What is Oppositional Defiant Disorder & Conduct Disorder
Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are important child and adolescent mental health concerns that are often referred to collectively as ‘conduct problems’ or ‘disruptive behavior disorders.’ Children and adolescents with these concerns show distinct behaviors, neurological functioning, processing of emotions like anger, and can cause significant disruption to their family, schools, and society. The causes of these disorders involve a complicated mix of genetic predisposition of certain characteristics and traits as well as many environmental factors. It is incredibly important to have a thorough diagnostic assessment completed by a qualified professional with expertise on these disorders to ensure proper diagnosis and consider any other mental, developmental, behavioral, or learning concerns.
Let’s talk ODD.
ODD is more common than CD and is often viewed as “less severe” than CD. ODD is typically thought of this way because ODD involves angry, moody, and argumentative behavior such as frequent tantrums or arguments, whereas CD involves lying, stealing, aggression, and sometimes hurting animals. It’s important to understand that ODD can be very serious and cause significant difficulty for the family as well. A "severe" case of ODD can cause more challenges for caregivers than a "mild" case of CD. Appropriate treatment is important for both mental health conditions.
As I outline below, the research shows that behavioral-based interventions with a parenting component are the most effective treatment. I want to highlight that just because the interventions involve changes to parenting strategies used with children, it does not necessarily mean that caregivers caused their child’s challenging behaviors. However, certain parenting behaviors including harsh parenting strategies can contribute to worsening of the child’s behavior and therefore are important to target in treatment.
When is a child diagnosed with ODD?
For a child or teen to meet criteria for ODD, they have to display “a pattern of angry or irritable mood, argumentative/defiant behavior, or vindictiveness” (American Psychological Association, 2013), displaying at least 4 of the 8 symptoms below.
A. Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from the below list. Importantly, they have to be seen in interactions with people other than a sibling. If your child is only displaying some of these concerns with a sibling, it is not considered ODD.
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
8. Has been spiteful or vindictive at least twice within the past 6 months.
B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, friends, school), or it impacts negatively on social, educational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.
Specify current severity:
Mild: Symptoms are confined to only one setting (e.g., at home, at school, with peers).
Moderate: Some symptoms are present in at least two settings.
Severe: Some symptoms are present in three or more settings.
So, your child may refuses to do what they’re told, tantrums, or gets angry easily. You, the caregiver, may feel overwhelmed, powerless, and stressed, not sure when to be strict and when to be lenient.
Like they say, pick your battles, right?
The great news is there are behavioral strategies that have been proven to reduce defiance and tantrums and increase listening and pleasant interactions with your family. These strategies have been shown in hundreds of research articles to help families and actually improve child behavior in those with mild to severe behavioral challenges.
Imagine how your day to day would be better if your child did their homework or stopped playing video games the first time you asked? How much time would you save in your day from not having to repeat yourself? Imagine your child completing their bedtime routine with few protests or arguments.
What interventions treat Oppositional Defiant Disorder?
The research is clear: parenting interventions such as Parent Management Training (kka “parent training” or "behavioral parent training") are the best way to improve disruptive behavior concerns like those seen in ODD. Behavioral strategies taught in in these interventions involve using positive and negative reinforcement to teach your child behaviors you like to see (e.g., sharing, asking nicely, accepting your limits and rules) and those you don’t (e.g., running in the house, screaming, whining). These strategies involve setting consistent boundaries, limit-setting, and house rules by providing rewards and punishments to the child for appropriate and inappropriate behavior. Importantly, caregivers are taught strategies that will help keep themselves calm and avoid from getting too upset with the child which often escalates the situation, making it worse.
The behavioral strategies that have shown to be the most effective at improving mild to severe child behavior include positive attending, creating house rules, consistent positive (i.e., rewards) and negative (i.e., punishment) consequences for appropriate and inappropriate behavior, when-then statements, transitional warnings, time-out from activities or positive reinforcement, effective (direct) commands, among others. These are tried and true strategies that work for the majority of families with children with behavior problems including ODD! In fact, much of these same strategies work for children with other diagnoses or concerns including ADHD and Conduct Disorder. The ways these strategies are used and implemented will depend on the age of the child and their specific difficulties.
