Good, Bad or
Ugly?
Treating Oppositional Defiant
Disorder in the Primary Care Setting
John A. Biever, MD
Child and Adolescent Psychiatrist
Central Pennsylvania Institute of Mental Health
Clinical Professor of Psychiatry, Penn State M. S. Hershey Medical Center
Life is too
important to
be taken
seriously.
-Oscar Wilde
ODD: Diagnostic Criteria [1]
A pattern of negativistic, hostile, and defiant behavior
lasting at least 6 months, during which four (or more) of
the following are present:
A.








often loses temper
often argues with adults
often actively defies or refuses to comply with adults’
requests or rules
often deliberately annoys people
often blames others for his or her mistakes or
misbehavior
is often touchy or easily annoyed by others
is often angry and resentful
is often spiteful or vindictive
ODD Diagnostic Criteria,
cont’d.
 NB: Consider a criterion met only if the
behavior occurs more frequently than is
typically observed in individuals of
comparable age and developmental
level.
 ...i.e. oppositional behavior normally
increases in early toddlerhood and early
adolescence
ODD Diagnostic Criteria,
cont’d.
B.
The disturbance in behavior causes clinically
significant impairment in social, academic, or
occupational functioning.
C.
The behaviors do not occur exclusively during
the course of a Psychotic or Mood Disorder
D.
Criteria are not met for Conduct Disorder,
and, if the individual is age 18 years or older,
criteria are not met for Antisocial Personality
Disorder.
Associated Features
 Symptoms usually more prevalent at home than
in community or school (often minimal in clinical
setting)
 Child usually considers behavior justified.
 Increased incidence in [boys] with difficult
temperaments, high activity in preschool years
(10% are “difficult” children)
 Higher incidence of illicit substance use
Nine Dimensions of Temperament
(Chess and Thomas)
 Activity level
 Mood quality
 Attention span-
 Approach vs.
persistence
withdrawal
 Distractibility
 Adaptability
 Threshold
 Rhythmicity
 Intensity
Associated Features, cont’d.
 More prevalent in families with multiple
caregivers
 ...in families with harsh, inconsistent or
neglectful parenting
 Associated with ADHD (~50%
comorbidity, with poorer prognosis) LD,
Communication Disorders
Prevalence and Course
 Estimated anywhere between 2-16%
 Boys>girls pre-puberty; even in adolescence
 Symptoms emerge gradually over months or
years, usually by age 8
 Sometimes, but not inevitably, followed by
development of Conduct Disorder (~1/3 [2])
Familial Pattern
 Often at least one parent has history of
Mood d/o, ODD, Conduct d/o, ADHD,
Antisocial PD, or substance use d/o.
 ? mothers with depression (cause or
effect)
 Increased incidence in families with high
marital discord
Mothers of Children with ODD vs.
GAD [3]
 ODD mothers had negative emotional
valence and detached personalities
 GAD mothers had somatic
preoccupations, were over-controlling
and overprotective
Additional Predisposing Factors
[2]
 Insecure attachment patterns in infancy
 Poverty, crowding, high crime neighborhoods
 Deficient information processing of social
stimuli (Dodge, [4]): underutilization of social
cues, misattribution of hostile intent, generate
fewer solutions to problems, expect to be
rewarded for aggressive behavior.
Neurobiology of ODD
 Diminished parietal event-related
potentials in children with ODD—i.e.
reduced orienting to cues [5]
 N.B. comorbidity with ADHD
Treatment Considerations
 Individualize
 Be mindful of safety issues for
child/family/community
 Long-term treatment is the rule
 Empirical support for: family therapy (including
psychodynamic,) parent counseling
Treatment Considerations, cont’d
 Collaborate with schools
 Psychopharmacological treatment of
comorbid conditions
 The earlier the treatment, the better
The Oppositional
Defiant Child in
the Primary Care
Office
Prevention Is the Best
Medicine
 Temperament stabilizes by about 4 months of
age. So, about 10% of babies will begin to
show signs by then of being “difficult” children:
dysrhythmic sleep/feeding patterns; withdrawalprone; slow-to-adapt; high intensity; negative
mood.
 Mothers need to understand their child’s
temperament, and need extra support in order
to woo the child into a hopeful feeling about the
world.
Prevention, Prevention
 Infants are capable of forming 2-3
significant attachments within the first 18
months of life.
 If mother is temperamentally
mismatched with her difficult infant or
otherwise limited in her ability to develop
a secure attachment bond with her baby,
all is not lost!
Prevention, Prevention,
Prevention
 Mother (and father) need to “feel felt” by
the doctor and treatment team, whose
greatest contribution may be to instill
hope unrelentingly. (e.g. Nurse-family
Partnership)
 Heads up: Identification and treatment of
the depressed mother can prevent
subsequent mental illness in the baby.
And More Prevention
 When we’re out of rest, we’re all ODD!—stress
adequate sleep...for parents as well as child.
 When we’re hungry, we’re all ODD!—stress
excellent nutrition.
 When we’re sick, we may temporarily become
ODD—be sure significant physical illness is
ruled out.
Know the Family System
 Authoritarian parenting style: Oppositional-
defiant behavior as defense against domination

