Oppositional Defiant Disorder in Teens

Angry outbursts, acting annoyed by the seemingly smallest things, defying the rules you’ve set, being spiteful, swearing, irritability, and making hurtful remarks when they’re upset.  Almost every parent of a teen has observed these frustrating behaviors at least on occasion, and perhaps even numerous times, particularly during periods of high stress.  Some degree of non-compliance in teens may seem normal as they strive to assert their burgeoning independence.  However, very frequent or daily occurrences of oppositional and blatantly defiant behavior can signal a mental health disorder known as oppositional defiant disorder, or ODD for short. 

Oppositional defiant disorder is one of the most commonly diagnosed behavioral disorders in children and adolescents.  This brief guide is designed to help you recognize the signs and determine the appropriate steps to take if you suspect your teen has oppositional defiant disorder.  

Adolescent Oppositional Defiant Disorder – Statistics and Facts

• Anywhere from 2% to 16% of children and adolescents in the U.S. meet the criteria for a diagnosis of ODD.
• By the age of 16, approximately 11% of youth will have had or currently have ODD
• After puberty, ODD occurs about equally in both girls and boys; prior to puberty it’s more common in boys.
• Oppositional defiant disorder is the primary precursor of conduct disorder, which is a more serious behavioral disorder. Conduct disorder in adolescence is the precursor to antisocial personality disorder (also known as sociopathy) in adulthood.
• Oppositional defiant disorder is one of the most common precursors for a wide range of adolescent and young adult mental health disorders.
• 40% of children with ADHD develop ODD at some point.
• Although ODD is often thought of as a childhood disorder, it can continue into adulthood.

Co-occurring Disorders with ODD

In some cases, adolescents with ODD often meet the criteria for at least one other psychiatric disorder.  A co-occurring disorder may have already been present when ODD first develops, or it may develop later.  The presence of one or more co-occurring disorders typically makes it more difficult to manage ODD. 

Psychiatric disorders most likely to co-occur with ODD in adolescents include:

• Attention-deficit hyperactivity disorder (ADHD)
• Anxiety disorders
• Depression and other mood disorders
• Substance use disorder
• Learning disorders
• Language disorders

Complications with ODD

Oppositional defiant disorder can potentially lead to the development of other serious problems in an adolescent’s life.  These include:

• Social isolation and frequent rejection
• Being suspended or expelled from school
• Substance abuse and addiction
• Suicidal thoughts and behaviors, especially if ADHD or depression is also present
• Poor academic performance
• Difficulties at work, including keeping a job
• Impulsive and / or self-destructive behavior
• Criminal behavior

Risk Factors for Oppositional Defiant Disorder

There isn’t a specific known cause of ODD.  However, the following risk factors are believed to play a role in the development of ODD in children and adolescents:

• Presence of ADHD
• Temperamental challenges such as difficulty handling frustration, a high level of emotional reactivity, or an aggressive nature
• Difficulties understanding social cues
• Developmental delays
• One of both biological parents have a history of ADHD, ODD, or other behavioral problems
• Childhood neglect or abuse
• Being exposed to violence
• A parent or caregiver abuses drugs or alcohol
• Lack of adequate structure and supervision
• Discipline is inconsistent or overly harsh
• Unstable or dysfunctional home life, such as often moving and changing schools, financial problems or poverty, and parental conflict and divorce
• A parent or caregiver has a mood disorder, personality disorder, or anxiety

Looking for and Recognizing the Signs of Oppositional Defiant Disorder

Some behavioral issues are normal depending on your child’s temperament and developmental level. This can make it difficult to determine when an actual disorder is present.  Oppositional defiant disorder symptoms typically first appear around age 8, but, in some cases, they may not manifest until early adolescence.  One of the tell-tale indicators of ODD is that your teen’s behavioral issues are causing frequent and significant problems at home, school, work, or socially.

Symptoms of ODD include:

• Frequent blatant defiance / refusal to follow rules
• Often challenges or questions rules or requests
• Negative attitude
• Argues excessively with parents and authority figures
• Frequent non-compliance with requests of parents, teachers, and other adults
• Short temper / easily angered
• Often swears or says obscene things
• Frequent arguments with parents or anyone in authority
• Irritability
• Frequent displays of anger and resentment
• Low frustration tolerance
• Always blaming others
• Deliberately tries to upset or annoy others
• Is frequently spiteful, mean, or vindictive
• Makes hurtful or hateful remarks when upset or angry
• Often seeks revenge
• Causes chaos
• Has temper tantrums

The behavioral problems listed above may occur in only one setting (e.g. only at home or only at school) or may occur in multiple or all settings.  The more settings in which they occur, the more severe the disorder.  It’s also not uncommon for the symptoms to initially start at home and then extend to other settings as time goes on. 

