What is the etiology of Oppositional Defiant Disorder?

The etiology of oppositional defiant disorder (ODD) is complex and multifaceted, involving a combination of biological, psychological, and social factors. Recent theories suggest that children with ODD may have deficits in specific cognitive and emotional skills that contribute to their oppositional behaviors. These deficits can include problems with executive functions such as working memory, task switching, and organized problem solving, as well as difficulties in emotional regulation, such as affective modulation. These skill deficits make it challenging for children to comply with adult demands, leading to what might appear as noncompliance or explosive behavior in response to seemingly normal requests. One study suggests that children with ODD have lower gray volume matter in the cerebellum, especially in areas of the brain involved in executive function. https://pubmed.ncbi.nlm.nih.gov/38795021/ 

There is no single known gene responsible for ODD, but several single nucleotide polymorphisms have been shown to be associated with increased risk for ODD, see sections on MAOA and 5-HTTLPR (SLC6A4) below. 

Parenting and the quality of parent-child relationships play a critical role in either exacerbating or mitigating these behaviors. The transactional model of ODD emphasizes the dynamic interactions between children and their parents. It suggests that the behavior of children with ODD and the reactions from their parents are interconnected and influence each other. For example, a parent’s response to a child’s noncompliance can either escalate or help manage the situation. If a parent reacts harshly or with frustration, it may worsen the child’s oppositional behavior. Conversely, parenting styles that are supportive and use positive reinforcement can help improve compliance and teach the child more effective emotional and behavioral regulation.

Research supports that consistent, predictable, and positive parenting practices are crucial in managing ODD. Strategies that involve clear communication of expectations, consistent consequences for misbehavior, and positive interactions when the child behaves appropriately can reinforce desired behaviors and reduce oppositional episodes. Moreover, teaching parents to anticipate potentially difficult situations (like bath time or dinner time as mentioned in the paragraph) and to plan strategies to handle these situations can prevent many behavioral episodes.

In addition to direct parent-child interactions, broader family dynamics and stressors also influence the manifestation of ODD. High levels of family conflict, stress, and instability can contribute to behavioral issues in children. On the other hand, a stable and supportive family environment can serve as a protective factor against the development of more severe behavioral problems.

Overall, understanding and addressing the specific skill deficits in children with ODD, alongside fostering supportive and structured parenting and family environments, are crucial for effective management and intervention in oppositional defiant disorder.

“Recent theories conceptualize children with oppositional defiant disorder as possessing deficits in a discrete skill set that lead to oppositional behavior.⁶ An apparently noncompliant child who “explodes” in response to a parental demand may lack the cognitive or emotional skills required to comply with the adult’s request. For example, a child may not have developed the skill of affective modulation, and tends to emotionally overreact, losing his or her capacity to reason. A child may possess deficits in his or her executive cognitive skills (e.g., working memory, ability to change tasks, organized problem solving). These deficits undermine the child’s ability to comply with adult demands. Such skill deficits are components of the transactional conceptualization of oppositional defiant disorder, which emphasizes the interaction of the children and parents, and the context of the behavior. An important feature of this model is the relative predictability of the context (e.g., bath time, dinnertime) and the parent and child behaviors that precipitate a child’s meltdown.” – AAFP https://www.aafp.org/pubs/afp/issues/2008/1001/p861.html 

Symptoms of Oppositional Defiant Disorder

Persistent, ongoing symptoms that last at least 6 months, and are excessive compared with what is usual for the child’s age.  

• Argumentative
• Angry or resentful
• Frequent temper tantrums
• Refusing to comply with requests, rules
• Deliberately disruptive
• Blames others for mistakes
• Frequent outbursts of anger
• Spiteful, seeks revenge
• Questions rules/authority
• Gender differences:
  • Boys are often aggressive
  • Girls are often manipulative or lying

Screening questions for Oppositional Defiant Disorder

In my opinion as a naturopathic doctor, though these questions lead to a diagnosis of ODD, they do NOT rule out other conditions. 

