Chapter: Oppositional defiant disorder

Authors:

1. Dr. Satish Chandra Girimaji

Professor, Child and Adolescent Psychiatry Unit,
Department of Psychiatry,
NIMHANS, Bangalore – 560029.

2. Dr. Preeti Kandasamy

Senior Resident, Child and Adolescent Psychiatry Unit,
Department of Psychiatry,
NIMHANS, Bangalore – 560029.

Introduction

The spectrum of externalizing disorders refers to conditions that present with persistent,
easily noticeable, troublesome behaviors and include oppositional defiant disorder
(ODD), Conduct Disorder (CD) and attention deficit hyperactivity disorder (ADHD).
Research in 1970‟s has shown though these conditions overlap to some extent, they are
sufficiently distinct from each other to be considered as separate disorders.

This chapter exclusively focuses on ODD. The reason for this is that authors believe that
this condition is far more commonly encountered in child and adolescent psychiatry and
often misdiagnosed as ADHD or CD. A better understanding of this condition, its origins,
and management will be of great benefit to these children and their families. Moreover,
effective management of ODD offers a window of opportunity for prevention; as a
proportion of these children go on to develop CD, which is a far more serious disorder.

Also, this chapter will not go into great details about many theoretical issues concerning
ODD. Interested reader is referred a comprehensive chapter written by Sharan and Gupta
in the recently published Indian Psychiatric Society Task Force guidelines on child and
adolescent psychiatry.1

The major focus of this chapter is to provide a brief overview of ODD to practitioners of
psychiatry and to provide them with simple and practical guidelines and tips on effective
management of this condition.

Concept and Definition

The phenomenon of terrible toddler and teen years is well known, when children of these
ages tend to question parental authority and develop challenging behaviors. Thus in a
way, symptoms of ODD are part of natural growing up or developmental patterns.
However, it is clear that this pattern can become too frequent, too intense, and persisting
long enough, creating problems for both the child and family, when it needs to considered

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as a disorder. Thus, ODD is by and large a relational disorder, that emerges in relation to
authority figures

ODD emerged as a separate disorder with a sharp focus only in the last 2-3 decades as a
disorder distinct from other externalizing disorders such as CD and ADHD 2 and was
included first in DSM-III3. The criteria were later revised to exclude milder forms of
ODD and incorporated in DSM-IV4. By definition, ODD cannot be diagnosed
concurrently with CD, because children with CD most often have ODD symptoms, and in
addition, fulfill 2 other criteria, viz., violation of rights of others and age-appropriate
norms of behavior.

The essential features of DSM criteria for ODD are listed in Table 1. From this
discussion, it is evident that DSM-IV organizes ODD, CD, and ASPD hierarchically and
developmentally, as if they reflect age-dependent expressions of the same underlying
disorder.5 However, this developmental model appears to be more applicable to boys
rather than girls, who are more prone to develop depression, and anxiety in later years
rather than CD.6

In ICD-10,7 though coming under the general rubric of conduct disorders, ODD is
considered as a category separate from socialized and unsocialized conduct disorder, and
is defined as presence of markedly defiant, disobedient, provocative behaviors and
absence of more severe aggressive acts that violate law or rights of others such as theft,
cruelty, assault, and destructiveness.

The question remains still open whether distinction between ODD and CD is qualitative
or quantitative.

Epidemiology

Prevalence and correlates: A number of epidemiological studies focusing on ODD have

yielded a wide range of prevalence, from 2 % to 15%. These variations appear to be
related to methodological differences such as age range of sample, criteria employed,
data collection procedures (single or multi-informant) and whether functional impairment
was included in definition of casesness.8 In general, rates tend to fall with age when strict
criteria for DSM-IV are followed.

