Module 2: How do I recognise ODD?

Symptoms of ODD

Sometimes it is difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It is normal to exhibit oppositional behaviour at certain stages of a child’s development. Signs of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. These behaviours cause significant impairment with family, social activities, school and work. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing ODD. The DSM-5 criteria include emotional and behavioural symptoms that last at least six months. An oppositional, defiant child will often lose his temper, argue with adults, actively defy requests or rules set by adults, deliberately annoy people, and blame others for misbehaviour. He will engage in angry, violent, and disruptive conduct directed at the adults in his life — parents, teacher, physicians, and other authority figures. And he may seem to feel most comfortable in the midst of a conflict, which is upsetting and exhausting for everyone involved — even the child himself. The ODD-diagnosed child is not merely an argumentative or difficult child; he or she is vindictive, rageful and deliberately antagonistic. The symptoms of ODD may look different for girls and boys. Boys with ODD tend to be more physically aggressive and have explosions of anger while girls often lie, refuse to cooperate, and otherwise express symptoms in indirect ways. ODD is usually diagnosed in early childhood; some patients outgrow the condition by age eight or nine. For a child to be diagnosed with ODD he must have a pattern of disruptive behaviour, for at least 6 months and involving an individual who is not a sibling, including at least four symptoms from the following categories: Angry/Irritable Mood

• Often loses temper
• Is often prickly or easily annoyed
• Is often angry and resentful

Argumentative/Defiant Behaviour

• Often argues with adults
• Often actively defies or refuses to comply with requests from authority figures or with rules
• Often deliberately annoys others
• Often blames others for his mistakes or misbehaviour

Vindictiveness

• Has been spiteful or vindictive at least twice within the past 6 months
• Is often spiteful or vindictive

ODD can vary in severity:

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

For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends. Clinicians will evaluate the frequency, intensity and duration of a child’s symptoms, as well as the impairment caused by them, when making a diagnosis. This will involve taking a detailed history of the child’s behaviours in various situations. Since children with ODD may show symptoms only in one setting — usually at home — and are more likely to be defiant in interactions with adults and peers they know well, the symptoms may not be in evidence in the clinician’s office. ODD is typically diagnosed around elementary school ages.

Symptoms of ODD may also include:

• Having frequent temper tantrums
• Arguing a lot with adults
• Refusing to do what an adult asks
• Always questioning rules and refusing to follow rules
• Doing things to annoy or upset others, including adults
• Blaming others for their own misbehaviours or mistakes
• Being easily annoyed by others
• Often having an angry or resentful attitude
• Speaking harshly or unkindly
• Seeking revenge or being vindictive
• Claims not to care about losing privileges as a consequence to negative behaviour
• Ignores directives
• Manipulate adults against each other (e.g., parent and teacher)
• Refuses to go to “time out”
• Resistance to directions
• Stubbornness
• Tests limits
• Unwillingness to compromise or negotiate with adults or peers
• Often loses temper

In adults:

• Feeling mad at the world, losing temper regularly, relentlessly defending self when criticized or blamed; may present as spousal abuse or road rage

• Physical aggression
• Verbal abuse
• Explosions of anger
• Deliberately annoying others
• Vindictive behaviour
• Frequent arguments
• Defiance of rules and laws

These symptoms may look like other mental health problems. Make sure your child sees his or her healthcare provider for a diagnosis. Seek help immediately for violent or self-harming behaviour that could be dangerous.

In summary

Most symptoms seen in children and teens with ODD also happen at times in other children without it. This is especially true for children around ages 2 or 3, or during the teen years. Many children tend to disobey, argue with parents, or defy authority. They may often behave this way when they are tired, hungry, or upset. But in children and teens with ODD, these symptoms happen more often. They also interfere with learning and school adjustment. And in some cases, they disrupt the child’s relationships with others. Children who develop a stable pattern of oppositional behaviour during their preschool years are at a greater risk to have oppositional defiant disorder during their elementary school years. Children with ODD are at greater risk of developing CD and antisocial personality disorder during adulthood. ODD often precedes the development of CD, especially for those with the childhood-onset type of CD. However, many children and adolescents with ODD do not subsequently develop CD. Children with ODD may have difficulty with interpersonal relationships, particularly with their parents, teachers, and peers. There is an increased risk for the development of anxiety disorders and major depressive disorders, even in the absence of CD. Children whose profile is predominantly defiant, argumentative, and vindictive symptoms carry most of the risk for CD, whereas angry and/or irritable profiles carry most of the risk for emotional disorders. Children and adolescents with ODD are at increased risk for a number of problems in adjustment as adults, including antisocial behaviour, impulse-control problems, substance abuse, anxiety, and depression. Coexisting conditions include ADHD and mood disorders. Children with high levels of emotional reactivity and poor frustration tolerance may have problems related to emotional regulation. This emotional profile is common in children with ODD. Parents of children with ODD have been shown to exhibit less effective problem-solving skills and negative parenting styles (e.g., uninvolved, rejecting, harsh). Thus, ODD could be a child’s response to the parent-child interaction. Neurobiological markers such as skin conductance reactivity, lower heart rate, reduced basal cortisol reactivity and abnormalities in the prefrontal cortex and amygdala have been investigated in their role with ODD. No single neurotransmitter or neurologic pathway has been identified as the root cause. ODD appears to be familial, but research has yet to determine what role genetics play because studies on the genetics of the disorder have produced inconsistent results.