Diagnostic Criteria of Oppositional Defiant Disorder as per DSM- 5

At least four symptoms from the list below should have been present on most days for at least 6 months demonstrating a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness:

1. Often loses temper
2. Often touchy or easily annoyed
3. Often angry and resentful
4. Often argue with authority figures or, for children and adolescents, with adults
5. Often actively refuse or defy to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or misbehavior
8. The child has been spiteful or vindictive at least twice within the past 6 months                                                    

There should be evidence of impairment either in the form of distress (in the individual, family, peers, etc.) and/or negative impact on social, educational, occupational, or other important areas of functioning. The behaviors do not occur exclusively during substance use, psychotic, depressive, or bipolar disorder. The patients must not meet the criteria for disruptive mood dysregulation disorder.

Severity: ODD is considered mild if symptoms are confined to only one setting, moderate if at least two settings and severe if symptoms are present in three or more settings.

Conduct Disorder: Diagnostic Criteria 

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

Aggression to People and Animals

1. Often bullies, threatens, or intimates others
2. Often initiates physical fights
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle,knife, gun)
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
7. Has forced someone into sexual activity

Destruction of property

8. Has deliberately engaged in fire setting with the intention of causing serious damage
9. Has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or Theft

10. Has broken into someone else’s house, building or car
11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

13. Often stays out at night despite parental prohibitions, beginning before age 13 years
14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period of time
15. Is often truant from school, beginning before age 13

B. the disturbance in behavior causing clinically significant impairment in social, academic or occupational functioning

C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Specify whether: 

Childhood-onset type: individuals show at least one symptom characteristic of conduct disorder prior to age 10 years

Adolescent-onset type: individuals show no symptom characteristics of conduct disorder prior to age 10 years

Unspecific onset: criteria for diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of first symptom was before or after age 10. 

Specify if:

With limited prosocial emotions:

• Lack of remorse or guilt
• Callous -lack of empathy
• Unconcerned about performance
• Shallow or deficient affect 

Reference: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787 

What are the risk factors for developing Conduct Disorder and Oppositional Defiant Disorder? 

Risk factors for developing ODD include:

• Parent with history of ADHD, ODD or CD
• Parent with a mood disorder like depression or bipolar disorder
• Mother who smoked during pregnancy
• Parent who has drinking or substance abuse
• Exposure to lead or other toxins affecting brain growth
• Fetal alcohol syndrome
• Neglectful or absent parent
• Inconsistent discipline or corporal punishment
• Poor nutrition
• Abuse or neglect
• Family instability
• Developmental disorders

Reference: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787 

Why is the incidence of ODD higher in boys than girls?

Oppositional Defiant Disorder (ODD) tends to be more prevalent and severe in boys compared to girls. This may be due to the interplay of testosterone and other hormones. Testosterone, the primary male sex hormone, is linked to aggressive behavior. Higher levels of testosterone in boys can contribute to increased aggression and defiant behaviors. Studies have shown that testosterone can influence brain areas related to aggression and social dominance.

Similarly, testosterone may also impact social bonding and empathy. High levels of testosterone can decrease sensitivity to social cues and reduce prosocial behaviors, making it harder for boys with ODD to form positive social bonds. This is often due to the interplay of testosterone, vasopressin and oxytocin. 

Vasopressin, a hormone involved in water retention by the kidneys, also plays a crucial role in social behaviors, particularly in males. It promotes protective and territorial behaviors, contributing to social recognition and the formation of social bonds, especially paternal behaviors and mate guarding. On the other hand, oxytocin, often referred to as the “love hormone,” is critical for social bonding, sexual reproduction, and maternal behaviors. It fosters nurturing, trust, and social attachment, making it essential in forming maternal bonds and social connections. The interaction between these hormones is complex, with testosterone modulating the effects of oxytocin and vasopressin. High testosterone levels can dampen the bonding effects of oxytocin while enhancing the aggressive and protective effects of vasopressin. This interplay significantly impacts social behaviors, influencing how individuals bond and nurture one another. For example, oxytocin promotes nurturing and attachment behaviors, whereas vasopressin is more associated with protective and territorial behaviors, particularly in males.

Higher testosterone levels in males contribute to increased aggression and oppositional behaviors, which are hallmark features of ODD. Additionally, the role of vasopressin in promoting aggression and protective behaviors may further explain the higher prevalence of ODD in males. Lower oxytocin levels or reduced sensitivity to its effects might result in less nurturing and cooperative behaviors, potentially leading to more oppositional behaviors.