In India, in a major epidemiological study initiated by Indian Council Medial Research,

the prevalence of ODD was 0.9% in 4-16 year old children. The rates were highest in the
urban sample (2%) and least in the rural sample (0.2%).9

Comorbidity: ODD carries much less risk for comorbid disorders compared to CD. A
community sample reported that 14% had ADHD, 14% had anxiety disorders and 9% had
depressive disorders.10

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Clinical impression suggests that some or other form of developmental problems such as
intellectual impairment, specific learning disability, and speech delays appear to be
common along with ODD.

Course and outcome

Both follow-forward and follow-back studies have been done to ascertain the course of
ODD. These studies by and large indicate that significant number of children with ODD
do not go on to develop CD. However, it is clear that a sub-set of children with ODD go
on to develop CD. In one study 60 % of children with ODD went on to develop CD11,
whereas in the Great Smokey Mountain Study of a community sample, it was 40%.6

Causes

The developmental models of disruptive behavior disorders (DBD) consider ODD to be

precursor for CD. Hence, etiological research has largely focused on DBD rather than
ODD per se. So far studies exclusively focusing on ODD have suggested sharing of risk
factors between DBD in general and ODD in particular. Therefore, this section
summarizes the risk factors for DBD, which largely holds good for ODD.

It must also be emphasized that ODD is multi-factorial in origin, with several factors
interacting with each other.

Child characteristics

Biological factors

Genetic and other temperamental factors may interact with adverse social factors in the
production of oppositional defiant disorder. Infants with „difficult' temperament
characterized by impulsivity, short attention span and restlessness together with the trait
of negative emotionality such as irritability, anger, and bad moods at 3 years of age are
more likely to be referred for aggressive problems later on.12 Social anxiety on the other
hand is protective.

Other factors largely studied in children with conduct disorder show that their pulse rates
are lower; their skin conductance is less, as is their rate of adrenaline and cortisol
excretion. Some have postulated that this leads to less anxiety when taking risks,13 while
others see it as part of a wider picture of decreased central nervous system inhibition.14
There is familial clustering of certain related disorders like other disruptive behavior
disorders, attention-deficit/hyperactivity disorders, substance-use disorders and mood
disorders.

Psychological Factors
Similarities between the behavioral manifestations of insecure attachment and disruptive
behavior disorders have been noticed. ODD has been linked to the presence of anxious-
avoidant attachment.

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Aggressive children have shown deficient information processing with regard to social
stimuli as described by Kenneth Dodge. They underutilize social clues, misattribute
hostile intent, generate fewer solutions to problems, and expect to be rewarded for
aggressive responses.15

Family characteristics

Parent–child interaction patterns

Responses of parents towards children have a powerful effect on their behavior.16
Children with oppositionality are likely to be ignored when they are behaving reasonably,
but criticized and shouted at when they are misbehaving. Therefore children will behave
in whatever way necessary to gain attention as stated by the „attention rule', even though
the attention given is negative.17 This leads to a vicious cycle further worsening the
behavior.

Other behaviors by parents can raise the probability of defiance in the child. For
e.g.,repeatedly giving in to demands and tantrums of the child or giving up a request
when the child starts whining and refusing to do something. It is not to imply that parents
are solely responsible for the child-parent sequences of interactions. It is often
bidirectional and the child influences the parent as well. When parents behave
inconsistently and unpredictably the child may engage in some deviant behavior in an
attempt to elicit predictable response.

Parenting practices

Disruptive behavior disorder is strongly associated with harsh, erratic, inconsistent

discipline, hostility directed at the child, lack of warmth, and poor supervision 18. Studies
show that these factors have a causal role in initiating and maintaining the child's
disorder, and are not just a reaction to the child's behavior. However, there is also good
evidence that children with defiant behavior also elicit negative parenting.

Among the many interaction patterns, those involving coercion have received the greatest
attention. Coercion refers to deviant behavior on the part of one person (e.g. the child)
that is rewarded by another person (e.g. the parent).16 Aggressive children are rewarded
for their aggressive interactions and their escalation of coercive behaviors, as part of the
discipline practices that sustain aggressive behavior.

