Oppositional Defiant Disorder (ODD)
What is it?
ODD is a psychiatric disorder that is characterized by two different sets of problems. These are aggressiveness and a tendency to purposefully bother and irritate others. It is often the reason that people seek treatment. When ODD is present with ADHD, depression, tourette's, anxiety disorders, or other neuropsychiatric disorders, it makes life with that child far more difficult. For Example, ADHD plus ODD is much worse than ADHD alone, often enough to make people seek treatment. The criteria for ODD are:
A pattern of negativistic, hostile, and defiant behavior lasting at least six months during which four or more of the following are present:
1. Often loses temper
2. often argues with adults
3. often actively defies or refuses to comply with adults' 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 and vindictive
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
How often is "often"?
All of the criteria above include the word "often". But what exactly does that mean? Recent studies have shown that these behaviors occur to a varying degree in all children. These researchers have found that the "often" is best solved by the following criteria.
Has occurred at all during the last three months-
8. is spiteful and vindictive
5. blames others for his or her mistakes or misbehavior
Occurs at least twice a week
6. is touchy or easily annoyed by others
1. loses temper
2. argues with adults
3. actively defies or refuses to comply with adults' requests or rules
Occurs at least four times per week
7. is angry and resentful
4. deliberately annoys people
What causes it?
Like most psychiatric illnesses, there are three main causes: environment, genetics, and medical problems
ODD is diagnosed in the same way as many other psychiatric disorders in children. You need to examine the child, talk with the child, talk to the parents, and review the medical history. Sometimes other medical tests are necessary to make sure it is not something else. You always need to check children out for other psychiatric disorders, as it is common the children with ODD will have other problems, too.
Diseases that look like ADHD and ODD
There are a number of sleep disorders which can look like ODD or make it worse.
Who gets it?
A lot of children! This is the most common psychiatric problem in children. Over 5% of children have this. In younger children it is more common in boys than girls, but as they grow older, the rate is the same in males and females.
ODD rarely travels alone - Comorbidity
It is exceptionally rare for a physician to see a child with only ODD. Usually the child has some other neuropsychiatric disorder along with ODD. The tendency for disorders in medicine to occur together is called comorbidity. Understanding comorbidity in pediatric psychiatry is one of the most important areas of research at this moment.
Common patterns of comorbidity
ODD plus ADHD
If a child comes to a clinic and is diagnosed with ADHD, about 30-40% of the time the child will also have ODD.
ODD plus Depression/Anxiety
This is the other common combination with ODD. If you look at children with ODD, probably 15-20% will have problems with their mood and even more are anxious.
What happens to children who have this when they grow up?
There are three main paths that a child will take.
First, there will be some lucky children who outgrow this. About half of children who have ODD as preschoolers will have no psychiatric problems at all by age 8.(19)
Second, ODD may turn into something else. About 5-10 % of preschoolers with ODD will eventually end up with ADHD and no signs of ODD at all. (19) Other times ODD turns into conduct disorder (CD). This usually happens fairly early. That is, after a 3-4 years of ODD, if it hasn't turned into CD, it won't ever. What predicts a child with ODD getting CD? A history of a biologic parent who was a career criminal, and very severe ODD.
Third, the child may continue to have ODD without any thing else. However, by the time preschoolers with ODD are 8 years old, only 5% have ODD and nothing else.
Fourth, They continue to have ODD but add on comorbid anxiety disorders, comorbid ADHD, or comorbid Depressive Disorders. By the time these children are in the end of elementary school, about 25% will have mood or anxiety problems which are disabling. That means that it is very important to watch for signs of mood disorder and anxiety as children with ODD grow older.
What is the difference between ODD and ADHD?
ODD is characterized by aggressiveness, but not impulsiveness. In ODD people annoy you purposefully, While it is usually not so purposeful in ADHD. ODD signs and symptoms are much more difficult to live with than ADHD. Children with ODD can sit still.
What difference does it make if you have ADHD or ADHD plus ODD?
A lot! Children and adolescents with ADHD alone do things without thinking, but not necessarily oppositional things. An ADHD child may impulsively push someone too hard on a swing and knock the child down on the ground. She would likely be sorry she did this afterward. A child with ODD plus ADHD might push the kid out of the swing and say she didn't do it.
Medical Interventions
ODD and CD are usually co-morbid with other problems. If your child has another co-morbid condition, you should look at the handout for information on the medical and non medical treatment of that disorder
When do you consider medications?
There are three reasons to consider this
1. if medically treatable CO-morbid conditions are present (ADHD, depression, tic disorders, siezure disorders, psychosis)
2. If non-medical interventions are not successful.
3. When the symptoms are very severe.
Which drugs do you use?
In choosing drugs for ODD, I look for drugs that have been proven safe in children, have no long term side effects, and have been found in research studies to be effective in extremely aggressive children and adolescents or in Comorbid conditions which children with CD often have. Each drug has certain problems that need to be watched for. The current medical literature suggests three basic principles when using psychiatric drugs in children. 1) Start low, 2) Go slow, and 3) Monitor carefully
What do you mean by Start low?