It should also be noted that some studies suggest that boys are more likely to externalize their stress through behaviors such as aggression and defiance, while girls may internalize stress, leading to anxiety and depression. The interaction between testosterone and social environment is crucial. Boys with higher levels of testosterone might be more sensitive to environmental triggers and stressors, which can lead to an increased risk of developing ODD when coupled with adverse social conditions such as inconsistent discipline, exposure to violence, or lack of positive role models.

• Testosterone modulates aggression https://www.sciencedirect.com/science/article/abs/pii/0031938495022465?via%3Dihub 

How is ODD diagnosed?

Diagnosing Oppositional Defiant Disorder (ODD) typically involves a combination of clinical interviews, behavioral assessments, and gathering information from multiple sources such as parents, teachers, and other caregivers. While primary care providers can initiate the diagnostic process for ODD, typically mental health professionals provide the final diagnosis. Here’s a breakdown of how ODD can be assessed in both primary care and specialized settings:

Diagnostic Tools in Primary Care

1. Clinical Interviews: Primary care physicians can conduct structured interviews with both the child and the parents to gather detailed information about the child’s behavior across different settings.
2. Questionnaires and Rating Scales: There are several standardized tools that can be used to assess symptoms of ODD. Note that many of the scales must be purchased and are intended for use by a mental health professional.  These include:
   • Vanderbilt ADHD Assessment: Primarily used to diagnose ADHD, the Vanderbilt also includes questions that identify ODD.  I prefer using the Vanderbilt, as the questionnaire is free. 
   • Connors Rating Scales: Widely used to assess behavior in children, these scales help identify symptoms of ODD, ADHD, and other behavioral issues. 
   • Child Behavior Checklist (CBCL): This is a comprehensive questionnaire that provides information about a wide range of emotional and behavioral problems, including those related to ODD.
   • Behavior Assessment System for Children (BASC): This system can be used for comprehensive assessment and provides a variety of scales, including those relevant to oppositional defiant behaviors.

Referral to Neuropsychology or Psychiatry

In some cases, primary care providers may refer a child to a specialist such as a child psychologist, psychiatrist, or neuropsychologist for further assessment. This is especially likely if:

• The diagnosis needs to be confirmed. (E.g., to set up educational resources, generate a 504 plan or IEP for a child.) 
• The diagnosis is unclear or the child’s symptoms are complex.
• There are co-occurring conditions (such as ADHD, anxiety, or mood disorders) that need to be evaluated.
• Specialized psychological testing or a more detailed behavioral analysis is required.

Additional Considerations

• Co-occurring Disorders: Children with ODD often have other co-occurring disorders, which can complicate the diagnosis. A thorough assessment to rule out or identify other conditions is crucial.
• Functional Assessment: Understanding the function of the child’s behavior in various environments can help in determining the appropriate interventions. This often requires observations across different settings (home, school) and can benefit from specialist involvement.

Differential Diagnosis and Comorbidities 

ODD vs ADHD:

Similarities between ADHD and ODD:

1. Overlap in Behavioral Issues: Both ADHD and ODD can involve issues with self-control and regulation. For example, children with either condition might show impulsivity or emotional dysregulation.
2. Co-occurrence: ADHD and ODD can co-occur; studies suggest that about 40% of children with ADHD also exhibit signs of ODD.
3. Impact on Social Interactions: Both disorders can negatively affect social interactions, peer relationships, and academic performance.
4. Management Strategies: Behavioral interventions are common to both, focusing on improving specific behaviors and managing symptoms through structured routines and consistent consequences.

Differences between ADHD and ODD:

• Core Symptoms:
  • ADHD is primarily characterized by inattention, hyperactivity, and impulsivity. It affects the person’s ability to maintain focus, stay organized, and follow through on tasks.
  • ODD is characterized by a pattern of angry or irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months. This is directed towards authority figures and is more than typical for a child’s developmental level.
• Causal Factors:
  • ADHD is often linked to genetic factors and differences in brain function and structure.
  • ODD can also have a genetic component, but it is more strongly associated with environmental factors, such as parenting styles, family dynamics, and social experiences.
• Nature of Symptoms:
  • In ADHD, symptoms are generally consistent across different settings (e.g., both at home and school).
  • In ODD, the defiant and oppositional behaviors are often more noticeable in specific contexts or in interactions with particular people.
• Treatment Approaches:
  • ADHD treatments may include stimulant medications, non-stimulant medications, and behavioral therapies aimed at increasing attention and reducing hyperactivity and impulsivity.
  • ODD treatments are primarily focused on behavioral therapies and parent training to manage and redirect behavior, with fewer options involving medication.