Parental factors that influence parenting include the following:

• Marital Discord
• Mental Illness in parent
• Social Isolation
• Poor socioeconomic status
• Poor parenting experiences as children
• Beliefs about one particular child

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Many neglectful or abusing parents experienced little good care while they were children
themselves. However, this does not mean that they are unable to become good enough
parents.

The quality of relationship between the same parent and different children in the family
varies. While some of this may be because of inherent characteristics of the individual
child, it is likely that the negative environment further added to their difficulties. Parent‟s
beliefs about what the child represents also would influence the parenting style, e.g.
mother may view her defiant child as resembling his abusive father.

Discord between parents is also associated with persistent disruptive behavior19. The
association of disruptive behavior disorder with large family size, or with broken homes
(divorce, single parenthood), seem to be mediated by parenting practices rather than by
the impact of the family size by itself.

Depression, psychoses, substance abuse or criminality in parents of children can also

affect the quality of interaction and parenting practices. It also indicates an increased
genetic risk. For instance, children of depressed mothers may have impaired cognitive
and social development.

Thus interaction patterns have significant impact on children‟s behavior. Rather than
viewing the child as being innately aggressive, he can be viewed as responding to the
immediate context he is in. Therefore changing the context offers the possibility of
changing the behavior of the child.

Summary of risk factors in family environment are shown in Table 2.

Management

Clinical evaluation

A detailed clinical evaluation should establish the presence and severity of ODD, and
comorbid conditions such ADHD, and risk factors that are operative in the given child.
Special attention needs to be given to patterns that are commonly present in these
families (Table 3). Such an evaluation includes the following:

• History from multiple sources

• Child interview and MSE
• Physical examination
• Rating scales / checklists
• Psychological testing
• Period of ward observation

History: some aspects of history-taking are as follows:

– Over many sessions
– Who referred, and why? Was the child informed?
– Full list of complaints
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 – Onset, evolution and current range of problems
– Severity of individual problems
– Functional consequences – school, peer, family life,
– Learning problems, depression, anxiety
– General intelligence, strengths, talents, interests
– School performance over time and any recent changes; School report
– Health and harmony in the family
– Daily life of the family
– Parenting and childrearing practices– nurturance, warmth, discipline,
protection, independence, quality time, does the family spend time
together?
– Parent-child interactions – how much do they sense the child‟s emotional
life? How do they respond? How do they respond to the good and bad
behaviors? Does the child confide the problems? With whom? Who is
he/she close to?
– Are there any stressors / life events – separation, loss, injury, death of
near and dear, frightening experiences, humiliating experiences
– Family‟s perception of the problems, past effort at treatment, response
– Child temperamental characteristics
– Past efforts at alleviation of problem

Assessment must ensure that comorbid disorders are not overlooked. It is common for
parents to focus on the more obvious and annoying behaviors and neglect mentioning less
conspicuous symptoms. The most frequent comorbid disorders are ADHD and emotional
disorders such as depression and anxiety disorders. Conditions such as obsessive
compulsive disorder, other anxiety disorders, tic disorders, specific developmental and
learning disorders, Asperger‟s syndrome, and mental retardation could also present itself
in the form of oppositionality and defiance. Therefore care needs to be taken to inquire
for symptoms to rule out the above disorders.

It is well established that patients with bipolar disorder have a high prevalence of DBDs
and vice versa. It has been suggested that some children with severe impulsivity,
hyperactivity, unstable mood, irritability, defiance, and conduct problems may suffer
from an atypical form of bipolar disorder.

It is also important to explore for comorbid medical disorders, especially chronic medical
conditions such as seizure disorder, juvenile diabetes and chronic renal disease. The
impact of illness on the child‟s lifestyle in terms of restrictions and privileges; parenting
practices- overprotection, permissiveness; parental anxiety, misconception, child‟s own
perception about prognosis of illness – all these may influence the child‟s behaviors.

