Those who work with children and adolescents in any capacity, recognize both the wonder and challenge of this clinical population. Whereas an adult can verbalize his or her needs and emotions, children do not possess this skill, and many adolescents internalize their pain. Children and adolescents express themselves through their behavior, in both positive and negative ways. In a therapeutic setting, a professional must rely on observation, interpretation, and reports from authority figures in order to assess and treat a young client. Children, unlike most adults, are brought into counseling by another figure – mainly, by concerned parents, teachers or representatives from Children and Youth.
A MFT referral for is typically precipitated by negative, disruptive or possible self-injurious behavior, and concerned parents who most likely feel completely powerless and unable to control the behavior and negative, angry attitude of their child. Defiance and disruptive behavior is common for very young children (think of a two year old refusing to go to sleep at night), as is acting out for older children and adolescents. However, when this behavior is pervasive, persistent, and lasts for a determined period of time, the child may meet the criteria for the diagnosis of Oppositional Defiant Disorder (ODD).
This disorder can permeate every facet of the child’s life – his or her family structure and stability, academic performance, peer relationships, and so on. Fortunately, through counseling, education, and behavior modification, there is a chance for an ODD child and his or her family to effectively cope with and learn to manage this disorder.
“In general, noncompliance is the most frequent presenting problem for children referred for mental heath services and is the most frequent ‘deviant’ behavior seen among non-referred children” (Schroeder & Gordon, 1991, p. 281). As mentioned above, all children and adolescents demonstrate defiance – the key is to consider the current developmental stage, and to determine if the child is in a “phase.” Bustamante (2000) explains that oppositional states are normal, and experienced by all children at one time or another. They can be explained by natural growth, unreasonable expectations, and trauma.
However, “openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when if affects the child’s social, family, and academic life” (American Academy of Child and Adolescent Psychiatry [AACAP], 1999, ¶ 1).
According to Chandler (2003), ODD is the most common psychiatric problem in children. Prevalence rates vary due to population samples and information-gathering methods, but it is estimated that five to 15 percent of all school-age children have ODD (AACAP, 1999). A child with ODD almost always comes to clinical attention at the request of a parent or teacher who is frustrated with the child’s behavior (Kronenberger & Meyer, 1996).
COMMON BEHAVIORS, MOODS AND ATTITUDES OF THE ODD CHILD
Before examining the formal diagnostic criteria for ODD, it is important for parents and authority figures to have objective measures for the child’s behavior. Barkley and Benton (1998) consider a child to be oppositional and defiant when he or she shows a pattern of failing to comply with a request within one minute, not finishing what is asked, and violating previously taught rules of conduct. To help parents recognize the vast array of ODD behavior, Barkley and Benton (1998) recommend looking for the following tendencies in the child:
Change from content to angry in a second. Fight the inevitable, such as going to bed, going to school, or coming to the table at mealtimes, even when they know that eventually they’ll be forced to comply. Insist on having their own way when playing with friends. Argue as vociferously about performing the little tasks as the big ones, as long as it’s something they don’t want to do. May lie or cheat to escape responsibility for their actions. Like to ‘get back at’ people instead of forgetting about minor slights. Are easily irritated. May seem hostile toward particular people for no obvious reason. Ignore commands. Deliberately disobey their parents and sometimes other adults. Break rules indiscriminately. Badger or taunt people, apparently for fun. Resist interrupting play. Seem to have a chip on their shoulder. Can’t control their temper as well as other children of their age. Often break or destroy things out of anger. May indulge in self-destructive behavior such as holding their breath or banging their head. Show little respect or regard for their parents, especially Mom. (p. 10)
ODD behaviors are manifested in different ways, depending on the age of the child. Preschoolers demonstrate frequent and severe temper tantrums, do not tolerate frustration, and have difficulty delaying gratification – kicking, thrashing, power struggles and destruction of property are common (Kronenberger & Meyer, 1996). Older children use more “sophisticated” means to produce a power struggle, such as talking back, refusing to comply in a passive-aggressive manner, and holding their parents “hostage” by use of threats to destroy property or become physically aggressive (Kronenberger & Meyer, 1996). Once the above behaviors and characteristics are recognized as being developmentally atypical and not components of an adolescent phase, it is crucial for the family to seek out a professional to make a formal diagnosis and assessment, so that the process of therapy can begin.