Identifying the differences:

• Vanderbilt ADHD assessment is my preferred tool, and can be used as an excellent screening tool for ADHD and reasonable tool for ODD. 

ODD vs. Depressive Disorder

Similarities between Pediatric Depression and ODD:

• Behavioral and Emotional Challenges: Both disorders can manifest in behavioral and emotional challenges that may affect a child’s functioning at home, in school, and in social situations.
• Impact on Social Relationships: Children with either pediatric depression or ODD may struggle with maintaining healthy peer relationships and might experience social isolation or conflicts.
• Co-occurrence: These two disorders can co-occur, meaning a child with one disorder may also develop the other. This overlap can complicate diagnosis and treatment.
• Family and Environmental Influences: Both conditions can be influenced by family dynamics and environmental stressors, such as parenting styles, family conflicts, or traumatic experiences.

Differences between Pediatric Depression and ODD:

• Core Symptoms:
  • Pediatric Depression is primarily characterized by persistent sadness, loss of interest in activities once enjoyed, changes in appetite or sleep, irritability, feelings of worthlessness or guilt, and in severe cases, thoughts of death or suicide.
  • ODD involves an ongoing pattern of angry or irritable mood, argumentative/defiant behavior, or vindictiveness towards authority figures that is more severe than typically observed in individuals of the same developmental level.
• Emotional Expression:
  • Depression in children often results in them appearing sad, withdrawn, or having a flat affect (lack of emotional expression).
  • ODD tends to manifest through outward expressions of anger, defiance, and irritability.
• Nature of Interactions:
  • Children with depression might withdraw from interactions or respond passively due to feelings of sadness or low energy.
  • Children with ODD are more likely to engage in confrontational or oppositional interactions, especially with authority figures.

Screening tools:

• https://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf
• PHQ-9 for adolescents: https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/GLAD-PC_PHQ-9.pdf 

ODD vs. Disruptive mood dysregulation disorder

• Shared symptoms: chronic negative mood and temper outbursts
• Severity, frequency and chronicity of temper outbursts are more severe in individuals with disruptive mood dysregulation disorder than those with oppositional defiant disorder

ODD vs Intermittent explosive disorder:

• Shared symptoms:high rates of anger
• Individuals with intermittent explosive disorder show serious aggression toward others that is not part of the definition of oppositional defiant disorder

Oppositional Defiant Disorder vs Intellectual disability (intellectual developmental disorder)

• Shared symptoms: oppositional behavior
• In individuals with intellectual disability, a diagnosis of oppositional defiant disorder is given only if the oppositional behavior is markedly greater than is commonly observed among individuals comparable mental age and with comparable severity of intellectual disability
• References:
  • Reference: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

ODD vs Language disorder

• Shared symptoms: failure to follow directions
• Must distinguish oppositional defiant disorder from a failure to follow directions that is the result of impaired language comprehension (e.g., hearing loss)

ODD vs Social anxiety disorder (social phobia)

• Shared symptoms: defiance
• Must distinguish oppositional defiant disorder from defiance due to fear of negative evaluation associated with social anxiety disorder 

ODD vs Autism Spectrum Disorder, formerly known as Asperger’s

• Patients with level 1 ASD (fka as Asperger’s) can have some similar symptoms of ODD, however the syndrome looks somewhat different.
  • Level 1 ASD is characterized by missed social and communication cues, restricted or repetitive patterns of behavior or interests, plus noticeable sensory issues. 
  • Consider diagnosis of ASD in a patient who struggles reading social/emotional cues, has difficulties in transitions, has rigid thinking patterns, is disturbed if their routine changes, and/or has sensory issues (picky eating, avoids certain sounds or textures).  ** In my opinion, ASD can look similar to ODD in many, many circumstances.  
  • In these cases the “rule breaking” or “defiance” can be because of distressing changes in routine, especially when rules or demands seem unfair or illogical.  In these cases the “ask” from the parent or teacher often causes significant distress to the patient, leading to defiance.
  • Autism “meltdowns” can certainly look similar to defiance, and can include hitting, breaking, punching, throwing.  Look out for sensory disturbances, or exhaustion.  Triggers can be sudden changes in routine, bright lights, itchy clothes, wet shoes, noises, smells, etc. 