A diagnosis of ODD should not be made when defiance and noncompliance occur only
in the course of major depression or if ODD symptoms appear when parents try to force
anxious children to confront their fears. The opposite scenario, viz., ignoring ODD
symptoms when making a diagnosis of depression or ADHD may also occur. Concurrent
diagnosis of ODD may be made if the child has shown symptoms of defiance, temper

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tantrums, etc. prior to the onset of the other disorder or if defiance persists after
symptoms of the comorbid condition have lessened. This could be very important not
only to plan management but also while psychoeducating families.

Questionnaires and checklists provide quantifiable data that can supplement information
obtained at interview. Besides general questionnaires such as the Child Behavior
Checklist, a variety of specific rating scales are available for disruptive behavior
disorders, including the Eyberg Child Behavior Inventory, the New York Teacher Rating
Scale for Disruptive and Antisocial Behavior, and the Home and School Situations
Questionnaire.

Psychometric and educational assessment should always be performed when children

show difficulties at school or if learning problems are suspected. A careful medical
history and review of systems is necessary. Physical investigations may be required to
evaluate comorbid physical illness if any. In children with comorbid medical conditions it
is also important to review the medications e.g., steroids, phenobarbitone.

Using the Rutter‟s multi-axial diagnosis will provide a better understanding about the
child‟s problems and in setting up an effective treatment plan.

Rutter‟s Multi-axial Diagnosis:

• Axis 1: clinical psychiatric syndrome

• Axis 2: specific developmental delays
• Axis 3: general intellectual functioning
• Axis 4: medical problems
• Axis 5: abnormal psycho-social situations

Interviewing techniques:

• After the initial contact, always try to speak to the child first
• Avoid child‟s presence while taking history from parents
• Interview parents together and, if necessary, separately
• Maintain privacy and confidentiality
• Encourage diary keeping; this will help in making an ABC analysis of the
problems (Antecedents, Behaviors, Consequences) and thereby make the
connections between interactions and behaviors clear. This information can
further be utilized for interventions.
• Allow parents to report problems the way they want initially; clarifications can
come later

Spend time with parents about how this situation has come about. Many families know or
have some idea that their parenting practices are not correct. It is a good idea to get them

7
to reflect on that, and also get other family members to synchronize with this approach.
This helps in getting the cooperation of the whole family. The “goodness of fit” model
could be used to explain the evolution of problem and how the parenting style currently
in place is contributing to it, rather than blaming them for the same.

With the children it is important to establish rapport, as they are often either not informed
by parents regarding the consultation or brought by force. With older children this can be
initiated by listening to the child‟s version. At times the child states ignorance of the
problem. Then talk of some of the positive things elicited from the parents and use
parental anxiety or worry over the child‟s behavior as the reason for the consultation e.g.
“your parents are upset that you are not respectful / rude ….. and they feel that they are
not handling you right, hence I need your view of this matter”. This will contextualise the
consultation. These children frequently feel quite angry inside, sometimes reasonably so.
This can be explored and acknowledged.

It is important to explain that anger is not the problem but rather the disruptive behavior
that follows and that help is being offered not for the child alone but the family as a
whole to improve the current situation.

Common difficulties in interviewing could arise due to frequent one-word

answers/nonverbal gestures even for open-ended questions. These children might view
therapist as another authority figure and test the therapist, generating negative counter-
transference. It is important to establish collaborative alliance by being patient and
supportive, without undermining parental authority.

If child present them in best light, confrontation does not help and increases child‟s
defensiveness. Indirect approach – side-stepping could facilitate interviewing. Using
hypothetical situations to elicit expected response would be better than direct
confrontation. These children will also need assistance in sequential description of events
that lead to the problem. Behavioral role-playing of anger provoking situation can also be
done. Once working agenda is set, in later sessions the child can be facilitated to reflect
on the maladaptive patterns of problem solving and its consequences.

With younger children simple paper pencil work could be tried to look for compliance
with adults out of family. Interactive patterns between child and parent can be observed
which will give clue regarding parenting style and later pointed to the parents.

