Oppositional Defiant Disorder (ODD)

What Causes Oppositional Defiant Disorder?

The cause of ODD is not yet known. However, some scientists believe that the disorder occurs when a child develops an atypical attachment to a parent or other adult figure and doesn’t learn to be independent. This theory suggests that the problematic behavior is actually typical developmental defiance that lasts longer than it should.

Other scientists believe ODD happens when a child is disciplined with negative reinforcement. The negative discipline gives the child attention for problematic behavior and encourages more of the behavior.

Regardless of the root cause, some factors seem to put a child at increased risk for ODD. Possible risk factors include:

• Genetics. Children with a family history of mental illness are at increased risk of ODD.
• Environment. Children exposed to a chaotic home life, substance abuse, or inconsistent discipline from parents are more likely to develop ODD.

Is Oppositional Defiant Disorder Hereditary?

Children with a family history of mental illness are more likely to have ODD, suggesting that the disorder may have a genetic component. However, no specific gene or genes have been associated with ODD. The condition could likely be caused by a combination of genetic predisposition and environmental factors.

How Is Oppositional Defiant Disorder Detected?

ODD is usually diagnosed by age 8, although symptoms might not appear until later in childhood. Early warning signs can include:

• Persistent temper tantrums
• Persistent irritability or anger
• Defiance of requests
• Disregard for rules and boundaries
• Being annoying on purpose
• Lying and refusing to take responsibility
• Physical aggression
• Vindictive behavior

How Is Oppositional Defiant Disorder Diagnosed?

Diagnosis of ODD begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. After these exams, if the doctor suspects that ODD or another mental disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.

Diagnostic steps may include:

• A physical exam. This exam will rule out physical conditions that could be causing the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for ODD in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for ODD include:

• The child exhibits at least four symptoms from three categories: angry/irritable mood, argumentative/defiant behavior, and vindictiveness.
• The symptoms have lasted for at least six months.
• The symptoms cause distress in the child or others.
• Another disorder does not explain the symptoms.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Oppositional Defiant Disorder Treated?

There is no cure for ODD. However, early intervention may help control the disorder’s symptoms and prevent future complications. Psychotherapy is the most common course of treatment. Medications usually aren’t used to treat ODD, but drugs may help symptoms of other co-existing disorders, such as ADHD or anxiety.

Types of therapy commonly used to treat ODD include:

• Cognitive-behavioral therapy
• Family therapy
• Peer group therapy
• Parent training
• Social skills training

How Does Oppositional Defiant Disorder Progress?

Without treatment, ODD sometimes evolves into more severe disorders, including conduct disorder (in children) and antisocial personality disorder (in adults). These disorders involve persistent disregard for rules and laws and a lack of concern for others. They can have serious consequences for the health and well-being of the sufferer and those around them.

Even when it doesn’t escalate to these other disorders, untreated ODD can produce complications. Long-term adverse effects of ODD can include:

• Depression
• Unemployment or homelessness
• Financial difficulties
• Legal difficulties
• Social isolation
• Lack of healthy interpersonal relationships
• Substance abuse
• Suicide attempts

How Is Oppositional Defiant Disorder Prevented?

Given that the cause of ODD is unclear, no definitive strategy for prevention is known. However, early intervention when a young child shows symptoms of ODD can help prevent worse problems in the future. Older children can benefit from psychotherapy and intervention programs at school. In all cases, parent involvement and training are essential for helping children cope with ODD.

Oppositional Defiant Disorder Caregiver Tips

Many people with oppositional defiant disorder also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the disorders commonly associated with ODD:

• Sixty percent of people with attention-deficit/hyperactivity disorder (ADHD) also have ODD.
• Many people with ODD also suffer from depression or anxiety disorders.
• Alcoholism and substance abuse are commonly co-morbid with ODD.
• People with ODD are at increased risk of developing more severe behavioral disorders such as conduct disorder and antisocial personality disorder.

Oppositional Defiant Disorder Brain Science

Researchers have attempted to find neurological explanations for problematic behaviors in people with ODD and the similar conduct disorder. Studies have found some differences in the way the brains of people with these disorders function in comparison to healthy brains. The key differences seem to lie in three different areas, including:

• The brains of people with ODD show an unusually low reaction to negative stimuli, stress, and fear, suggesting they do not respond typically to punishment.
• Their brains have lower than expected activity in the areas involved in processing incentives, suggesting that they are not as likely to be motivated by rewards.
• They showed impairment in the parts of the brain that control executive function. These areas help people gain rational control over their emotions, an ability that might be limited in people with ODD.

Oppositional Defiant Disorder Research

Title: Addressing Depression and Positive Parenting Techniques (ADAPT) (ADAPT)

Stage: Not Yet Recruiting

Principal investigator: Brendan F. Andrade, PhD

Centre for Addiction and Mental Health

Toronto, Ontario

Children with emotional and behavioral difficulties (EBD) experience disproportionate social, family, and academic impairment and have two to five times the increased likelihood of developing an anxiety disorder, mood disorder, or other severe mental illness in adolescence and adulthood. There is a close association between parental depression and the emergence and maintenance of childhood EBD that is likely bidirectional. Parents of children with EBD experience disproportionate stress, increasing their risk for depression; yet chronic and untreated parental depression is associated with the emergence of child EBD in the first place. Therefore, designing targeted and effective assessment and treatment for parents of children with EBD that consider the parents’ depression is necessary. Of pressing concern, first-line Behavioral Parent Training (BPT) treatments for parents of children with EBD are not tailored to parents’ mental health needs, which may be why upwards of 40 percent of parents and children treated in these programs fail to sufficiently benefit. Existing research highlights emotional and cognitive factors that may differentiate depressed parents from non-depressed parents that may be treatment targets to improve outcomes for depressed parents and children.