Diagnostic Criteria for Autism Spectrum Disorder:

1. Persistent Deficits in Social Communication and Social Interaction Across Contexts, as manifested by all of the following, currently or by history:
   • Deficits in social-emotional reciprocity: This might range from abnormal social approach and failure of normal back-and-forth conversation to reduced sharing of interests, emotions, or affect, to failure to initiate or respond to social interactions.
   • Deficits in nonverbal communicative behaviors used for social interaction: This can include poorly integrated verbal and nonverbal communication, abnormalities in eye contact and body language, or deficits in understanding and use of gestures, to a total lack of facial expressions and nonverbal communication.
   • Deficits in developing, maintaining, and understanding relationships: This ranges from difficulties adjusting behavior to suit various social contexts, to difficulties in sharing imaginative play or making friends, to absence of interest in peers.
2. Restricted, Repetitive Patterns of Behavior, Interests, or Activities, as manifested by at least two of the following, currently or by history:
   • Stereotyped or repetitive motor movements, use of objects, or speech: Examples include simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases.
   • Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior: Examples are extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat the same food every day.
   • Highly restricted, fixated interests that are abnormal in intensity or focus: For example, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests.
   • Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment: Examples might include apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement.
3. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
4. These disturbances cause clinically significant impairment in social, occupational, or other important areas of current functioning.
5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

ODD vs. Pathological Demand Avoidance

Pathological Demand Avoidance (PDA) is a proposed sub-type of Autism Spectrum Disorder (ASD) characterized by an extreme avoidance of everyday demands and an anxiety-driven need to control situations. It is not officially recognized in all diagnostic manuals, such as the DSM-5, but it is gaining recognition, particularly in the UK, where it was first described. The concept of PDA helps explain the behaviors of some individuals on the autism spectrum who do not respond well to traditional approaches used for autism. The most essential part of PDA to acknowledge is that every-day demands cause a crippling anxiety for the patient, leading to resistance. 

Key Characteristics of ASD with Pathological Demand Avoidance:

1. Extreme Avoidance of Everyday Demands: Individuals with PDA might resist typical daily activities and requests that most people would find reasonable. This resistance is believed to stem from an anxiety-based need to control situations and avoid demands that feel overwhelming.
   • An overwhelming desire to be in in control and to avoid being controlled by others is key in seeing this diagnosis.  
2. Social Approach with Difficulties:
   • Surface Sociability: Individuals with PDA may appear socially adept, but this sociability is often superficial. They may have significant difficulties understanding social hierarchies and norms.
   • Manipulative or Socially Shocking Behavior: In an attempt to avoid demands, individuals might use social strategies that are deemed manipulative or socially inappropriate, such as being charming one minute and extremely oppositional the next.
3. Mood Swings and Impulsivity: People with PDA can display rapid mood changes and impulsivity. Their behavior can be unpredictable, and they may switch quickly from one emotional state to another.
4. Comfort in Role Play and Pretend: Engaging in role play or pretending to be other people, characters, or animals can be a prominent feature. This can sometimes be an escape mechanism from real-world demands.
5. Obsessive Behavior: While individuals with traditional ASD profiles might have repetitive and restricted interests, those with PDA may show obsessiveness about other people or controlling environments rather than objects or specific topics.
6. Emotional Outbursts: There are often intense emotional outbursts, which might seem disproportionate to the situation. These outbursts are typically triggered by anxiety when demands are placed upon them.
7. Resistance to Typical Autism Management Strategies: Traditional strategies for managing ASD, such as structured schedules and clear expectations, may not be effective for someone with PDA. They may perceive these as demands, increasing their anxiety and resistance.

In my opinion, treating patients with parenting techniques to help Pathological Demand Avoidance is highly effective, even if the patient does not meet criteria for PDA or ASD. 