Summary of child interview techniques:

• Non-judgmental, empathic and non-critical – build rapport

• Find out whether he has been told about consultation
• Get to know the child, ask about hobbies, interests, talents etc

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 • Contextualize the interview in neutral terms – problem arising out of disturbed
relationships, skill deficits, stressors, etc
• Ask about felt problems: get an idea of his/her side of the story
• Do not focus on negative behaviors unless the child is ready to do so
• Ask about emotions in general terms - things that „upset‟, times he/she feels „off-
mood‟
• Gently bring the focus on difficult behaviors, and get the child to talk about them
• 3 wish test
• Make contracts – both do‟s and don‟ts

Developing a treatment plan

The first consultation basically targets at establishing rapport to get the child back for
sessions. It also focuses on helping parents to learn that the family needs help as a system
and also to understand how the maladaptive behavior has been learnt over time and what
parents could do to help the child unlearn it. It is important to spend adequate time to
explain the principles of parent management training and their rationale so that parents
are convinced about what they are going to do. In addition to imparting skills, beliefs
about the child need to be explored and attempts made to help the parent view the child
more positively.

In case of problem behavior in hospital setting behavioral techniques such as limit setting
(clear instructions in a firm tone) can be demonstrated, while compliant behaviors could
be positively reinforced for parents to learn differential reinforcement. In case of severe
tantrum with associated self-injurious behavior (SIB) such as head-banging (especially in
preschoolers) family can be taught to properly restrain them by firmly holding them in
their lap with the face of the child turned away till they are quieted. This is required as
often family gets hassled with SIB and subsequently yield to the child‟s demands.

Some general principles of treatment of ODD are listed in Table 4.

Treatment

Parent training delivered in structured way is the most effective intervention for the
treatment of ODD. It is the most widely researched psychological intervention in child
and adolescent mental health and the effects have been found to be enduring.

Parent management training (PMT) refers to procedures in which parents are trained to
alter their child's behavior at home. It is based on extensively researched models of
parent–child interaction, social learning theories and behavioral principles.19, 20

9
It is primarily conducted with parents to help them to alter their interaction with the child
so that prosocial rather than coercive behavior is directly reinforced within the family.
The treatment includes teaching them behavioral techniques such as positive
reinforcement (e.g. the use of social praise and tokens or stars), mild punishment (e.g. use
of time out from reinforcement, loss of privileges), negotiation, and contingency
contracting. An equally important component of PMT is improvement in parent-child
interactions and relationships so that they become optimized. The sessions provide
opportunities for parents to see how the techniques are implemented, to practice using the
techniques, and to review the behavior-change programs in the home.

Most basic programs take 8–12 sessions lasting 1.5–2 hours each. However, many
parents are able to grasp the basic principles of PMT even with less number of sessions.
Interested readers could read manuals by Patterson, Barkley, Webster-Stratton &
McNeil.19-22 The following approaches are a summary of the techniques suggested by the
authors mentioned above. These have to be individualized to the given child and his or
her family.

Approach to PMT:

A Sympathetic and collaborative approach is preferred. It is important to ask about child

strengths and difficulties, understand their beliefs about the child‟s behavior and respect
parents as the expert on the child. Also, parents need to be praised for good aspects of
parenting.

Step 1: Promoting a child-centered approach

This first step in PMT is to help the parents learn to provide adequate positive attention to
the child. This is done by asking parents to spend quality time with the child, where
child is allowed to choose the activity. Parents are suggested not to guide or instruct the
child but follow the child‟s lead and only describe what the child does in a non-
judgmental manner. In short, quality time is about having a mutually enjoyable time; it
could be a shared activity such as cleaning up child‟s room, or a simple game, or cooking
or kitchen work, or even going to park, or story telling. It is preferable to use a fixed time
of the day e.g., after school or after dinner, in a ritualistic manner and the quality time
could be named after the child (Kushi‟s time) so that the child knows that the parent is
available for the child everyday consistently. It is also important for parents to verbally
express the joy at the end e.g., mama had a good time playing with Kushi.

