ODD in Children: A Parent’s Behavior Management Guide

Oppositional defiant disorder (ODD) is characterized by persistent patterns of anger and irritability, argumentative behaviors, and vindictiveness toward others. ODD is listed as a childhood disorder but it commonly persists into adult life and continues to be highly impairing with symptoms impacting a person’s functioning and causing significant distress to family, friends, and educators. ODD is also commonly associated with other disorders, especially ADHD.

Families impacted by ODD can often feel alone and unsupported in their struggles. They might even wonder if treating the disorder and other existing conditions is possible under the circumstances of extreme defiance. Interventions are indeed available for ODD in children, but it is critical for families to understand the facets of the disorder, including how disruptive behaviors actually play out in daily life, and their potential impact on family dynamics and even quality of treatment and care.

What is ODD?

ODD is listed under the DSM-5’s disruptive behavior disorders category. To merit a diagnosis, a patient must exhibit at least four of the symptoms outlined below that demonstrate a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness for at least six months with at least one individual who is not a sibling:

Anger or Irritable Mood

1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful

Argumentative or Defiant Behavior

4. Often argues with authority figures or, for children and adolescents, with adults
5. Often actively defies or refuses to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or misbehavior

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months

[Self Test: Oppositional Defiant Disorder (ODD) in Children]

These behaviors are associated with distress in others but the individual usually does not see their behaviors as wrong, unjustified, and harmful to others. The behaviors can also severely impact social, educational, and familial areas of functioning.

While ODD has an estimated prevalence of 10 percent, it occurs in about half of children with ADHD, making it one of the most common disorders occurring with ADHD¹.

ODD in Children: The Reality

The DSM-5’s description of ODD (as with many other disorders) fails to truly capture its breadth. It effectively ignores a central feature of ODD: that the person is genetically and neurologically hardwired to thwart, frustrate, antagonize, and defeat anyone whom they perceive in a position of authority. This is the feature that destroys the individual’s ability to create or sustain relationships, that alienates them, that makes treatment difficult, and that can ultimately crush families.

The person with ODD is also willing to suffer severe consequences for their disruptive behaviors. The goal is not so much to score a “win” over the authority figure, but to bring them down, defeat, thwart, and humiliate the authority figure. The mere perception of authority can, therefore, change the behavior of an individual with ODD from agreeable and mild-mannered to hostile.

[ODD vs. ADHD: The Facts About Oppositional Defiant Disorder and Attention Deficit]

Even then, ODD doesn’t always manifest in overt displays of negative behaviors. Disruptive behaviors, especially thwarting an authority figure’s efforts, can be covert. People with ODD are not always “up in your face.” They may be disguised, for example, as pseudo-compliance. For example, they may agree to do something but have no intention of ever doing it. They may agree to take their medication only to cheek the pill and spit it out later.

What’s more, people with ODD typically do not regard themselves as oppositional or defiant. They often justify their behaviors as a response to unreasonable demands or provocation from the person in authority. As such, there is often no remorse or discomfort involved with these disruptive behaviors.

Dealing with ODD: Behavior Management and Medication

Can ODD in Children be Managed?

Parents often assume that ODD can be wholly reined in. But the uncomfortable truth is that ODD doesn’t work like this. The reality is that the individual with ODD often has the upper hand. Even in treatment, they might sabotage parent and clinician efforts by feigning compliance (“I agreed to give it a try, but it doesn’t work for me”), by diverting attention away from the topic, by picking fights, and other methods. Showing enthusiasm for any intervention often triggers the patient’s urge to defeat it. (Children and adolescents with ODD are not the only ones who may thwart treatment; given ODD’s heritability, it’s possible that one parent or family member also has the disorder and secretly sabotages everything the other parent tries to do.. The oppositional behaviors, therefore, may even come from them!)

And while ODD symptoms do improve over time for the majority children, the disorder is a strong predictor for conduct disorder¹, characterized by behaviors that can include aggression toward people and animals, destruction of property, deceitfulness and theft, and rule breaking. ODD’s genetic aspect² also means that the condition is unlikely to resolve on its own, and psychotherapy alone is typically only so effective.

Early intervention and treatment in the form of behavior therapy and medication, therefore, are critical for addressing ODD and managing its impact on the individual and others.

