Approach

Treatment for oppositional defiant disorder (ODD) typically focuses on the most salient impairments for a given individual. Most commonly these involve the patient's interactions with parents, teachers, co-workers, and significant others; improving compliance to directives and reducing antagonism and oppositionality often feature prominently.

Behavioural interventions are the first-line treatment modality for the condition. Emotion regulation skills are usually required to address chronic irritability and enhance overall success with other intervention efforts. Problem-solving skills may be needed to help improve adaptive, successful, and pro-social decision making.

Parents of children with ODD should be involved throughout treatment and may themselves benefit from psychoeducation, behavioural parent training (BPT), and communication skills and, for adolescents, negotiation strategies. Evidence for the management of ODD in adulthood is scarce, but psychotherapy should be considered as appropriate to the individual and their symptomatology.

Behavioural treatment

Children and adolescents

Refer all children and adolescents with ODD (and their families) for behavioural interventions, which are the first-line treatment modality for the condition.[53][55][84][85][86] Most evidence-based interventions for ODD are provided to families by licensed outpatient mental health providers, although some research has examined alternative deliveries.[53][87][88]

Central to treatment of ODD is BPT, sometimes referred to as parent management training (PMT). BPT aims to teach effective and supportive parenting skills, counsel on the effective use of contingencies, and improve parent-child communication among other components.[89]

Many effective BPT interventions also include child-directed treatment components. These are typically based on cognitive behavioural therapy (CBT) interventions and may target areas such as emotion-regulation skills, problem-solving skills, or cognitive reframing.[53][90][91]

Specific empirically supported treatments of note include:

  • Parent-Child Interaction Therapy (PCIT)[92] ​Parent-Child Interaction Therapy Opens in new window

  • Incredible Years[93] ​The Incredible Years® Opens in new window

  • Problem-Solving Skills Training and Parent Management Training[91][94]

  • Parent Management Training - Oregon model[95]

  • Triple P Positive Parenting Program[96] ​Triple P Positive Parenting Program Opens in new window

  • Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH ADTC)​[90][97]

  • Coping Power.[98]

The majority of these interventions have primarily been tested in developed countries such as the US, the UK, and Australia, although some studies also support the use of cognitive behavioural interventions for ODD in developing country settings.[99][100] Note that the historical confounding of ODD and conduct disorder (CD) has impacted the literature on treatment for ODD.

Although most validated treatments for ODD focus on early to middle childhood, the principles of management in children can usually be applied to adolescents.

Adults

Refer adults with ODD to a specialist for consideration of psychotherapeutic interventions. Evidence for the treatment of adults with ODD is scarce; this may be due to the historical tendency to regard ODD as a childhood disorder. Until validated interventions for adult ODD are available, it is reasonable to take inference from evidence-based psychosocial treatments (EBTs) for ODD in childhood. Specifically, intervention components that target emotion-regulation skills, cognitive reframing, and problem-solving skills should be prioritised. Many effective treatments for children and adolescents - especially those grounded in CBT (e.g., dialectical behaviour therapy [DBT], acceptance and commitment therapy [ACT]) - include appropriate components to apply to the treatment of ODD in adulthood.

Pharmacotherapy

Do not give pharmacotherapy for the routine management of behavioural problems to people with ODD in the absence of comorbidities.[9][53] However, effective pharmacotherapy for any associated comorbid conditions (e.g., ADHD or CD) should be considered, which may help to reduce the severity of co-occurring ODD symptoms.[53][55][101][102]

See Attention deficit hyperactivity disorder in children and Attention deficit hyperactivity disorder in adults.

Safeguarding

A safeguarding assessment should be conducted as part of the management of ODD. It is recommended that this assessment includes positive and negative aspects of parenting, the parent-child relationship, positive and negative adult relationships within the child's family, including domestic violence, and parental wellbeing (covering mental health issues, substance misuse, and criminal behaviour).[53]

Risks that may be faced by the patient (e.g., risk of physical, sexual, and emotional abuse) should be assessed and managed. If required, a risk management plan should be developed for self-neglect, exploitation by others, self-harm, or harm to others in line with local protocols.[53]

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