Parents are advised to:

 Follow child‟s lead

 Describe what the child is doing
 Observe for 10-15 minutes
 Discuss experiences and difficulties with the clinician

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  Practice every day

Step2: Increasing acceptable child behavior

The parents are taught to notice and positively reinforce desired and prosocial behaviors,
however small those are - in other words, “catching them being good”, taking pleasure in
it, and communicating the same to the child – “I am happy that you did such and such a
thing”. Sometimes even an appreciative glance serves the purpose. Some families might
need reassurance as they might be apprehensive that positive reinforcement might
decrease the frequency of desired behaviors. Parents are suggested to maintain a chart of
desired behavior and grant the child star/tokens, which can be reviewed by the clinician.
Social and material reward which are appropriate and that which can be provided
immediately and consistently can be set in consensus with the child. This can be initially
facilitated by the clinician. The difference between bribe and reward is to be explained to
parents.

 Positive reinforcement of desired behavior

 Reward charting

Step 3: Setting clear expectations

Giving simple and clear instructions in a firm voice is discussed as most parents end up
commanding in an angry tone. Importance of using „Do‟ commands rather than don‟t is
also explained. (For example, saying, “switch off the TV and wash your face”, rather than
saying, “stop watching TV”). It might be difficult for parents to practice the same
initially, therefore whenever possible simple demonstration in clinic setting would help
them practice better.
 Making demands more authoritative, less nagging
 Focus on what the child should be doing, not what the parent doesn‟t want the
child to do
 When-then Commands are better than threats

Step 4: Reducing unacceptable behavior

Methods of limit setting and negative reinforcement techniques for undesired behavior
are discussed. Parents are advised not to use physical punishment with children, which
are commonly in practice. Techniques to de-escalate when trouble starts such as
disengagement on the part of parents are suggested. It is important to warn or remind the
child of the negative consequences and follow through the warning consistently rather
than merely using it as a threat.

 Consequences for disobedience

-Applied as soon as possible
-Should „fit the crime‟, meaning minor misbehaviors should have only minor

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 negative consequences
-Not be punitive on long term
-Consistency of enforcement
 Ignore negative behavior
-Can ignore harmless behavior like whining, swearing, arguing, and tantrums
-Avoid discussion and eye contact
-Stay in the room to monitor, if SIB is present
 Time out from positive reinforcement
-Put the child in a boring place – room which is bright and spacious or time-out
chair for younger children
-For a previously agreed reason
-For a short time-one minute per year of age
-Child must be calm at the end of the time out
-Time for adult to calm down too

Step 5: Strategies for avoiding trouble

Finally, parents are encouraged to plan ahead whenever problem behaviors are
anticipated, for e.g., to discuss with child the desired behavior in a marriage party or
shopping mall and to adhere to the reward agreed upon.
 Planning ahead to avoid potential situations
 Negotiating to incorporate child‟s wishes if reasonable

Step 6: identifying and rectifying long-standing maladaptive patterns

Common maladaptive patterns of interactions and relationships between children and
adults in the family are listed in table 3. Once they are identified, steps may be taken to
break these patterns at various points and put in place more adaptive and healthy patterns.

In general it is always better to start with simple targets first and move on to more and
more difficult behaviors as parents gain confidence.

Some messages for parents regarding the dos and don‟ts with defiant children have been
listed in Table 5.

Other family-focused interventions

Family therapy

In families with significant family or marital discord, family or marital therapy could be
offered. Parent training by itself appears to lead to increased marital satisfaction which in
turn probably leads to greater parental unity, which leads to better enforcement of
consequences.

Child-focused therapy

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Cognitive behavior therapy may have a larger effect with older school-aged children and
adolescents than with younger school-aged children. For younger child, CBT could
include less discussion and be more action oriented.