Medications for ODD

While there are currently no FDA-approved medications to treat ODD, clinicians commonly prescribe a series of medications off-label that can dramatically impact symptoms. Which medications are prescribed often depend on co-existing conditions.

Stimulants for ODD

For co-occurring ODD and ADHD, clinicians often prescribe stimulants to treat ADHD first. Typically, the ADHD stimulant medications greatly reduce ODD symptom severity and frequency. One study also found that patients with ADHD who consistently took medication significantly lowered their risk of developing ODD or CD in later life compared to patients with lower drug adherence³. In practice, clinicians often use liquid formulations to avoid having the patient potentially dispose of tablets.

Atypical Neuroleptics (Antipsych0tics) for ODD

Risperidone (Risperdal), Aripiprazole (Abilify), and Olanzapine (Zyprexa) are among the most commonly prescribed antipsych0tics to treat symptoms of ODD off-label, including acute and chronic maladaptive aggression. All of these products have oral dissolving tablet formulations that are useful to prevent “cheeking.”

When the atypical antipsych0tic medications work, they provide dramatic benefits at low dosages, and fairly quickly. This allows trials on medication to be done in a matter of days. Clinicians can start patients on 1 mg of Risperidone at bedtime and increase by half a milligram the next two nights if well tolerated. If there is not a robust positive response, clinicians can stop Risperidone and switch to 2.5 mg of Aripiprazole the following evening and then 5 mg the following evening. If this medication is not effective, the clinician can stop the Aripiprazole and switch to 2 mg of Olanzapine the following evening, and 5 mg the next.

Behavior Management Therapy for ODD

Behavior therapy and psychosocial treatment are essential components of ODD treatment. Medication can work to minimize symptoms, but patients and families still need to learn techniques and strategies to manage behaviors. Some effective programs for children and adolescents with ODD include:

• Defiant Children: A Clinician’s Manual for Assessment and Parent Training (3rd Edition) (#CommissionsEarned). Created by Russell Barkley, Ph.D., this program trains parents to deal with noncompliant behaviors mainly through parent effectiveness training (rewarding appropriate behaviors and ignoring misbehavior; time-outs when failing to comply). While parents must implement strategies at home, practicing management strategies under professional trained supervision is essential to the program. (Families sometimes choose to work in a group to find a child specialist who can guide them in this program.) The program is an effective treatment, when practiced over time, for managing oppositionality. The 3rd edition has been expanded to include behavior management techniques when outside the home at school, in restaurants, and out shopping.
• The Real Economy System for Teens – R.E.S.T. (#CommissionsEarned) by David B. Stein, Ph.D. and Edward Smith. This program essentially teaches oppositional teens what the world is going to require from them once they leave home. The program requires parents to calculate the cost of daily living for their teen (from Internet use to clothes to video games), and only provide them with their day’s money if they complete a list of tasks without being reminded. While the program can be done at home with no clinical intervention, many families find it helpful to follow the program in a support group.

Dealing with ODD in Children: The Bottom Line

The very nature of ODD can make patients fight against and even sabotage any plan to address symptoms. Even if they seem in compliance, patients may lie about actually taking medication; report intolerable, impossible side effects; or otherwise try to thwart interventions. After all, people with ODD seldom see themselves as even having a disorder at all.

With ODD, families and clinicians must understand that good patients are made – not born. It can take years to see adherence and progress, and improvement requires enormous amounts of patience. The process can be aided by reflecting back to the patient the unavoidable consequences of their behaviors over time until they can begin to see patterns and their own role in negative situations.

It is also important for families to remember that ODD is an illness. Focusing on blame and fault will certainly discourage adolescents and adults with ODD from participating in treatment, and it may even fuel symptoms. Rather than framing behaviors as right or wrong, it can help to question the individual on whether their behaviors are actually working for them (the answer, of course, is no). These questions can eventually get the person to at least try an intervention in earnest – for themselves.

The content for this article was derived from the ADDitude Expert Webinar “How Oppositional Defiant Disorder Ruptures Families — and How You Can Learn to Manage It” [Video Replay & Podcast #349] with William Dodson, M.D., LF-APA, which was broadcast live on April 6, 2021.

ODD in Children: Next Steps

• Read: The ADHD and ODD Link in Children
• Read: How to Discipline a Child with Oppositional Defiant Disorder (ODD)
• Read: Could Positive Parenting Decrease the Risk for Oppositional Defiant Disorder?

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