ODD vs. Substance Use disorder:

• Shared symptoms with Oppositional defiant disorder: Avoidance, irritability, anger, argumentative, deliberately annoys others, blames others for his or her mistakes or misbehaviors, refuses to comply with requests from authority figures or with rules
• Shared symptoms with conduct disorder: risky behavior, deceitfulness, theft, violation of rules, aggression toward people or animals
• Poor family functioning, problems in school bonding, low academic achievement, and deviant peer relationships are among the shared risk factors for substance use and ODD
• Alcohol and drug use are frequently observed among teenagers and young adults grappling with Oppositional Defiant Disorder often serving as a coping mechanism for their underlying issues. Additionally, substance abuse can be a way to rebel against authority, exacerbating symptoms and leading to increased risky behaviors. This pattern of substance use can escalate into abuse, compounding the challenges faced by individuals already struggling with ODD.
• References:
  • https://childmind.org/guide/quick-guide-to-substance-use-disorder/
  • Gunes H, Tanidir C, Adaletli H, et al. Oppositional defiant disorder/conduct disorder co-occurrence increases the risk of Internet addiction in adolescents with attention-deficit hyperactivity disorder. J Behav Addict. 2018;7(2):284-291. doi:10.1556/2006.7.2018.46

ODD vs. Sleep Apnea

Pediatric patients with sleep apnea often exhibit symptoms that can overlap with those of Oppositional Defiant Disorder (ODD). Sleep apnea in children can lead to significant behavioral issues due to poor sleep quality and resultant daytime sleepiness. Some of the symptoms include:

• Irritability: Children with sleep apnea may become easily frustrated or angry.
• Hyperactivity: Similar to ADHD, sleep-deprived children may exhibit hyperactive behavior.
• Inattention: Poor sleep can impair concentration and focus, leading to difficulties in school and daily activities.
• Aggressive Behavior: Sleep apnea can lead to increased aggression and defiance.
• Mood Swings: Children may experience rapid changes in mood due to lack of restorative sleep.

ODD vs. Constipation: 

• Shared symptoms with Oppositional defiant disorder:  internalizing (negative affect, avoidance, irritability) and externalizing behavior problems (problematic behavior related to poor impulse-control, including rule breaking, aggression, impulsivity, and inattention)
• “Crosstalk exists between gut and brain through a complex communication system and has multiple effects on different behavioral aspects and higher cognitive functions…
• …On the other hand, behavioral problems in children with FC may be related to the effect of chronic illness. Any chronic illness has biological, social and behavioral impacts that affect the child psychosocial development and the family coping”
• References:
  • El-Sonbaty MM, Fathy A, Aljohani A, Fathy A. Assessment of Behavioural Disorders in Children with Functional Constipation. Open Access Maced J Med Sci. 2019;7(23):4019-4022. Published 2019 Dec 13. doi:10.3889/oamjms.2019.677 
  • Samek DR, Hicks BM. Externalizing Disorders and Environmental Risk: Mechanisms of Gene-Environment Interplay and Strategies for Intervention. Clin Pract (Lond). 2014;11(5):537-547. doi:10.2217/CPR.14.47
  • Liu J, Chen X, Lewis G. Childhood internalizing behaviour: analysis and implications. J Psychiatr Ment Health Nurs. 2011;18(10):884-894. doi:10.1111/j.1365-2850.2011.01743.x

ODD vs. Reactive hypoglycemia:

Pediatric patients with reactive hypoglycemia may present with symptoms that overlap with those of Oppositional Defiant Disorder (ODD). Reactive hypoglycemia, characterized by low blood sugar levels following a meal, can lead to a range of behavioral and emotional symptoms due to fluctuations in glucose levels. Some of the symptoms include:

1. Irritability: Children experiencing low blood sugar may become easily frustrated and irritable.
2. Mood Swings: Rapid changes in blood sugar levels can cause abrupt mood changes, contributing to unpredictable behavior.
3. Aggressiveness: Low blood sugar can result in aggressive behavior and defiance.
4. Anxiety: Children may experience anxiety or nervousness as a result of hypoglycemia.
5. Fatigue: Fatigue from low blood sugar can lead to decreased ability to cope with stress and frustration, potentially resulting in oppositional behavior.
6. Poor Concentration: Fluctuations in glucose levels can impair concentration and focus, similar to ADHD symptoms.

Single nucleotide polymorphisms and Oppositional Defiant Disorder

MAOA (MAOA-uVNTR)

The MAOA enzyme (monoamine oxidase A) is known for its role in breaking down neurotransmitters such as serotonin, norepinephrine, and dopamine in the brain. Variations in this gene, particularly the low-activity variants (sometimes referred to as MAOA-L or low MAOA activity), have been studied for their potential link to behaviors such as increased aggression or risk of psychiatric disorders under certain environmental conditions.