help the parents toward an authoritative style
 Permissive parenting style: Oppositional-defiant
behavior as lingering omnipotence

help the parents toward an authoritative style
Know the Family System II
 Brothers and sisters: Oppositional-defiant
behavior as a means to secure one’s position
within the family

appraisal of and focus on the child’s positive
strengths
 The single parent household: the Oedipal
victory

assert the parent as authoritative, the child as a
child
Know Yourself
 What’s your style of relating to parents and
children?


authoritarian? Not good for the ODD child!
authoritative? Works better
 The “Dutch Uncle (Aunt)”—the benevolent but
no-nonsense authoritative confrontation of the
ODD child.
 Keep a sense of humor.
Life is too important to
be taken seriously.
-Oscar Wilde
Your Treatment Team
 Be sure that they are educated regarding
oppositional defiant disorder.
 Be vigilant about “countertransference” feelings
and behavior and confront it empathically but
quickly, firmly.
 Have ready access to a seasoned mental
health professional, within or outside your
practice, and foster in all patients a sense that
mental health care is as normative as physical
health care.
Case Presentation:
Jeremy H.
Bones of Wisdom
 Carefully manage “countertransference” reactions to angry or
rejecting behavior by patients/parents.
 Understand the oppositional defiant behavior as an effort by a
mind to adapt to the stresses of life and relationships.
 Be an ally of every family member. Empathize with the unique
position and challenges of each, and avoid the pitfall of
inadvertently aligning with one of opposing forces in the family
system.
 Always be prepared to counter despair with hope.
“God did not make this person as I would
have made him. He did not give him to
me as a brother for me to dominate and
control, but in order that I might find
above him the Creator. Now the other
person, in the freedom with which he was
created, becomes the occasion of joy,
whereas before he was only a nuisance
and an affliction.”
-Dietrich Bonhoeffer
References
1.
DSM-IV TR. Diagnostic and Statistical Manual of Mental Disorders. Fourth
Edition. Text Revision. American Psychiatric Association, Washington, D.C.,
2000.
2.
Sadock B, Sadock V, eds. Kaplan and Sadock’s Comprehensive Textbook of
Psychiatry. 7th ed. Lippincott Williams & Wilkins, Philadelphia, 2000.
3.
Nordhal, H, et. al.: Does maternal psychopathology discriminate between
children with DSM-IV generalised anxiety disorder vs. oppositional defiant
disorder? The predictive validity of maternal axis I and axis II psychopathology.
Eur Child Adolesc Psychiatry 16(2), 2007
4.
Dodge K: Social-cognitive mechanisms in the development of conduct disorder
and depression. Annu Rev Psychol 44:559, 1993.
5.
Baving L, et. al.: Children with oppositional-defiant disorder display deviant
attentional processing independent of ADHD symptoms. J Neural Transm
113(5), 2006