DIAGNOSTIC CRITERIA
According to the American Psychological Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the following criteria must be met in order to diagnose Oppositional Defiant Disorder (2000):
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present: (1) often loses temper (2) often argues with adults (3) often actively defies or refuses to comply with adults’ requests or rules (4) often deliberately annoys people (5) often blames others for his or her mistakes or misbehavior (6) is often touchy or easily annoyed by others (7) is often angry and resentful (8) is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
D. 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. (p. 102)
Establishing a history of the ODD’s progression is very important in making an accurate diagnosis, according to Bustamante (2000). “The classic ODD syndrome has become evident by middle elementary school, and certainly by early adolescence. The syndrome unfolds gradually over months and sometimes years” (Bustamante, 2000, p. 112).
THE COURSE, ETIOLOGY, AND CO-MORBIDITY FACTOR OF ODD
ODD usually becomes evident before the child is eight years old, with symptoms beginning to appear between ages one and three (Chandler, 2003). “Onset is typically gradual, usually occurring over the course of months or years. In a significant portion of cases, ODD is a developmental antecedent to Conduct Disorder (CD)” (APA, 2000, p. 101).
ODD and CD are referred to as Disruptive Behavior Disorders, and are often combined for research, theory, and treatment approaches (Kronenberger & Meyer, 1996). The older a child gets, the greater number of oppositional symptoms displayed. ODD is more prevalent in males before puberty, but the rates appear to be equal afterwards (APA, 2000). Symptoms are similar in each gender, “except that males may have more confrontational behavior and more persistent symptoms” (APA, 2000, p. 101).
In terms of etiology, “there is mounting evidence that parental psychopathology, family problems, and behavioral factors are responsible for the oppositional, noncompliant, negative and defiant behaviors typical of ODD” (Kronenberger & Meyer, 1996, p. 81). In terms of parents of boys referred to clinics for antisocial or aggressive behavior problems (Frick et al, 1992), high rates of Antisocial Personality Disorder, substance abuse, and maternal depression have been found. Frick et. al. (1992) also review parenting styles: “Two of the strongest correlates to severe conduct problems in children were poor parental supervision and lack of parental involvement in their child’s activities . . . Harsh or abusive forms of discipline and inconsistent discipline have also been linked to severe child conduct problems” (p. 49). ODD has a high rate of co-morbidity – it is rare for a clinician to see a child with this single diagnosis (Chandler, 2003). A child diagnosed with Attention-Deficit/Hyperactivity Disorder (AD/HD) will also have a diagnosis of ODD 30 to 40 percent of the time (Chandler, 2003). Other common combinations with ODD include Mood Disorders and Anxiety Disorders (Chandler, 2003), and Learning Disorders and Communication Disorders tend to be associated with ODD (APA, 2000).
ASSESSMENT CONSIDERATIONS AND METHODS
A useful assessment should have clinical utility, providing an “accurate estimate of the type and extent of ‘problems’ or ‘areas of concern’ prior to any intervention and give direction to effective treatment options” (Christophersen & Mortweet, 2001, p. 22). Assessment includes several functions, such as determining the problem behaviors, determining the child’s and family’s history of relevant problems, formulating a treatment plan and altering it as necessary, and evaluating the long-term outcomes of treatment (Christophersen & Mortweet, 2001). An accurate diagnosis and effective treatment plan require a multi-rater/multi-method assessment (Kronenberger & Meyer, 1996). Christophersen and Mortweet (2001) suggest asking parent(s) and child for a thorough family history, including questions about disruptive behavior problems in both biological families, information from parent(s) and child about situations in which current behavioral problems are manifested, what precedes these episodes, characteristics of all family members that may be important contributors to the problem, and consequences/reactions that may be maintaining or exacerbating problem behaviors. Along with the interview, there are several broad assessment strategies that may be used.
Cognitive Assessment
“As a group, CD/ODD children are more likely to suffer from academic deficiencies than are their normal peers. Because poor school performance is characteristic of CD/ODD children, it is important to assess intellectual deficits or learning disabilities that may be masked by oppositional behavior” (Kronenberger & Meyer, 1996, p. 90). Tests such as the WISC and IQ may be helpful in determining intellectual ability and functioning.
Psychological Assessment
The Rorschach, TAT and MMPI are tests that may assist diagnosis, if the child is willing to cooperate. Kronenberger & Meyer have recognized that “psychological test responses in children with CD/ODD often are characterized by aggressiveness, alienation, anger and/or socialization problems” (1996). The authors suggest these test patterns may alert the clinician to “potential problems, situational interpretations, or personality predispositions that may put the child at risk to misbehave or to behave impulsively” (1996).
