices. The prognosis for this group is usually more positive as they would have developed a higher level of social skills and better relationships with their peers and parents in earlier childhood. The family environment plays a part in determining prognosis, with warm parent-child relationships being helpful in reducing the severity of ODD symptoms.
However, therapy, if well-planned, can lead to positive outcomes. For ODD, improving parenting practices with PMT is one of the most common targets. Other therapies and programs may be added given the child’s age and if required. For example, more family-based approaches may benefit older children. Other benefits reported from therapy include improved levels of self-esteem and the ability to build positive relationships with authority figures and peers. That said, considering that not all individuals with ODD grow out of it, it is important that interventions focuses on avoiding long-term consequences too to prevent the subsequent development of CD or APD.