Knowing the First Steps to Take

If the troubling behaviors you observe in your teen cause you to suspect he or she may have ODD, there are some initial steps to take to handle the situation:

1 – Talk to your teen.  Talking to a defiant, argumentative teen is no easy task.  Pick a time when things are calm and share your concerns about the troubling behaviors you’ve been noticing.  Make sure you refrain from attacking, accusing, arguing, or blaming.  Strive to keep any negative feelings you’re experiencing, such as anger or frustration, in check.  Assure your teen that your desire is to help in any way possible and that you’re willing to listen. 

A teen with ODD probably won’t be particularly eager or willing to be open with you, especially if there has already been a lot of conflict surrounding his or her behavior.  You can be gentle and firm at the same time.  It’s important to avoid engaging in a power struggle with your teen when you address your concerns.  Your teen will very likely not see his or her behavior as problematic and may blame you for all the problems you’re describing.

2 – Set up an appointment for an evaluation.  With behavioral issues, a good place to start is with your family doctor or your child’s pediatrician.  He or she can do a basic examination to rule out any underlying medical causes or substance use issues that may be contributing to your child’s behavioral problems.  Keep in mind, though, that he or she isn’t a mental health professional and therefore lacks the specialized training and expertise in diagnosing and treatment behavioral disorders in teens. 

With behavioral disorders, it’s important to have a child psychologist or psychiatrist evaluate your teen.  Their extensive training and experience in working with child and adolescent disorders enable them to understand the subtle nuances of adolescent behavior, common co-occurring disorders – particularly ADHD and learning disorders – and the treatment challenges that often go with the territory. Ask your child’s pediatrician or family doctor for a referral or recommendation.  

3 – Get your teen into treatment.  The third step to take is to get your teen into the appropriate treatment.  Treatment for ODD in teens usually involves a multi-faceted approach that often includes some form of parenting training or parent-child interaction training, individual and / or family therapy, and social skills training.  Medication may also be indicated if other disorders are present.  It’s crucial that any co-occurring disorders, such as ADHD, are treated simultaneously with the ODD for treatment to be effective.   

Parent Training – Parent training is an essential part of treatment for ODD.  Many parents lack the skills and knowledge to manage and guide their child’s behavior in an effective, healthy way.  Parent training helps parents learn to parent in ways that are consistent, positive, and focus on paying more attention to and reinforcing positive behaviors rather than negative behaviors.  Effective discipline methods are also taught.  This is often referred to as Parent Management Training (PMT) and may include the child in training sessions.

Parent-Child Interaction Therapy (PCIT) – This involves having a skilled therapist observe and coach parents, often through an audio device in the parent’s ear, as the parent (or parents) interacts with their child.  The therapist can help guide the parent in using methods that encourage and reinforce positive behaviors and reduce undesirable behaviors.

Parent training methods have been shown to have ongoing positive effects for years after treatment ended.  The most positive effects have been found when it is used in children with less severe ODD. 

Individual – Individual therapy for ODD can help your child learn effective problem-solving skills and find healthy ways to manage and express negative emotions.  Behavior therapy and cognitive therapy are often used to treat ODD.  Behavior therapy can help teens unlearn problem behaviors and cognitive behavior therapy can help teens recognize and change negative thought patterns and distorted beliefs that play a role in their defiant behavior. 

Family Therapy – Since ODD effects the entire family, treatment for ODD often includes family therapy.  Family therapy may include behavioral methods to help family members focus on reinforcing desirable behaviors and create a healthier and more supportive home environment. Family therapy can also help everyone develop healthier coping skills and interact with each other in more positive ways.  

Social Skills Training – Teens with ODD often have difficulties in their social interactions, often resulting in conflicts with and rejection by their peers.  Social skills training can help teens learn and practice healthy ways to interact in social settings. 

Medication – Medication isn’t usually indicated for ODD by itself, although it is sometimes used to help reduce particularly distressing and disruptive behaviors. Medication may be warranted, only in combination with other forms of treatment, to alleviate symptoms of co-occurring disorders such as ADHD, depression, or anxiety.  

Medications for teens with both ADHD and ODD may include antomoxetine (Strattera), stimulants such as methylphenidate (e.g. Ritalin, Concerta) or amphetamine (e.g. Adderall), clonidine, and guanfacine (Tenex).  Atypical antipsychotics such as aripiprazole (Abilify) and risperidone (Risperdal) are sometimes used for the short-term treatment of disruptive behaviors.  Medications to treat anxiety and depression may include fluoxetine (Prozac) and escitalopram (Lexapro).  

All medications, particularly atypical antipsychotics, can have potentially serious side effects and should be closely monitored by a psychiatrist.

