Oppositional Defiant Disorder

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Will Winter, MD, FAAP

Oppositional Defiant Disorder (ODD) is exactly that- dysfunction caused by oppositional and defiant behavior. Symptoms include arguing with adults and not following the rules. These can be situational and specific in nature. However, ODD includes more general symptoms like having a propensity to lose one's temper, being touchy/easily annoyed, and often being angry, among others.

As might be guessed from this description, the population we tend to find ODD in is adolescents. (It is rare to see it in young children). ODD is a pre-adult diagnosis. That is, if one is over 18, according to the DSM IV, he cannot meet criteria for this.

One might say that challenging authority is ubiquitous and is par for the course for teens. But what we are talking about here is above and beyond "normal" adolescent rebellion. In fact, the oppositional and defiant behavior is so marked that it can drastically alter family functioning. Often the condition affects the child's ability to function in school and grades suffer.

What causes this?
It is crucial to understand that a teenager doesn't exist in a vacuum. He is a part of a family. And if he is the symptomatic one, we can refer to him as the "identified patient" or IP, (the whole patient being the family). How a teenager behaves is reinforced by family members' behaviors.

How do we treat it?
Behavior is the product of one's free will choice. Therefore, the first line of treatment is talk therapy. And it is bi-faceted. It is important to have one on one time with the teenager with ODD. He or she must feel comfortable and there must be a real therapeutic relationship here.

Also, and just as importantly, the family must be included in the process. Going through particular events with the IP and family is important. This is because for every action there is a reaction. And by acting on the family, the teenager's behavior can and will change

My teenager is extremely irritable. Does he have ODD?
To diagnose ODD, a psychiatric evaluation is required. It is important to realize that ODD just describes a constellation of behaviors. It does not tell us how someone became this way or why.

Prior to ruling in ODD, it is the job of the psychiatrist to rule out other possible diagnoses which may look like ODD. For example, when children and adolescents are irritable, it may be a sign of a mood disorder, i.e. Major Depressive Disorder or Bipolar Disorder. Treatment will depend upon what the diagnosis is.

My child has ODD. It is severe. Talking doesn't work. We tried that with a therapist for the past 3 months. He's out of control. Is there medication that will help?
In some cases, medication can be helpful. It is important to know that medication does not take away one's free will choice. It does not force him to "behave" and it does not change who someone is in his essence. Ultimately, if your child chooses to lose his temper, no medication alone will be able to change that. Individual talk therapy and family therapy are crucial to making a difference. Medication can be helpful as an adjunct.