The focus of CBT is to alter the experiences or the interpretation of experiences

 By changing consequences – Behavioral Management
 By changing behavior and social interaction the child witnesses – modeling
 Child‟s response to events – social problem solving
 Interpretation of events - cognitive restructuring and self management
Most children deny their responsibility in the vicious cycle. But children are aware and
agree with the fact that they “end up in trouble” in many situations. It is therefore
important not to convince the child otherwise in the initial phases of therapy but focus on
establishing a working alliance with the child against common enemy – anger, and later
move on to problem solving. Initially child is helped to become more aware of the anger
experience and implement anger management techniques before it escalates. Later they
are taught constructive ways of solving a problem.

 How Anger can “get them into trouble ”

 More aware of anger experience
 2 components – cognition & physiological
 Self monitoring of physiological processes
 Recognize the maladaptive cognitive-physiological-behavior chain
 Can control - Not a Helpless victim
 Not merely triggered by environmental events
 How it is perceived & processed
 Not to misinterpret thoughts and feelings of others
 Cognitive/affective perspective taking
Problem Solving Skills Training

Children with behavioral difficulties generate fewer solutions to social problems and tend
to misinterpret positive and neutral cues from others as negative ones. They attend only
to immediate consequences and ignore longer-term ones.

Problem Solving Skills Training23,24 helps them to deal with external problems that may
provoke problem behaviors. It helps them to stop and think about the situation, and deal
the problem in a constructive way. The child is first encouraged to generate potential

13
solutions to a problem, choose the best solution and identify steps in implementing it. It
also helps the child acquire and strengthen pro-social skills. Social reinforcement is used
to facilitate skill development.

In general, the 4 aspects of cognitive therapy include sequential thinking (verbally

describing blow-to-blow account of events), means-ends thinking, problem solving
(generating several alternatives to solve a problem, looking at pros and cons of each, and
choosing the best, implementing it, and reflecting on the results), and perspective taking
(to look at events, situations and oneself from others‟ viewpoints)

Social Skills and Anger Coping Skills Training focus on modifying and expanding the
child's understanding of beliefs and desires in other.25 These children also have poor
abilities to label emotions, they show labile and intense emotions and they come from
families where there is a diminished vocabulary concerning feelings. It therefore helps in
improving the child's own emotional response. This can be done through games and
stories to help them understand the importance of rules and to recognize verbal and non-
verbal expressions of others which could further facilitate perspective taking.

Pharmacotherapy has a limited role in ODD. Co-morbid conditions may need

medication.

School related intervention:

Considering the possibility of progression of ODD to CD, the most strategic point for
intervention is during the early school years. Social skills group programmes, such as the
Dinosaur School curriculum 26 have been developed for the younger age group. These
include:

• Relaxation techniques
• Recognition of emotions and empathy training
• Social problem-solving skills
• Anger management
• Friendship skills
• Communication skills
– how to ask questions and tell something
– how to listen carefully
– why it is important to speak up about something that is bothering them
– understand how and when to give an apology or compliment
– learn how to enter into a group of children who are already playing
– how to give suggestions rather than commands
– friendship skills.
• Managing in the classroom setting.
- pairing the index child with another, low-risk child from the class

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Conclusion

The importance of ODD lies in the fact that it is distinct from ADHD and CD, and that it
is a significant risk factor for CD, which is more serious disorder. ODD by and large
develops in relation to child‟s response to authority figures such as parents, though there
are other risk factors such as difficult temperament. Evaluation of children with suspected
ODD should focus not only on establishing the diagnosis, but also on comorbidities and
on mapping all the predisposing, precipitating, and maintaining factors. This will serve as
good base for planning intervention, which is mostly psycho-social in nature.

PMT is the most effective approach to management, and there is reason to believe that
the effects may last beyond the period of intervention. Child focused therapy such as
cognitive behavior therapy is more applicable to older children and adolescents. Family
therapy and school-based interventions are other forms of therapy that are employed
whenever needed. Medications have a role only if there are comorbidities that need
pharmacological intervention.