Supporting and Encouraging Your Teen with ODD

Behavioral disorders can significantly disruptive family life and make parenting especially challenging.  However, there are many things you can do to support and encourage your teen with ODD that will help reduce problem behaviors and create a happier, more peaceful home environment, including the following:

• Educate yourself about ODD. The more you know about and understand the disorder the better equipped you will be to help your teen. 
• Set clear limits and household rules; enforce them consistently
• Create structure by establishing and sticking to a regular routine for your teen
• Be a role model for your child by effectively managing your own frustration and other negative emotions as well as modeling healthy interactions with others
• Work with your partner to help ensure consistency in your parenting
• Give positive attention to your teen’s positive behaviors rather than focusing on or criticizing (inadvertently reinforcing) his or her negative behaviors
• Strive to have a loving relationship with your teen
• Avoid power struggles as much as possible (in other words, choose your battles carefully). Engaging in power struggles will generally escalate conflict, reinforce, negative behaviors, and damage your relationship with your teen
• Be sure to watch for and praise any decrease in negative behaviors
• Provide consistent, reasonable, and appropriate consequences (e.g. loss of privileges) for negative behaviors, particularly behaviors that are destructive or aggressive
• Make it a priority to spend quality one-on-one time with your teen
• Give your teen household chores, starting with ones that are readily achievable and moving to more challenging ones as your child’s behavior improves; make sure your instructions are clear
• Enlist the support of other adults (e.g. teachers, coaches) in your teen’s life to provide positive reinforcement of desired behaviors and consistent consequences for problematic behaviors
• Practice patience. Positive change takes time.  Work with treatment providers when obstacles arise, or setbacks occur.
• Accept your teen unconditionally (which doesn’t mean condoning or ignoring negative behaviors). Remember that he or she is still learning about life and is a work in progress; not to mention, adolescence is challenging enough even without the presence of ODD and other disorders.  

What to Do When Things Escalate

Poor impulse control, self-destructive acts, aggression, irritability, and suicidal thoughts and behavior are not uncommon in teens with ODD.  These are even more likely to occur if your teen is experiencing a lot of stress, is using alcohol or drugs, and / or also has ADHD, depression, or another mental health disorder.  If things start to escalate and your teen is putting himself / herself or others in harm’s way or threatening to do so, your immediate attention and response is vital.  Some things you can do to intervene include:

• Contacting your child’s therapist, psychiatrist, or other treatment provide asap (if it’s during business hours or there is an after-hours number available)
• Seek the help of a close friend or family member to assist you in diffusing the situation or getting help
• Call 911
• Take your teen to the nearest hospital emergency room (if you can do so safely; if not, the 911 operator can send an ambulance or police)

When Individual Therapy isn’t Enough

Sometimes the typical treatments outlined above simply aren’t enough to effectively help teens with ODD.  If things have started to escalate and your teen is engaging in any of the following:

• Becoming increasingly aggressive or destructive
• Putting themselves or someone else at risk of harm
• Threatening or actively planning suicide, or engaging in suicide gestures in attempts
• Demonstrating the inability to function at home, school, or other settings

then it’s time to pursue a more intensive level of treatment for your teen.  More intensive types of treatment include:

• Intensive outpatient treatment (IOP) / Psychiatric day treatment
• Residential treatment (sometimes referred to as “inpatient treatment” but done at a residential treatment facility rather than a hospital, and usually lasting for several weeks to a few months)
• Dual diagnosis treatment
• Short-term psychiatric hospitalization

Intensive outpatient treatment or psychiatric day treatment can vary in terms of the length and frequency your teen spends in treatment each week (e.g. twice a week, 5 days a week).  These programs are usually the first level of treatment above regular outpatient treatment (i.e. individual and family therapy, skills training, etc.)

Residential treatment involves having your teen stay at a non-hospital treatment facility that specializes in treating adolescents with mental health disorders.  Typically, residential treatment programs last anywhere from 1 to 6 months, depending on the disorder(s), severity of symptoms, and rate of progress. If your teen is also struggling with substance abuse or addiction, you’ll want to locate a residential treatment center that offers dual diagnosis treatment.

Dual diagnosis treatment is recommended for adolescents who have ODD and a substance use disorder.  Many intensive outpatient treatment programs and residential treatment programs also offer dual diagnosis treatment.

Short-term psychiatric hospitalization (inpatient psychiatric treatment) is the highest and most intensive level of treatment for teens with ODD and is most frequently utilized when they are an imminent danger to themselves or others.  Treatment typically lasts for a few days or for as long as is required to ensure safety and stability.

Each of these intensive levels of treatment typically includes various types of daily therapy, such as individual, group, and possibly family therapy, as well as additional therapies (e.g. music or equine therapy) and frequent visits with a staff psychiatrist for medication monitoring.

Taking Care of Yourself

Parenting a teen with the significant behavior problems associated with ODD can be both frustrating and exhausting.  It’s easy to lose patience and neglect your own self-care in the process.  To help yourself stay calm, make good decisions, and not neglect your physically or emotional well-being, taking good care of yourself is crucial. 

Tips for self-care include:

• Striving to make time for yourself, even if it’s just a few minutes a day
• Enlisting the help of your partner, other family members or relatives, and friends when you need a break
• Doing your best to get adequate sleep
• Finding healthy ways to relax and keep stress as minimal as possible, such as regular exercise, practicing yoga or meditation, and engaging in hobbies and activities you enjoy

If you’re having a difficult time coping it may be helpful to work with a therapist or counselor or find a support group for parents dealing with similar challenges.

With time, proper treatment, and lots of love, patience, and consistent parenting, your teen’s ODD can significantly improve or even become a thing of the past.