Oppositional defiant disorder (ODD): symptoms, causes and treatment

ODD is about a pattern, not a single bad day. NICE's guideline on antisocial behaviour and conduct disorders says the core symptoms to assess in children under 11 are patterns of negativistic, hostile or defiant behaviour. In children over 11 the guideline looks for aggression to people and animals, destruction of property, deceitfulness or theft and serious violations of rules, which is closer to conduct disorder.

NICE also says assessment should cover current functioning at home, at school or college and with peers. In other words, the question is whether the behaviour is persistent and is affecting the child's life, not whether they sometimes argue or refuse.

• Persistent negativistic, hostile or defiant behaviour, particularly in children under 11.

• Behaviour that shows up across settings, such as home, school and with friends.

• Behaviour that affects how the child manages day to day, including school and relationships.

ODD is a behavioural diagnosis in children and young people. In UK guidance it sits within the wider group of conduct problems that NICE covers in its guideline on antisocial behaviour and conduct disorders in children and young people aged under 19. The guideline gives recommendations for children who have, or are at risk of, ODD or conduct disorder.

Challenging behaviour on its own does not mean a child has ODD. The NHS describes challenging behaviour as behaviour that puts the person or those around them at risk or leads to a poorer quality of life, and notes it is often seen in people with health problems that affect communication and the brain, such as learning disabilities. A proper assessment looks at the reasons behind the behaviour.

There is no single cause. NICE discusses risk factors in its guidance on preventing conduct disorders. It lists individual risk factors such as low school achievement and impulsiveness, family risk factors such as parental contact with the criminal justice system and child abuse, and social risk factors such as low family income and little education. NICE says risk can also be higher where there is parental conflict, separated or divorced parents, or parental mental health or substance misuse problems.

These are risk factors, not causes that apply to every child. Many children with some of these factors do not develop ODD, and children without them sometimes do. NICE also asks professionals to be aware that many children with a conduct disorder may have had poor or punitive experiences of care and may be mistrustful of offers of help as a result.

NICE says an initial assessment should be undertaken if a child's parents or carers, health or social care professionals, school or college, or peer group raise concerns about persistent antisocial behaviour. It suggests considering the Strengths and Difficulties Questionnaire, completed by a parent, carer or teacher.

The initial assessment looks for significant complicating factors: a coexisting mental health problem (for example depression or post-traumatic stress disorder), a neurodevelopmental condition (in particular ADHD and autism), a learning disability or difficulty, and substance misuse in young people. If any are present, NICE says to refer to a specialist child and adolescent mental health service (CAMHS) for a comprehensive assessment. If none are present, a direct referral for an intervention can be considered.

A comprehensive assessment includes the child on their own, a parent or carer who can describe past and present behaviour, current functioning and parenting quality, and a look at the parents' or carers' own wellbeing. NICE says to assess risks, to look for abuse in line with local protocols, and to develop a care plan with the child and their family.

NICE recommends psychosocial interventions, not medicines. For children aged 3 to 11 with ODD or conduct disorder, or at high risk of developing it, the first recommendation is a group parent training programme. NICE describes these as based on a social learning model, typically with 10 to 12 parents in a group and 10 to 16 meetings of 90 to 120 minutes, using modelling, rehearsal and feedback to improve parenting skills. If the family cannot take part in a group, an individual programme is offered, typically 8 to 10 meetings of 60 to 90 minutes.

For children whose problems are severe and complex, NICE recommends individual parent and child training programmes of up to 10 meetings of 60 minutes. For foster carers and guardians of children aged 3 to 11, group or individual training programmes are offered.

NICE says parents might feel blamed for their child's problems or stigmatised by contact with services, and that professionals should address those concerns directly when offering parent training. The programmes are about giving parents tools, not about faulting them.

NICE says not to offer medicines for the routine management of behavioural problems in children and young people with ODD or conduct disorder. It does recommend methylphenidate or atomoxetine, within their licensed indications, for ADHD in children and young people who also have ODD or conduct disorder.

NICE says risperidone may be considered for short-term management of severely aggressive behaviour in young people with a conduct disorder who have problems with explosive anger and severe emotional dysregulation and have not responded to psychosocial interventions, started by a qualified professional with expertise in conduct disorders after a comprehensive assessment, and discontinued if there is no clinically important response at 6 weeks. The NHS also says that in extreme circumstances, if a child's behaviour is harmful to themselves or others and all methods of calming them have been tried, a doctor may prescribe medicine.

The NHS guidance on challenging behaviour suggests trying to understand why a child is behaving this way. For example, they might feel anxious or bored, or be in pain. If you can recognise the early warning signs, you may be able to prevent outbursts, such as by arranging a smaller group or one-to-one support if a large group makes your child anxious. Distraction can focus a child's energies elsewhere.

The NHS adds that a child might behave in a challenging way to get attention, in which case it suggests not responding directly to the behaviour, although you should not ignore them completely, and that if their behaviour puts them or someone else at risk you will need to intervene as calmly as possible. It says to ask a GP to refer you to a specialist if you are finding it hard to cope, and suggests carers seek support from others in a similar situation, such as through the Carers UK helpline.

NICE says not to regard a history of a neurodevelopmental condition such as ADHD as a barrier to assessment for conduct problems, and says assessment should look for ADHD and autism as significant complicating factors. If ADHD is present alongside ODD, treatment for the ADHD is in line with NICE's ADHD guideline.

The NHS describes ADHD in children as involving problems with attention, high energy levels and impulsiveness, usually starting before the age of 12. It also says many children, particularly under the age of 5, are easily distracted, impulsive and have high energy levels without having ADHD, because they may be tired, anxious or stressed.

On the NHS, concerns are usually raised with a GP, school, SENCO or health visitor, and a referral can be made to local children's services or CAMHS. NICE says local care pathways should have multiple means of access, including self-referral where possible, and should deliver parent training programmes in a variety of settings, including outside normal working hours and in the home or community.

Some families also see a private child psychologist or psychiatrist. NICE's recommendations on parent training programmes and on what a comprehensive assessment should include are the same whichever route you use, and it helps to share the findings with the GP and school so that support is joined up.