Learning to communicate and manage frustration is part of growing up. But some children don’t master those skills. If their frequent angry outbursts and aggressive behaviors interfere with family life, making friends or school performance, they may have oppositional defiant disorder (ODD), which, by some estimates, affects up to 16 percent of school-age children. Though no statistics are available for younger children, experts say that most children with ODD show signs of the disorder in the preschool years.

At the Yale Medicine Child Study Center, we have expertise and experience treating ODD as well as other mental health conditions that affect children. This is key since ODD often is accompanied by other mental health conditions and we offer access to an array of treatment options for complicated cases. 

Oppositional defiant disorder describes a pattern of angry/irritable mood, argumentative/defiant behavior, and/or spitefulness that lasts at least six months. This pattern also must be present in multiple settings and occurs almost daily in children younger than 5, and at least once a week in older children. (By 6 or 7 years old, most children have learned to express anger in productive, socially acceptable ways.)

Examples of anger and irritable mood include frequent loss of temper and being easily annoyed or resentful. Argumentative and defiant behavior includes refusing to obey rules, continually challenging authority, being deliberately annoying to others and/or blaming others for mistakes or bad behavior. Acting in spiteful or vindictive ways frequently (at least twice in six months) is another red flag.

While parents are usually first to notice something is amiss with a child’s behavior, a professional assessment provides valuable context in understanding what’s going on, says Denis Sukhodolsky, PhD, Yale Medicine Child Study Center clinical psychologist. 

Yelling, screaming, and fighting with siblings are common preschool behaviors, Sukhodolsky says. “Our first job is to evaluate how often temper tantrums and anger outbursts occur and whether or not, in number and intensity, they are proportionately appropriate, given a child’s age,” he says.

Many children with ODD have other mental health challenges, such as anxiety, mood disorders, and language and learning disorders, he says. Trauma, parenting, styles and other environmental issues may also contribute. For children facing many frustrations, the angry outbursts are often “just the tip of the iceberg,” Sukhodolsky says. “We don’t just evaluate the anger,” he says, “we look at the full spectrum of mental health disorders and how they are affecting a child’s life.”

As with many mental health conditions, ODD occurs on a continuum. Children with mild ODD may show symptoms only at home or only at school. Moderate ODD may be the diagnosis when a child’s ODD behaviors happen in two settings. ODD is classified as severe when the acting out is seen in three or more settings.

Assessing a child for ODD involves a comprehensive medical history and interviews. For children under 8, Sukhodolsky bases his assessment on information from parents and, perhaps, teachers or medical professionals. Older children speak for themselves.

Sukhodolsky says that his experience and training have taught him ways to elicit information without making a child feel threatened, uneasy or angry. For example, “I don’t ask a child if he gets into fights at school,” he says. “What I might ask instead is, ‘Does anyone give you a hard time at school?’”

While some children with ODD may take medication for other problems (such as anxiety), the primary treatment is psychotherapy with the goal of helping the family communicate calmer and manage frustration better.

There are many different approaches, but the Child Study Center relies mostly on two types for treatment of ODD. Cognitive behavioral therapy (CBT) teaches children to use new, more effective strategies to regulate their emotions, thoughts and behaviors. “CBT is conducted with the child, but the parent is deeply involved,” Sukhodolsky says. Parents may be present for the entire session or may take part at the beginning or end.

The other therapeutic approach is called parent management training (PMT), which gives parents new techniques for managing a child’s misbehavior.

Sukhodolsky illustrates how this works with the example of a 10-year-old boy who fights with his mother when she tells him to put his clothes in the hamper. A therapy session might be devoted to helping the child take apart the pieces of this interaction, its timing, the emotions involved for him and his mom, and the consequences, which Sukhodolsky sums up concisely as: “Nobody benefits!”

For her part, mom might be encouraged to learn about her son’s favorite video games and the levels of play—and try to understand why stopping in the middle of a level might be upsetting. This may help her realize that she could reframe her request, respecting her son’s wish to complete his level and then clean up. The result? “Parents and children both learn different strategies and actions that help them communicate better, with less anger,” Sukhodolsky says.

Both of these therapeutic approaches focus on emotion regulation, so that parents and child can understand the triggers for angry outbursts. Next comes problem solving, to explore potential solutions that everyone can accept, followed by a discussion on consequences. Rewards are emphasized over punishments. Sukhodolsky urges families to emphasize positive interactions over bribes. 

“Nothing is more rewarding to a child than positive interaction in the family,” he says. “We help families learn to enjoy spending time together and that becomes the biggest motivation for reducing the angry outbursts.” He says that this treatment approach works for 65 percent of the families he sees, defining success as a measurable reduction (“We look for 50 percent,” he says.) in the frequency and intensity of outbursts.

At the Child Study Center, we have expertise in all mental health conditions that affect children—not just ODD and issues related to anger and aggression. “We treat the whole child, not just the angry behavior,” Sukhodolsky says. That’s important because ODD often accompanies other mental health conditions.

“We use time-honored therapeutic approaches that are applied in a focused and systematic way,” he says. “If psychotherapy on its own doesn’t get enough traction, we have other resources to offer. Oftentimes one treatment approach doesn’t work in isolation. Yale provides access to a wide range of mental health services for children with complicated profiles.”

Equally valuable, he says, is that the Child Study Center is a preeminent research institution engaged in ongoing study of child mental health issues. “We always want to make treatments better,” he says. “It’s good that 65 percent of patients respond to the treatment we offer. But what about the 35 percent who don’t?”

We are focused on helping children reach their full potential, above and beyond their mental health issues. “There is a lot of work that still has to be done, and we do that work at Yale,” Sukhodolsky says. “Our clinical services reflect cutting-edge research.”