Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is a persistent pattern of angry or irritable mood, argumentative or defiant behaviour, or vindictiveness, lasting at least 6 months, in children and adolescents.

• Prevalence 2 to 11%, boys more affected before puberty.
• Risk factors: harsh or inconsistent parenting, family conflict, parental psychopathology, ADHD, temperament, poverty.
• Comorbid ADHD (30 to 50%), anxiety, depression, learning disorders; may progress to conduct disorder and antisocial behaviour, or to mood disorders.

• Frequent temper loss, touchiness, refusal to comply, deliberately annoying others, blaming others, spiteful acts.
• Symptoms across settings (home, school), peer conflict, school suspension.
• No serious violation of rights of others (distinguishing conduct disorder).

• DSM-5 criteria with multi informant assessment: parent and teacher scales (Vanderbilt, Child Behaviour Checklist, Eyberg Child Behaviour Inventory).
• Exclude ADHD, conduct disorder, DMDD, depression, anxiety, trauma, autism, learning and language disorders, substance misuse, hearing and vision loss.
• Assess parenting, family stressors, school function, abuse.

• Parent management training (Incredible Years, Triple P, parent child interaction therapy), the first line with response in 60 to 70%; positive reinforcement, consistent consequences.
• School interventions and teacher training; child social problem solving skills.
• Treat comorbid ADHD: methylphenidate 0.3 to 1 mg/kg/day or atomoxetine 0.5 to 1.2 mg/kg/day; anxiety or depression: fluoxetine 10 to 40 mg or sertraline 25 to 150 mg with CBT.
• Antipsychotics (risperidone 0.25 to 2 mg) only for severe aggression with monitoring, short term.
• Family therapy, addressing parental mental health; multisystemic therapy for adolescents with escalating behaviour.