What is Conduct Disorder (CD) and how it is different than ODD?
Now that you have a sense of what ODD is and how you treat it, let’s talk about CD. Conduct Disorder is a pattern of rule-breaking and sometimes law-breaking behavior. Symptoms and problematic behaviors include lying, stealing, aggression toward people or animals, among others. Just like with ODD, in order to be diagnosed with CD, the youth’s behavior has to be persistent, not just a one-off bad day or week. Symptoms must be present for at least 12 months, with at least one symptom present in the last 6 months as outlined below:
Symptoms of Conduct Disorder
A. Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following 15 symptoms in the past 12 moths from any category below, with at least one criterion present in the past 6 months:
1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon that can cause serious physical harm to others (e.g., bat, brick, knife, gun)
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity
8. Has deliberately engaged in fire setting with the intention of causing serious damage
9. Has deliberately destroyed others’ property (other than fire setting)
10. Has broken into someone else’s house, building, or car
11. Often lies to obtain goods or favors or avoid obligations
12. Has stolen items of nontrivial value without confronting a victim
13. Often stays out at night despite parental prohibitions, beginning before 13
14. Has run away overnight at least twice while living with parental or parental surrogate home, or once without returning for a lengthy period
15. Is often truant from school, beginning before age 13
B. The disturbance in behavior causes clinically significant impairment in home, social, academic, or work settings.
Other considerations:
Age of onset: If the child or adolescent began displaying at least one symptom before age 10, they would be diagnosed with “childhood-onset type” conduct disorder. If they have not shown symptoms before age 10, they would be diagnosed with “adolescent-onset type” conduct disorder. The research is clear that children who have “childhood-onset type” tend to show more severe and problematic behaviors initially and as they age. For example, they tend to show more aggression and violence than the youth who have “adolescent onset type”. Those that show “adolescent-onset type” conduct disorder are more likely to show behavior concerns only while they are adolescents, although there are exceptions. Regardless of the type of conduct disorder a child meets criteria for, there are research-backed treatment options that do help families and improve child behavior!
Presence of Limited Prosocial Emotions (LPE): Some children have difficulty experiencing and expressing empathy, have a limited emotional experience, don't feel guilt after they do something wrong or hurt someone, and do not care about important activities such as school. These children may have what's called Limited Prosocial Emotions (LPE). Youth with Limited Prosocial Emotions have more severe difficulties and often show difficulties at younger ages than those with Conduct Disorder without Limited Prosocial Emotions. If you have concerns that your child has Limited Prosocial Emotions, contact the Center for Child Behavior. Dr. Robertson is an expert in youth with these traits, and her research on these children have been recognized by leading psychological associations including the American Psychological Association's Society of Clinical Child and Adolescent Psychology. Children with Limited Prosocial Emotions often need treatment that is tailored to their specific challenges so it's important to work with a mental heath provider who has expertise in this area.
What does treatment look like for children and teens with Conduct Disorder?
Depending on the age of the youth and the severity of the behavior, treatment can look similar to treatment for ODD. In fact, many youth with Conduct Disorder also meet criteria for ODD. However, sometimes families need more support for more serious behavior. For example, when that’s the case, Multisystemic Therapy, frequently referred to as MST, and Functional Family Therapy, referred to as FFT, are the go-to treatment options for older children and teens.
Research on FFT show that the treatment reduces arrests by 60%, saves taxpayers $36,000 per year per youth, and is more effective than individual therapy such as Cognitive Behavior Therapy. Similarly, MST leads to improvements in the youth living at home (vs. in out of home placement), 86% of youth are in school or working by the end of treatment, and 87% of youth have no arrests by the end of treatment. Research looking at the effectiveness of these treatments over time also support their effectiveness, meaning that the results of treatment can last over time.
If your child is having some of the symptoms described above, but does not actually meet full criteria for these disorders, please still reach out to our team. Often time behaviors get worse without treatment. We can work together to improve the symptoms/challenges so that you and your child are healthy and happy.
In the end, treatment for symptoms related to these behavior problems are important for the health of the youth and the family as a whole.
The Center for Child Behavior specializes in treatment for these behavior concerns. Please contact us to learn how we can help your family.