“So what? He’ll grow out of it.” Oppositional Defiant Disorder in Primary Care

John V. Lavigne, PhD

aSpring 2001

Everyone who has worked  with or raised a young child knows about the “terrible twos.” This term refers to that set of behaviors associated with being two years old, in which the child becomes increasingly willful, stubborn, and demanding, with frequent temper tantrums as the all-too-common result. Of course, everyone also knows that the children all “grow out of it.”

Indeed, the twos can be terrible, and few children’s bids to become more autonomous are completely trouble-free. But some children cross a line that separates the normal “terrible two” behavior from a rather more serious problem and develop a disorder known as oppositional defiant disorder (ODD). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994) defines ODD as a condition in which the child shows “a pattern of negativistic, hostile, and defiant behavior lasting at least six months,” for which at least four of the following behaviors are present. The child:

1. Often loses his or her temper
2. Often argues with adults
3. Often actively defies or refuses to comply with adult requests or rules
4. Often deliberately annoys people
5. Often blames others for his or her mistakes or misbehavior
6. Is often touchy or easily annoyed by others
7. Is often angry and resentful
8. Is often spiteful or vindictive

To be considered to have ODD, the child must engage in those behaviors at rates higher than expected for children of similar developmental level, and the problem must cause clinically significant impairment in social, academic, or occupational functioning. Not many preschoolers have jobs, but the social impact of ODD symptoms on family life can be considerable. Spend a little time listening to a child’s parent describe his or her daily struggles with the young child, and this becomes clearer. Life begins to revolve around these difficult children, and the parents can become very stressed. Prolonged and frequent temper tantrums, frequent struggles over the simplest tasks, “tiptoeing around” the child, ruined vacations and daily activities, losing babysitters because of the child’s behavior, finding that “only my sister” will babysit for the child, or that the child is about to be kicked out of preschool—such stories mean you need to listen carefully to the full panoply of events the child precipitates to determine if ODD is present. When the mother is ready to pull her hair out pretty regularly, it’s time to consider a diagnosis of ODD.

To be sure, there is sometimes an ambiguous line between normal “terrible two” behavior and the behavior of the child with ODD, but the line is less ambiguous than some believe. The diagnostic reliability of ODD, along with a number of other aspects of the disorder, has been investigated in research conducted at Children’s Memorial throughout the 1990s and ongoing. This has involved a longitudinal study of ODD and other behavior problems (the Preschoolers’ Project), followed by a more recent effort, still in progress, to examine ways to intervene in ODD through primary care settings (Pediatric Partners). These studies have been conducted with the deeply appreciated cooperation of over 60 pediatricians affiliated with the Pediatric Practice Research Group (PPRG).

Through this work, we have learned that mental health professionals can diagnose ODD in children ages 2–5 years with at least moderate reliability, at a level as good or better than most other child psychiatric disorders. We have also learned that the term “terrible twos” seems like a bit of a misnomer, at least at the severity that warrants an ODD description. Certainly, ODD is common in two-year-olds (prevalence in primary care settings, 13% overall, 7% severe), but it is even more common among three-year-olds (22% overall, 13% severe). Maybe we should be talking about the “terrible threes.”

The prevalence data obtained through this study of preschoolers provide an estimate of the frequency of behavioral problems among children ages two to five years as they present in pediatric primary care practices (Table). This study shows an overall prevalence of 21%, with 9% considered “severe” by virtue of the functional impairment accompanying the disorder. Most of the children exhibit ODD (prevalence rate 17%, 8% severe). While ODD is a relatively common psychiatric disorder among school-age children, the rate is lower than among preschoolers. What happens to the preschoolers who exhibit ODD?

Well, some of them “grow out of it,” but a substantial number do not. After two to three years, approximately 50% of children with ODD no longer have that problem. Of course, 50% still do. Among children seen in primary care who exhibited ODD for two consecutive years, 67% still had ODD in the third year. After approximately five years, only 20% still had ODD, a rate three times higher than children who did not exhibit ODD initially. Perhaps more importantly, 60% of the children with ODD initially still had some psychiatric diagnosis after five years, a rate much higher than that for children who did not have an initial psychiatric disorder.

When most authors talk about the long-term significance of ODD, they do so in reference to conduct disorder. A more serious problem, conduct disorder includes problems of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious rule violations (e.g., running away from home). Finding ways to reduce conduct disorder (CD) is important because it is relatively resistant to treatment, and the connection between ODD and CD is significant: while the majority of children with ODD never develop CD, most children with CD initially had exhibited ODD. Thus, ODD can serve as a partial marker for the development of CD.

What our data show is that ODD might best be considered a general marker for the development of later psychiatric disorder; one might say that ODD is the mother of many other diagnoses among young, school-age children. The number of children ages two to five who had ODD at their initial evaluation and who still have ODD as a single diagnosis five years later is relatively small. More common is the development of ODD “comorbid” with another disorder, i.e., ODD occurring in conjunction with another psychiatric disorder. Children who initially had ODD would often exhibit ODD comorbid with attention deficit disorder with hyperactivity (ADHD), ODD with an anxiety disorder, or ODD with a mood disorder. Other children who began with ODD later exhibited ADHD alone. Few children converted to develop a mood disorder or anxiety disorder without first exhibiting ODD. ODD with mood disorder is a particularly serious combination because of its association later with drug use. Among students of the development of psychopathology, ODD is said to exhibit multifinality, the tendency for a single disorder to show several different outcomes. The pathways involved in linking the initial state of having ODD with any of these later manifestations of disorder have yet to be sorted out. Did the child who eventually develops ODD and a mood disorder have a mood disorder that was always present but masked by ODD symptoms? Or did the child encounter so many life problems because of ODD (less satisfying peer, parent, and teacher relationships) that depression developed? We do not know.

ODD is also a relatively treatable disorder if intervention begins in preschool or early school years. In conjunction with PPRG practices, we are currently studying ways of intervening through primary care settings, comparing outcomes of children whose parents’ training is conducted by nurses and psychologists to outcomes of children receiving usual care. The primary care setting is particularly important for providing treatment because ODD is often more apparent at home than in school, thus allowing intervention at an early age. With proper screening and the right intervention efforts, reducing both ODD and its sequelae may become increasingly possible.

REFERENCE

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.

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