This means that you do not start any of these drugs at the usual dose, or the maximum dose. When you have pneumonia, it can be a real emergency. You want to give people plenty of medicine right away, and if there are problems, then you reduce it. Unfortunately, many people use this same strategy in the medical treatment of ODD. The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines. So I start with the lowest dose possible. For example, if I use a drug called Clonidine, for a boy about 60 lb., I know that the dose that will probably work for most boys that size is two pills a day. If I gave him that to start out with, I might win and it would work. But if he happens to be sensitive to that drug, he could have big problems. Although they would be reversible problems, it would probably make most children and adolescents and or parents never want to take the drug again. So what do I do? I start with a half of a pill a day, about 25% of the usual dose. That way if the child is sensitive to the drug, it causes little problems. I also find that many children respond to drugs at very low doses, far below the usual recommendations.
What do you mean, go slow?
ODD is not an acute illness. Less than 10% of the people I see with this need to be treated very quickly. Most people whom I see with this problem have had it for years. As a result, there is no need to increase the dose quickly. By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly. Also, it is easier to find the lowest effective dose.
What do you mean, monitor?
For each of the medical treatments for ADHD, there are specific side effects which need to be checked regularly. Some common ones (see individual drugs below) are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications. In this way, if there is a problem, we can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.
If the child has any diagnosis besides CD or ODD first try the drugs for that condition.
If that fails, or they don’t have a comorbid disorder then-
Drugs which are used for Violence, Oppositionality, and aggression regardless of diagnosis
These are drugs which have been tested in adults and children who are violent and aggressive for a variety of reasons - from ADHD to brain damage, to Conduct Disorder, and of course ODD.
First choice-
Atypical Antipsychotics
These drugs were first used for schizophrenia, and that is how they got this name. They are now commonly used for many conditions where people are not psychotic. As you can see, these are not benign medications. All of them can have serious side effects. As a result, they are not used for small problems.
Risperidone (Risperidal)
This drug was initially developed to be a safer drug for adult schizophrenia. It was then found to be effective in children with schizophrenia and other psychoses. Then it was found to be helpful in some children with Tic disorders. Based on those findings it has been used in Conduct Disorder and ODD. In 2006, a large study of the use of this drug in over 500 children with ODD and/or CD found that it was much better than placebo and that this improvement was still present 6 months later.
These studies are probably the most exciting news for the medical treatment of CD in 20 years. Risperidone is called Risperidal and comes in a variety of sizes; 25mg, .5 mg, 1mg, 2mg and liquid. It also helps Tourettes and psychosis. Usually this is given twice a day. This drug usually shows an effect within hours of a dose. There are more studies done on this drug than all the other atypical antipsychotics combined.
Olanzapine (Zyprexa)
This drug was recently approved for mania in adults. It has been studied less in children. However the early reports are positive. The usual dose is about 5-15 mg a day. It comes in 2.5 mg, 5mg and 10 mg. It is also called Zyprexa. It is more expensive than Risperidone and in adults is associated with more weight gain. This can be given once a day.
Quetiapine (Seroquel)
This drug is a little different than the above drugs as it seems to cause very little problems with things like tremor and stiffness. In adolescents it can lower the blood pressure so the dose has to be increased slower. The dosage range is 200-800 mg a day. There are only a few articles on its use in children and adolescents, but these have been quite positive for mood disorders. I do not know of any study on using in CD. It comes in a 25mg and 100 mg size and has to be given twice a day. It is called Seroquel.
Third line drugs for ODD/CD
Clonidine
This drug was originally developed for treating blood pressure and it is very safe. It turns out to be useful for a lot of things. Tics, severe ADHD, detoxifying Heroin addicts, menopausal flushing, and sometimes autism with hyperactivity or severe aggression are the usual indications. The good thing about this is that it never aggravates tics, works when autism is present, and works in very aggressive children and adolescents who never sleep. It is safe for pre-schoolers and comes in a pill called dixarit that is sweet tasting and looks exactly like smarties. As a result, children and adolescents will easily take it. It also comes in a larger size. It is also used in autism, preschoolers, and very aggressive children and adolescents with ADHD and insomnia.
And the bad side?
About one out of every 10 to 20 people who take this will become depressed. It comes on within about 3-4 days and after the drug is stopped, it can take 3-4 days to clear. However, if you are not watching for this, you might think the child is depressed for another reason, and never stop the drug, thus leaving the child depressed. With careful monitoring, you will always pick this up if it appears.
This drug also has an effect on the heart. It can lower the pulse and blood pressure. To be cautious, I check an EKG before I start the drug and once the child is on it. I also check their blood pressure and pulse at every visit.
It will make some children sedated, but usually by cutting back the dose you can avoid this.
New and other mood stabilizerss
This includes three drugs at present, Gabitril, Tegretol Lamictal (Lamotrigine) Neurontin (gabapentin) and Topamax (Topiramate).
They are being used a fair amount in children as they have been tested for epilepsy in children. There is evidence that they are effective in adults with bipolar disorder but there are still no reports in the literature of careful trials of these drugs in children and adolescents. They are occasionally used in ODD/CD if all else fails. There are no good studies to show that they work.
So why use them?
Because nothing else has worked.
More non-Medical Interventions
Enlist others to help you
Caring for a child with ODD can take a lot out of anyone, especially if you are one of the main people the child is trying to aggravate. Some children with ODD and more children with ODD plus other psychiatric problems can require an incredible amount of patience, energy, and determination. Often this is more than any one or two human beings can provide. There is no natural law that states that all children can be managed by one or two reasonable parents. Many children are born who require three to five full-time parents. You may have one!
A_A (from this page
http://www.klis.com/chandler/pamphle...#_Toc135732025)
ODD and drugs
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