The MAOA-uVNTR (monoamine oxidase A-variable number of tandem repeats) polymorphism refers to a variation in the genetic sequence in the promoter region of the MAOA gene. This gene encodes an enzyme, monoamine oxidase A, which is critical for the metabolism of key neurotransmitters such as serotonin, norepinephrine, and dopamine. These neurotransmitters play significant roles in regulating mood, aggression, and emotional responses.

The MAOA-uVNTR polymorphism involves variations in the number of tandem repeats in the MAOA gene’s promoter region. These repeats can affect how much MAOA enzyme is produced. Typically, the polymorphism is classified into two main types based on the activity level of the enzyme:

• High-activity variants (3.5, 4 repeats): These variants are associated with a higher enzymatic activity, leading to faster breakdown of neurotransmitters.
• Low-activity variants (2, 3 repeats): These variants result in lower enzymatic activity, slowing the breakdown of neurotransmitters.

Research has explored the link between low-activity MAOA variants and behavioral issues, including aggression, impulsivity, and disorders like ODD. The proposed connection is that lower MAOA activity may lead to higher levels of neurotransmitters associated with aggressive and impulsive behavior, potentially contributing to the symptoms of ODD. However, it’s crucial to emphasize that genetic factors like the MAOA-uVNTR polymorphism interact with environmental factors (e.g., childhood trauma, family dynamics) to influence behavior. This interaction is often referred to as the gene-environment interaction.

The proposed mechanism by which the MAOA-uVNTR polymorphism might influence behavior, particularly in the context of ODD, includes:

1. Neurotransmitter Levels: Lower MAOA activity can lead to increased levels of neurotransmitters like serotonin, norepinephrine, and dopamine. Elevated levels of these neurotransmitters may disrupt normal brain functions related to emotion regulation, stress response, and impulse control.
2. Neural Circuits and Behavior: Changes in neurotransmitter levels can affect neural circuits that regulate mood and behavior. This might result in increased impulsivity, aggression, and difficulty managing anger—traits often observed in individuals with ODD.
3. Environmental Interaction: The impact of the MAOA-uVNTR polymorphism is particularly pronounced when combined with adverse environmental factors. For example, individuals with low-activity MAOA who also experience childhood adversity may have a higher risk of developing behavioral disorders like ODD due to their increased biological vulnerability to environmental stresses.

MAOA-uVNTR polymorphism severity is worse in males for several reasons. First, the MAOA gene is located on the X chromosome. Since males have only one X chromosome (XY) and females have two (XX), any genetic variation in the MAOA gene has a more direct effect in males. In females, the presence of a second X chromosome can provide a compensatory effect if the variant on one chromosome is less functional. Secondly, testosterone, which is higher in males, has been found to interact with MAOA gene expression. Higher testosterone levels combined with low MAOA activity might exacerbate tendencies towards aggression. Testosterone can modulate brain chemistry and behavior, often enhancing aggression, which might explain the increased severity of symptoms in males.

On the other hand, females benefit from the protective effects of estrogen and progesterone. Progesterone can be metabolized into neuroactive steroids, such as allopregnanolone, which influence brain function and mood. These metabolites can modulate neurotransmitter systems indirectly affecting the neuronal environment and potentially the expression of genes like MAOA. Estrogen can directly influence gene expression through estrogen receptors that interact with DNA. Specifically, estrogen has been shown to increase the transcription of the MAOA gene. This involves the binding of estrogen receptors to specific promoter regions of the MAOA gene, enhancing its expression.

5-HTTLPR (SLC6A4 serotonin transporter gene)

5-HTTLPR is a genetic variant of the serotonin transporter gene (known scientifically as SLC6A4). This variant affects how serotonin is transported in the brain. Serotonin (5-HT) plays a vital role as a neurotransmitter, influencing various behaviors including appetite, movement, aggression, and focus. Research has shown that impaired serotonin function can lead to significant issues, such as enhanced pain perception, anxiety, aggression, symptoms of attention deficit hyperactivity disorder (ADHD), and impulsivity, which are often observed in cases of substance abuse, oppositional defiant disorder (ODD), and personality disorders. Previous research has linked impulsive aggression, antisocial behaviors, and other types of disinhibited behavior to a malfunctioning serotonin system in the brain. Additionally, studies have identified a clear correlation between impulsive aggression and reduced serotonin levels in the cerebrospinal fluid. It has been suggested that ODD may also be linked to serotonin system dysfunctions. 5-HTTLPR is also suggested to be associated with increased risk for alcohol abuse, neurotic personality disorders, panic disorders, and depressive symptoms. 

