All children disagree with their parents or teachers from time to time, but ODD isn’t a temporary phase. It involves extreme long-lasting, aggressive and defiant behaviour, often to people in authority.
‘Children with Conduct Disorders are different. It's not a bit of tantruming or getting into trouble now and then. It's picking up the 14in TV and throwing it through the window,’ says Professor Steven Pilling, National Collaborating Centre for Mental Health.
ODD is a behaviour disorder like Conduct Disorder. Both terms are used to refer to children who persistently argue (‘oppose’) and disobey (‘defy’) those looking after them, much more than would normally be expected at their age. These behaviours have a negative impact on their lives and learning, on their psychosocial development and, if untreated, a significant effect on mental health in adulthood.
Often a child with ODD has trouble at home with parents and siblings, in school with teachers, and usually struggle to make and keep friends. ODD is first seen in younger children; some may persist with conduct disorder through life, others may find it resolves; another form tends to begin with adolescence. These behaviour disorders form half of all referrals to the Children and Adolescent Mental Health Service (CAMHS).
ODD affects around five per cent of boys and two per cent of girls. Children with ODD very often have other mental health and behavioural problems, particularly ADHD, depression, anxiety, and learning and communication disorders.
Studies show 35-60 per cent of those with ADHD also have ODD. This may be because children with ADHD receive a lot of negative feedback and are less likely to form good peer relationships – both of which can lead to ODD.
How is ODD different to Conduct Disorder?
ODD is less severe and more common than conduct disorder, but if a child with ODD is not treated properly, it may lead to conduct disorder.
ODD refers to younger children and teenagers who fight against being controlled. In general, they:
- are angry and irritable
- often lose their temper
- argue with authority and refuse to comply with requests or rules
- often deliberately annoy people and blame others for mistakes
- are spiteful or vindictive.
CD refers to older children or adolescents who will fight not only against being controlled but will attempt to control others as well. They may:
- become highly aggressive towards people and animals
- steal or damage property
- violate rules
- fail at school or college
- misuse drugs and alcohol.
How is ODD different from Pathological Demand Avoidance?
ODD is sometimes confused with Pathological Demand Avoidance (PDA). PDA is characterised by an extreme avoidance of everyday demands and is an anxiety-driven need to be in control. Also unlike ODD, children with PDA share many of the social communication, social interaction and sensory difficulties seen with Autism.
‘I think for me the difference I found was that when I was told he was ODD I got tougher with him… but it still wasn't helping, and was in fact exacerbating the problems. It was only after getting the PDA diagnosis that I began to notice whilst he was refusing to do things it was more so in relation to something that was causing anxiety, for example going into shops, school etc. Then I began to also notice that he was displaying the behaviours to avoid demands.’ Parent of child misdiagnosed.
Dr Laura Cockburn, an educational psychologist at the National Autistic Society, says: ‘It is possible for a child with autism to be given one of these diagnoses [ODD or CD] if a proper history is not taken and the proper psychological investigations are not carried out. If this happens the needs of the child concerned and their family are likely to be misjudged, with disastrous results.’ She recommends that parents ask to be referred to someone who specialises in the field of autism if they are concerned about misdiagnosis.
Causes of ODD
This is unknown but a combination of environmental and biological factors can contribute:
- insecure attachment parenting
- parental mental health problems such as depression and substance misuse
- abuse or neglect
- harsh parenting and lack of warm relationships with parents
- co-occurring conditions, such as ADHD
- poverty and socio-economic factors
- the presence of other mental health problems
- inherited genetics
- deviant friendship groups.
Treatment of ODD
Early intervention is vital. About half of children with antisocial behaviour miss out on education, end up unemployed, often get involved in crime and go on to have serious mental health issues such as antisocial personality disorder.
Firstly the environment in which the child lives will be assessed; a stable home is essential. Schools or colleges and social services will often be involved in the assessment and care of these children. Improving relationships, particularly at home, is key, and parent training along with family therapy is highly effective. For the children, psychological therapies plus social skills training is recommended.
Medications alone generally aren't used for ODD unless another disorder co-exists. Some ADHD medication can make some of the ODD symptoms appear worse as the drugs help children become more focused, which in turn can make things like irritability more focused too.
How parents can help
‘Firmness and saying “no” is not the solution for these children. We need to get parents to switch the focus from being controlling and punitive to encouraging positive behaviour,’ says Prof Peter Fonagy, one of the authors of the NICE guidance for the NHS.
Parenting programmes run by health and social care professionals can be useful to help parents not only improve their children’s behaviour, but also learn how to manage it. Parents are advised to:
- Create a structured environment, set house rules, routines and expectations.
- Be consistent, be clear.
- Use a calm voice.
- Pick your battles and avoid power struggles.
- Learn to play with your child, spend time together.
- Celebrate successes and praise good behaviour.
- Assign a weekly household chore.
- Persevere - expect behaviour to get worse before it starts getting better.
How schools can help
There is evidence that a school can improve the disorder; in studies, 11 year olds have shown lower rates of delinquency in schools with clear, fair and consistently enforced rules, therefore school can be protective. Teachers should:
- Work in partnership with parents and/or carers.
- Identify what triggers the child’s behaviour.
- Develop classroom rules and a daily schedule so the student knows what to expect.
- Provide structure, even during free time or break times.
- Communicate clearly the consequences for the behaviours you will not accept.
- Be positive; give praise and positive reinforcement. Children with ODD are highly motivated by rewards. Reward effort as much as achievement.
- Do not provide opportunities to argue.
- Avoid raising your voice, be neutral and speak calmly.
- Put the child near a good role model.
- Assign additional responsibilities so they get used to carrying out small and reasonable requests.
- Minimise distractions.