Oppositional defiant disorder

Oppositional defiant disorder is recurrent or persistent negative, deviant, or even hostile behavior directed toward authority figures. Diagnosis is based on history. Treatment for oppositional defiant disorder involves individual psychotherapy combined with family therapy (or other caregivers). Sometimes medications may be used to reduce arousal.

Prevalence varies widely due to the highly subjective nature of diagnostic criteria; the prevalence of oppositional defiant disorder (ODD) may be up to 15% among children and adolescents. Before puberty, the disorder is significantly more common in boys than in girls; after puberty, this difference diminishes.

Although oppositional defiant disorder is sometimes considered a “mild version” of conduct disorder, there are only superficial similarities between the two. The hallmarks of oppositional defiant disorder are hyperarousal and deviant behavior. A child with conduct disorder, on the other hand, appears to lack a sense of conscience and fairness, and readily violates the rights of others, sometimes without any evidence of hyperarousal. The cause of oppositional defiant disorder is unknown, but it is probably most common among children from families in which adults model relationships with loud arguments and interpersonal conflict. The diagnosis should not be viewed as a clear-cut disorder, but rather as an indication of deeper problems that may require further evaluation and treatment.

Symptoms of Oppositional Defiant Disorder

Children with oppositional defiant disorder tend to lose their temper easily and frequently, argue with adults, frequently ignore adults, refuse to follow rules, deliberately get in people's way, blame others for their mistakes or misbehavior, become easily irritated and angry, hold grudges, and are vindictive. Oppositional defiant disorder is diagnosed if a child has had 4 or more of these symptoms for at least 6 months. The symptoms must also be severe and defiant. Care must be taken to avoid overdiagnosing oppositional defiant disorder in cases of mild to moderate oppositional behavior, which almost all normal children and adolescents experience from time to time.

Some medications used to treat bipolar disorder

Preparation	Indications	Starting dose	Maintenance dose	Notes
Lithium	Treatment in the acute period and maintenance	300 mg 2 times a	300-1200 mg 2 times a day	The dose is gradually increased until the blood level reaches 0.8-1.2 mEq/l.

Antipsychotic drugs

Chlorpromazine	Acute phase	10 mg once	50-300 mg 2 times a day	Rarely used because newer drugs have fewer side effects
Olanzapine	Acute phase	5 mg once a day	Up to 7.5 mg 2 times	Weight gain may be a limiting side effect in some patients.
Risperidone	Acute phase	1 mg once a day	Up to 3 mg 2 times a	High doses increase the risk of neurological side effects
Quetiapine	Acute phase	25 mg 2 times a	Up to 200 mg 2 times	Sedation may limit dose escalation
Olanzapine/fluoxetine fixed combination	Bipolar depression	6mg/25mg once daily	Up to 12mg/50mg once daily	Limited experience in children
Aripiprazole	Acute phase	5 mg once a day	Up to 30 mg once daily	Experience with use in children is extremely limited.
Ziprasidone	Acute phase	20 mg 2 times a	Up to 80 mg 2 times a	Experience with use in children is extremely limited.

Antiepileptic drugs

Divalproex	Acute phase	250 mg 2 times a	Up to 30 mg/kg, divided into 2 doses	The dose is gradually increased until the blood level reaches 50-120 mg/ml.
Lamotrigine	Supportive therapy	25 mg once	Up to 100 mg 2 times	The dosage recommendations on the package insert should be strictly followed.
Carbamazepine	Acute phase	200 mg 2 times a	Up to 600 mg 2 times	Due to induction of metabolic enzymes, dosage adjustment may be necessary.

¹ Dose ranges are approximate. There is considerable variability in both therapeutic effect and adverse reactions; the starting dose is exceeded only if necessary. This table does not replace complete information on the use of the drugs.

Note: There is a low but serious risk of developing a wide range of severe side effects when using these drugs. Therefore, the benefits and potential risks of prescribing such drugs should be carefully weighed.

VOR-like symptoms are common in untreated children with attention deficit hyperactivity disorder (ADHD). VOR-like symptoms often resolve with adequate treatment of ADHD. In addition, major depressive disorder in children may be mistaken for VOR because some children present with hyperarousal rather than depressed mood as the dominant symptom (an important distinction between children and adults with major depressive disorder). Because hyperarousal is also a hallmark of VOR, anhedonia and neurovegetative symptoms (e.g., sleep and appetite disturbances) are important differential diagnoses in children with major depressive disorder; these symptoms are often missed in children.

Prognosis and treatment of oppositional defiant disorder

Prognosis depends on identifying and successfully treating underlying mood disorders, ADHD, and family relationship problems. Even without treatment, most cases of VOR gradually improve over time.

The treatment of choice is primarily a behavior modification program that uses deserved punishment and rewards for past behaviors, designed to help the child develop more socially acceptable behavior. In addition, many children with SAD have little or no social skills, so group therapy to help them develop social skills may be effective. Sometimes medications used to treat depressive disorders may be effective.