The main aim of the proposed project is to evaluate the feasibility and acceptability of a novel targeted treatment for depressed parents of children with EBD, along with adherence to study protocol. In addition, the investigators will use the pilot study results to make key modifications to study procedures and the treatment itself to increase the success of a future randomized controlled trial (RCT) to test treatment efficacy.

Title: Virtual Reality to Improve Social Perspective Taking

Stage: Recruiting

Principal investigator: Tom A. Hummer, PhD

Indiana University School of Medicine

Indianapolis, IN 

Oppositional defiant disorder (ODD) and conduct disorder (CD), collectively known as disruptive behavior disorders (DBDs), involve persistent physical or verbal confrontations, antisocial behavior, and emotional outbursts. Despite a range of biological and environmental risk factors for DBD, social-cognitive impairments are a common link, and improving these deficits should be beneficial for all patients with DBD.

Children and adolescents with DBD have deficits in social perspective-taking that contribute significantly to these behavior problems. Perspective-taking is the ability to perceive the world from another person’s point of view, including making inferences about the capabilities, feelings, and expectations of others. Perspective-taking requires substantial motivation and cognitive resources and can be challenging to achieve, particularly for children. A failure to understand or value another person’s perspective inhibits helping behavior without clear, direct benefits. Perspective-taking skills are related to empathic concern, which encompasses feelings of sympathy and concern for unfortunate others, and theory of mind, the ability to accurately infer others’ mental states, such as intentions. Negative attribution biases are more likely in individuals with poor theory of mind. Thus, improving children’s perspective-taking skills should allow them to understand a counterpart’s thinking and intentions better, increasing empathic concern and reducing hostile attribution biases-and, therefore, improving the likelihood that prosocial behavior occurs.

In the brain, perspective-taking engages circuitry underlying empathic concern and theory of mind. In fMRI studies, imagining pain to the self or other, often in conjunction with images depicting painful scenarios, engages the brain’s salience network. Dorsal ACC and bilateral anterior insula, the regions most commonly activated in response to others’ pain, also show strong responses to self-perspective pain. However, in youth with DBD, there is a decreased response to other-perspective pain in dACC and anterior insula, despite no change or a heightened response to self-perspective pain.

Software interventions have shown some promise to improve perspective-taking. In particular, VR has exciting therapeutic potential to address perspective-taking deficits because it provides naturalistic yet controlled environments where users can experience interactions from multiple viewpoints. In addition, VR interventions typically provide a better generalization to real-world behavioral changes compared to traditional methods. Finally, VR has an advantage over traditional interventions because it provides an embodied experience that is a middle ground between therapy room settings and the real world (e.g., school, home) where problematic behaviors occur.

The investigators will build upon a current VR design using an Oculus Quest virtual reality headset in this investigation. After experiencing virtual interpersonal conflicts in a school cafeteria setting, participants will re-experience scenarios in one of two manners: an enriched perspective from the virtual counterpart’s point-of-view, with internal dialogue and background information; or a control perspective, which replays the original point-of-view. During this proof-of-concept phase, the primary target is social perspective-taking. The investigators will assess the functional engagement of this target by quantifying (1) the ability to recognize and understand the virtual counterpart’s perspective; and (2) the neural response (in pain circuitry) to pain experienced by the virtual counterpart, a common marker for perspective-taking that is abnormal in DBD.

Title: SKIP for PA Study: Team and Leadership Level Implementation Support for Collaborative Care (SKIPforPA)

Stage: Not Yet Recruiting

Principal Investigator: Renee M. Turchi, MD, MPH

Drexel University

Philadelphia, PA 

This study is a randomized, hybrid type 3 effectiveness-implementation trial to support the adoption of a chronic care model (CCM)-based intervention in pediatric primary care settings by testing the impact of implementation strategies directed towards the provider care team (TEAM) or practice leadership (LEAD) level. The treatment investigators seek to deliver is Doctor Office Collaborative Care (DOCC), an evidence-based intervention for managing child behavior problems and comorbid ADHD. The implementation strategies being tested to enhance DOCC uptake include TEAM coaching/consultation strategies, which will be delivered to care team providers and target provider competency to deliver DOCC, and LEAD facilitation strategies, which will be delivered to practice leaders and target organizational support of DOCC delivery. These multi-level implementation strategies have not been formally evaluated to learn about their separate and combined effects in any randomized clinical trial conducted in pediatric primary care. Such information is needed to optimize our approaches to promoting the implementation of a CCM-based intervention in pediatric practice.

The statewide sample includes 24 primary care practices from the Medical Home Program of the Pennsylvania Chapter of the American Academy of Pediatrics. After standard training in the DOCC EBP, all practices will be randomized to one of four implementation conditions: 1) No TEAM or LEAD (ongoing technical support only); 2) TEAM implementation; 3) LEAD implementation, or 4) TEAM+LEAD implementation. TEAM and LEAD implementation will be delivered via videoconference (or possibly in person) on a graded schedule. Care teams will deliver DOCC to 25 children who meet a clinical cutoff for modest behavior problems and their caregivers. Investigators will collect practice/provider measures from enrolled practice staff (0, 6, 12, 18, 24 months) and caregivers over several time points (0, 3, 6, 12 months) to support all analyses evaluating implementation and treatment outcomes, mediation, and moderation. By proposing one of the first large pragmatic pediatric trials of a CCM-based evidence-based intervention to address these aims in response to RFA-MH-18-701 and the NIMH’s Strategic Plan (4.2), this research will advance the implementation science knowledge needed to optimize promising strategies for promoting the delivery and scale-up of DOCC in a pediatric medical home.