Oppositional Defiant Disorder

Information for Professionals

Overview

Referral to a child and adolescent psychiatrist is appropriate where medication is being considered or where the diagnosis is not clear. If second or third line treatment is being considered then referral is indicated.
Oppositional Defiant Disorder is essentially a description of a sustained pattern of “naughty” behaviour such as not following adult requests, answering back and minor physical aggression that goes on for at least six months. It is very common and often occurs along with other problems such as Anxiety Disorders, Depression and Attention Deficit Hyperactivity Disorder. At other times, children may engage in misbehaviour transiently when they are stressed by change, loss or illness. Depressed adolescents and older children may appear to have Oppositional Defiant Disorder but the symptoms may resolve with treatment of depression.

Transient “naughty” behaviour can be part of the normal range, in fact children who “never” misbehave may be quite fearful and have difficulties of their own.

When children or adolescents have a long-standing pattern of more severe actions that aim to harm and/or deceive others for personal gain this is referred to as Conduct Disorder.

Both of these disorders are most usefully understood as relationship difficulties and are associated with parental distress, isolation and mental health problems such as depression and substance use disorders. Biological factors have been found to be associated with the more sustained problems, however the effective treatments address relationships.

It is worth noting that while the parent and child are often relating in ways that are unhelpful, this is not what either the parent or child started out wanting in their relationship. Blame is often a barrier to parents getting appropriate help and is unlikely to be helpful, while letting parents know that other parents in their situation have found therapy useful may be. Parents are often desperate for something to change the situation and feel powerless to do so in the context that the difficulties seem to be continuing despite whatever they have tried.

Treatment for Oppositional Defiant Disorder is most effective when the child’s environment including both home and school is safe and their parent/s and carers are going well. Addressing parental problems including depressive disorders and social isolation is one of the most important determinants of outcome for children with these difficulties. Another important factor is finding and addressing the frequent co-morbidities (ADHD, Depression, Specific Learning Difficulties and hearing problems).

Evidence-based treatments include Parent Management Training (such as Triple P – Positive Parenting Program) and teacher equivalents of this as well as some forms of Family Therapy. Treatment for parental mental health or other difficulties is essential and in some situations Parent Management Training may be inappropriate because the level of parental symptoms prevents them from using this approach safely and they require a more intensive intervention.

For the more severe, Conduct Disorder, an intensive treatment program which assertively addresses the home, school and social environments (Multi-Systemic Therapy) can be very effective. Individual treatment with specific forms of Cognitive Behavioural Therapy may be helpful in older adolescents.

Referral to a child and adolescent psychiatrist can be useful when the diagnosis is unclear or complex and when initial treatment is not sufficient. Optimal treatment of adolescents with Conduct Disorder is a well-resourced team approach with a capacity to work with multiple services, and a private psychiatry setting may not be well placed to provide this.

Resources

American Academy of Child Adolescent Psychiatry: Children With Oppositional Defiant Disorder - Facts for Families Guide

Woolfenden S, Williams KJ, Peat J. Family and parenting interventions in children and adolescents with conduct disorder and delinquency aged 10-17. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD003015. DOI: 10.1002/14651858.CD003015.

Australian Psychological Society: Helping troubled children: Seven things you should know about the origins of mental health disorders

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