Behavioral Assessment
Using checklists such as the one provided in the above section “Common Behaviors, Moods and Attitudes of the O.D.D. Child,” parents and teachers can report to clinicians a child’s presenting difficulties and disturbances. “Almost all child behavior checklists include items assessing aggressive, oppositional, rule-breaking and antisocial behaviors” (Kronenberger & Meyer, 1996, p. 92). These checklists can also help distinguish between ODD behaviors and the more severe CD behaviors. Family Assessment The family is of utmost importance in the assessment and treatment of ODD. Kronenberger & Meyer offer the following (1996): Based on research indicating that inconsistent supervision and lack of household rules may contribute to CD/ODD, the FES Organization subscale is likely to show deficits in CD/ODD families. The Controlling factor and Control subscale, however, may be elevated, especially in families with a strong hierarchy and harsh discipline . . . The Supportive factor and its components, on the other hand, may show deficits in the CD/ODD family. (p. 93) A history of marital problems may be present, as well as a history of mood disorders, AD/HD, ODD, CD, Antisocial Personality Disorder, and substance abuse (Bustamante, 2000). Syndrome-Specific Tests There are structured interview formats for children with ODD and Behavioral Coding Systems available to clinicians (Kronenberger & Meyer, 1996). Also useful are several inventories (such as the Social Situations Analysis) which may be completed by the parent(s) or child.
TREATMENT APPROACHES AND OPTIONS
According to the AACAP (1999), treatment and interventions for ODD may include the following: Parent Training Programs to help manage the child’s behavior, Individual Psychotherapy to develop more effective anger management, Family Psychotherapy to improve communication, Cognitive-Behavioral Therapy to assist problem solving and decrease negativity, and Social Skills Training to increase flexibility and improve frustration tolerance with peers. (¶ 5) The most common and effective treatments for negative and disruptive behaviors are parent-child interaction training programs, and when these are combined with other specifically targeted therapies, the rate of success is increased (Schroeder & Gordon, 1991). More than anything, parents of the ODD child need support and guidance, and the AACAP (1999) offers parents the following suggestions:
Always build on the positives - give the child praise and positive reinforcement when he shows flexibility or cooperation.
Take a time-out or break if you are about to make the conflict with your child worse, not better.
This is good modeling for your child.
Support your child if he decides to take a time-out to prevent overreacting.
Pick your battles.
Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do.
Set up reasonable, age-appropriate limits with consequences that can be enforced consistently.
Maintain interests other than your child with ODD, so that managing your child doesn’t take all your time and energy.
Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.
Manage your own stress with exercise and relaxation.
Use respite care as needed.
Structural family therapy protects the integrity of the family and improves family functioning and safety by helping them identify and alter maladaptive family systems and interactional processes (Christophersen & Mortweet, 2001).
When combining behavior management training, problem-solving and communication training, and structural family therapy (Christophersen & Mortweet, 2001), the results have included “significant reductions in negative communications, conflicts, and anger during conflicts, as well as improved ratings of school adjustment, reduced internalizing and externalizing symptoms, and decreased maternal depressive symptoms” (p. 34).
In their work Your Defiant Child: 8 Steps to Better Behavior, Barkley and Benton (1998) have developed an easy to follow parent-child interaction training program. These steps, based on teaching parents new ways to think, act, and relate to their children, enable parents to understand and implement the principles behind better behavior. Barkley and Benton’s steps are outlined and summarized below.
Step 1: Pay Attention – Deep down, even the most defiant child wants parental approval. A parent’s first job is to restore a child’s belief that approval is within their reach. This step teaches parents how to balance negative attention given to the child with positive appreciation, by taking time out of each day to simply be together. (p. 84)
Step 2: Get Peace and Cooperation with Praise – Now that the child feels more confident with parental approval, respond to the child’s obedience and cooperation with acknowledgment, appreciation and praise. Instead of only focusing on the negative, point out the positives of the child’s behavior. (p. 85)
Step 3: When Praise Is Not Enough, Offer Rewards – Most children with ODD present behavior that is too severe to be handled with praise alone. Here, the parent’s job is to make what the parent wants from the child more attractive than what the child wants (for example, completing homework assignments). To do this, offer future rewards for present compliance. (p. 85)
Step 4: Use Mild Discipline – Time-Out and More – Once positive reinforcement methods are in place, the parent can begin to reintroduce mild forms of punishment, such as reducing the rewards earned for good behavior (for example, if a child earned an extra hour of TV time, reduce it by one-half hour). At this step, parents can begin – slowly – to utilize time-outs, which is a benign but very effective because it immediately removes the child from what he or she wants to do. (p. 86)
Step 5: Use Time-Out with Other Misbehavior – The step for refining the time-out method: expand its use to a few additional misbehaviors. (p. 86)
Step 6: Think Aloud and Think Ahead: What to Do in Public – Before leaving home, establish a plan for managing any misbehavior, share this with the child, and then follow this plan in public. Activities – such as drawing in the car, helping with groceries, etc. – that keep the child busy while accentuating his or her positive attributes can offer boosts to the child’s self-esteem. This can also work to keep them busy at home during a transition in household activities. (p. 87)
Step 7: Help the Teacher Help Your Child – For school-age children, a teacher is often willing to collaborate with parents if they feel it will make classroom behavior more manageable. A daily planner and assignment sheet can keep parents and teachers on the same page, and offer incentives for the child. (p. 87)
Step 8: Moving Toward a Brighter Future – The principles of this program should be permanently incorporated into the parenting style, but things such as incentive programs can be slowly phased out. This step teaches parents ways to monitor and respond to progress or regression, in both the children and the parents, and how to anticipate problems such as new social situations and changes in work schedules. (p. 88)
Sometimes, the above-mentioned treatment approaches are not enough to manage the symptoms of ODD. In these instances, medical interventions should be considered. The three main reasons to consider medication are the presence of medically treatable co-morbid conditions (such as AD/HD, depression, tic disorders, seizure disorders and psychosis), if non-medical interventions are not successful, and if the symptoms are very severe (Chandler, 2003).
