Treatment of Childhood Oppositional Defiant Disorder
Curr Treat Options Peds
Treatment of Childhood Oppositional Defiant Disorder
Bradley S. Hood
Marilisa G. Elrod 1
David B. DeWine 0
0 Pediatric Psychology & Psychiatry Service, Mary Bridge Children's, 1220 Division Ave. , Tacoma, WA 98403 , USA
1 Department of Developmental-Behavioral Pediatrics, Madigan Army Medical Center, Joint Base Lewis McChord , Tacoma, WA 98431 , USA
Oppositional defiant disorder I Attention-deficit hyperactivity disorder I Parent management training I; Disruptive behavior disorders
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Opinion statement
Oppositional defiant disorder (ODD) is a common behavioral disorder of childhood which
can be described as a learned pattern of behavior reinforced by caregivers’ responses.
Behavioral modification for ODD, particularly in preschool and school-aged children,
should primarily focus on teaching caregivers to reinforce positive behaviors, discourage
negative behaviors, and ultimately interrupt the cycle of argumentativeness and
deliberate attention-seeking behavior. Unfortunately, children who are referred for behavioral
therapy for ODD often do not receive evidence-based treatments that target the root cause
of the disorder. There is some role for the use of psychopharmacology in the treatment of
ODD, though primarily in the treatment of underlying and comorbid disorders. The core
symptoms of ODD are not amenable to pharmacotherapy, and behavioral modification is
the mainstay of intervention. Attention-deficit hyperactivity disorder (ADHD) frequently
occurs with ODD. Poor impulse control is a core feature of ADHD, and appropriate use of
stimulant and/or non-stimulant ADHD medications can help children with ODD make
better behavioral choices and be more successful with behavior modification programs.
There is some evidence for the effectiveness of atypical antipsychotics in disruptive
behavior disorders (DBDs), but the target symptoms of explosive and aggressive behaviors
are seen only in children with more severe ODD who progress to conduct disorder (CD).
Pediatric providers should understand the evidence-based behavioral interventions and targeted psychiatric medications that will achieve the best outcomes for children with ODD.
Case
You are seeing a previously healthy 4-year-old
William in your office for behavior problems at
preschool and at home. This is the third preschool he
has attended after having been asked to leave his
prior two for out of control behavior. His mother
reports that he refuses to comply with her directions
and will argue with her when confronted. He
frequently is involved in physical altercations in his
preschool class. He tells his teacher at school and
his mother that they are Bstupid^ and that he hates
them. His mother has brought William in today
because she feels that she is at her Bwit’s end^ and
his teacher thinks Bhe needs to be medicated.^
Vanderbilt scales from his mother and teacher indicate
attention-deficit hyperactivity disorder, combined
inattentive, and hyperactive type. You note that the
oppositional defiant disorder (ODD) screen is
Introduction
positive for both mother and teacher. On further
discussion, his mother states that she and William’s
father are divorced and that they differ significantly
in their parenting styles. She admits she has mostly
Bgiven up^ on correcting her son’s behavior, but his
father is extremely strict and Bon him all the time.^
You discuss the importance of consistent parenting
with the mother and recommend that the child and
both parents establish care with a mental health
professional for Parent Management Training
(PMT). You also provide recommendations for
parenting books. You discuss with William’s mother
that you would consider starting a stimulant
attention-deficit hyperactivity disorder (ADHD)
medication if behavioral interventions do not
improve his functioning and plan to see him back in
3 months.
ODD is a pattern of negative behavior and interaction characterized by an angry
or irritable mood, argumentative or defiant behavior, and vindictiveness. In the
Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), it is
contained in the Disruptive, Impulse-Control, and Conduct Disorders section,
grouped with intermittent explosive disorder, conduct disorder (CD), antisocial
personality disorder, pyromania, and kleptomania [
1
]. According to DSM-5
diagnostic criteria, symptoms must last at least 6 months and be exhibited
during interaction with a non-sibling as evidenced by at least four symptoms
from any of following: loses temper, is touchy or easily annoyed, is angry and
resentful, argues with authority figures, actively defies or refuses to comply with
requests from authority figures or with rules, deliberately annoys others, blames
others for his or her mistakes or misbehavior, or has been spiteful or vindictive
at least twice within the past 6 months. These must be seen often and more
frequently than would be typically observed in children of comparable age and
dev (...truncated)