References

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S (Eds), Child & Adolescent Psychiatry Taskforce on Clinical practice guidelines
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2. Lahey, B.B., Applegate, B., Barkley, R.A., Garfield, B.D., McBurnett, K.,
Kerdyk, L., et al. (1994). DSM IV field trials for Oppositional Defiant Disorder
and Conduct Disorder in children and adolescents. American Journal of
Psychiatry, 151, 1163–1171.

3. American Psychiatric Association. (1980). Diagnostic and statistical manual of

mental disorders (3rd edn). Washington, DC: American Psychiatric Association.

4. American Psychiatric Association. (1994). Diagnostic and statistical manual of

mental disorders (4th edn). Washington DC: American Psychiatric Association.

5. Moffitt TE et al. Research Review: DSM-V conduct disorder: research needs for
an evidence base. Journal of Child Psychology and Psychiatry 49:1 (2008), pp 3–
33.

6. Rowe, R., Maughan, B., Pickles, A., Costello, E.J., & Angold, A. (2002). The
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Tables:

Table 1: DSM-IV Criteria for Oppositional Defiant Disorder

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

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Table 2: Summary of Risk factors in Family environment

1. Childrearing practices – problems in “goodness of fit” between temperament and

parenting
2. Inconsistent, inadequate, ineffective disciplining patterns
3. Inappropriate reinforcing patterns
4. Lack of adequate supervision
5. Punitive parenting
6. Parental discord – child as the presenting symptom of parental or family discord
7. Inconsistencies due to multiple parenting figures - grandparents vs parents
8. Special position of the child
9. Parental beliefs about the child
10. Sibling rivalry

Table 3: Common maladaptive patterns in families of children with ODD

Pattern 1: tolerating the child for long periods with building up of inner tension and
then suddenly beating the child for a minor misbehavior

Pattern 2: Polarization of rearing functions – father being responsible for authority

and mother for love – mother hides misbehaviors from father, fearing that he will
badly beat up the child. Child well-behaved in father‟s presence and moment he
leaves, starts troubling mother

Pattern 3: overindulgence with child in younger years and later trying to enforce
discipline to which the child does not comply

Pattern 4: child with ADHD blamed for his symptoms, and over time develops ODD
symptoms

Pattern 5: grandparents not allowing parents to set limits for child; child gets his
unreasonable demands fulfilled by grandparents – inconsistent disciplining across
generations

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Table 4: Some general principles of treatment of ODD
1. The main aim of treatment is to increase compliance, make the child more
cooperative and better accepted.
2. Structured psychosocial intervention is the only effective treatment available.
3. Treatment should involve the both parents; improving parenting skills and parent-
child interactions are the main goals.
4. Comorbid conditions (ADHD, depression) are to be identified and treated.
5. Parental depression, psychosis, substance abuse, marital discord needs to be
explored and addressed.
6. It is important to build on children's and families' strength in addition to focusing
on their problems.
7. De-stressing the family should be a necessary initial step.
8. Impairment in other several aspects of functioning, e.g., learning difficulties, are
to be effectively intervened. If necessary school system needs to be involved to
the extent that is required for the given child‟s problem.

Table 5: Some messages for Parents of children with ODD

1. Catch the child being good and appreciate
2. Spend Quality time with the child
3. Give Clear do and don‟t commands
4. Avoid bribing, pleading, false threats, false promises to obtain compliance
5. Give warning before enforcing discipline
6. Ignore minor transgressions
7. Learn to be firm without being angry
8. Star-charting of child‟s specified behaviors for contingency management
9. Children need appropriate authority in the form of limits
10. Set clear limits and enforce
11. Do not put up with child‟s aggressive behaviors
12. Learn to negotiate with child
13. Avoid excessive and indiscriminate physical punishment
14. Use “if…then….”statements rather than “I will give you this and you promise me
that you will behave better”
15. Avoid discussing child behavior issues in front of him with others

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