If the child has any diagnosis besides ODD or CD, first try medications for that condition. If that fails, or if they do not have a co-morbid disorder, the first class of medications is those used for violence, oppositionality, and aggression (Chandler, 2003). These include atypical anti-psychotics such as Risperidal, Zyprexa and Seroquel. Older mood stabilizers such as Epival and Lithium are the second choice (Chandler). And when these don’t work, even when added to atypical anti-psychotics, a third option is the category of new mood stabilizers, such as Gabitril, Neurontin and Topamax (Chandler).
“In some cases the child’s oppositional or antisocial behaviors are of sufficient severity or threat to warrant more intensive interventions” (Kronenberger & Meyer, 1996, p. 108). The most common of these interventions are hospitalization, partial hospitalization such as day programs, and residential placement. These forms of interventions are the last resort for families and treating clinicians.
POTENTIAL OUTCOMES FOR CHILDREN WITH ODD
Chandler (2003) has identified four possible paths a child with ODD will take.
Some children can “outgrow” ODD – “about half of children who have ODD as preschoolers will have no psychiatric problems at all by age eight” (p. 5).
For others, ODD may turn into something else, such as CD – which usually happens after three or four years of ODD, or not at all – or lessen while another diagnosis dominates (such as AD/HD).
A third path is for the child to continue to have ODD without anything else, although this is rare.
And finally, a child can “continue to have ODD but add on co-morbid anxiety disorders, co-morbid AD/HD, or co-morbid depressive disorders” (p. 5). This translates into importance to watch for signs of mood and anxiety disorders as the ODD child grows older.
Disruptive Behavior Disorders such as ODD are very common and often the reason families seek treatment. They can destroy parents must faster than the children that present them. With early and consistent interventions that address all aspects of the behavior, educate the family, and encourage cooperation, there is hope for families and clinicians to manage this disorder.
References
American Academy of Child and Adolescent Psychiatry (1999). Children with Oppositional Defiant Disorder. Retrieved May 31, 2003, from http://www.aacap.org/publications/factsfam/72.htm American Psychological Association. (2000).
Diagnostic and statistical manual of mental disorders (4th edition, text revision). Washington, DC: The American Psychiatric Association.
Barkley, R. A. & Benton, C. M. (1998). Your Defiant Child: 8 Steps to Better Behavior. New York, NY: The Guilford Press.
Bustamante, E. M. (2000). Treating the Disruptive Adolescent: Finding the Real Self Behind Oppositional Defiant Disorders. North Bergen, NJ: Book-mart Press, Inc.
Chandler, J. (2003). Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in Children and Adolescents: Diagnosis and Treatment. Retrieved May 31, 2003, from http://www.klis.com/chandler
Christophersen, E. R. and Mortweet, S.L. (2001). Treatments That Work With Children: Empirically Supported Strategies for Managing Childhood Problems. Washington, DC: The American Psychological Association.
Frick, P. J., Lahey, B. B., Loeber, R., Stouthamer-Loeber, M., Christ, M. A., & Hanson, K. (1992). Familial risk factors to oppositional defiant disorder and conduct disorder parental psychopathology and maternal parenting. Journal of Consulting and Clinical Psychology, 60, 49-55.
Kronenberger, W. G. & Meyer, R. G. (1996). The Child Clinician’s Handbook. Needham Heights, MS: Allyn & Bacon. Schroeder, C. S. & Gordon, B. N. (1991). Assessment and Treatment of Childhood Problems: A Clinician’s Guide. New York, NY: The Guilford Press.