The 5-HTTLPR variant consists of a short (s) and a long (l) allele, based on the number of repeats in the gene’s promoter region. The short allele typically leads to less efficient serotonin transport, which may influence brain function and, subsequently, behavior and mood. 

The relationship between 5-HTTLPR and oppositional defiant disorder (ODD) has been explored in various studies, focusing on how genetic predispositions might interact with environmental factors (like stress or parenting) to influence the development of ODD. Some research suggests that individuals carrying the short allele of the 5-HTTLPR may be more susceptible to developing behavioral issues, including ODD, especially when exposed to adverse environments. 

Currently the research shows interaction between 5-HTTLPR, MAOA uVNTR and various social stressors.  For example, Teenage delinquency is associated with the combination of 5-HTTLPR x MAOA uVNTR x family conflicts, OR sexual abuse.  However, research shows that positive child-parent relationships confers protective benefits, and those patients have the lowest delinquency scores. Note that research is not conclusive, and one study actually found that the long allele was associated with higher risks.  Most studies, however, show that the long allele confers greater resilience to stress and depression. 

Examination & Laboratory workup for Oppositional Defiant Disorder

Here’s what typically should be included in the physical exam and what signs a physician would look for to rule out comorbidities or other potential causes:

• Screening for Fetal Alcohol Spectrum Disorder.  Look for:
  • Small head circumference
  • Smooth philtrum (the groove between the nose and upper lip)
  • Thin upper lip
  • Small eye openings
• Screening for constipation – abdominal exam, checking for palpable stool in LLQ. 
• Screening for genetic abnormalities, dysmorphisms. Always check growth charts!

Here are some evidence-based laboratory tests and other recommended screenings:

1. Complete Blood Count (CBC) with differential: This is crucial to rule out anemia, which can cause symptoms of fatigue and irritability that might mimic or exacerbate behavioral issues.
2. Comprehensive Metabolic Panel (CMP): Though rare in a patient with ODD, a CMP can be helpful to rule out diabetes, major fluid/electrolyte dysfunction, kidney and liver disorders.  This test is part of my standard pediatric panel. 
3. Thyroid Function Tests (TSH and Free T4): Both hypo- and hyperthyroidism can lead to mood disorders and fatigue. Thyroid function tests can help identify these conditions, allowing for appropriate management which might improve behavioral symptoms if they are related to thyroid dysfunction.
4. Whole Blood Lead Level: There is evidence to suggest that increasing whole blood lead levels are associated with defiant behaviors, even at levels well below the commonly referenced value of 5 µg/dL (levels as low as 0.19 µg/dL have been associated with psychiatric conditions). Screening for lead exposure is especially important in children due to the neurotoxic effects of lead which can influence behavior.
5. Iron and Ferritin Levels: Iron deficiency has been linked to various neuropsychiatric disorders, including developmental and behavioral problems in children. Testing for iron levels and ferritin can help diagnose iron deficiency or anemia, which could contribute to symptoms like fatigue and irritability.
6. B12 and folate levels: poor methylation has been linked to a number of developmental problems, including ADHD, autism, depression, anxiety and more. 
7. Celiac Screening: Consider celiac testing in any patient with gastrointestinal comorbidities, including constipation.  For more information see the Constipation module. 
8. Random Urine Mercury Test: Although more commonly associated with autism spectrum disorder (ASD) than ODD, considering the potential effects of mercury toxicity on neurobehavioral health, this test may still be relevant, particularly if there is a known exposure risk or relevant symptoms.
9. RBC Zinc: also known as blood zinc, this test is more reliable than serum zinc.  Low zinc has been linked to aggressive behaviors in children. 
10. RBC Magnesium: also known as blood magnesium, this test is more reliable that serum magnesium.  Low magnesium has been linked to behavior problems in children. 
11. Consider serum copper.  Elevated serum copper, especially with low serum zinc is associated with poor psychological outcomes. 
12. Other testing:
    • Studies show that patients with ODD and Conduct Disorder have lower levels of oxytocin than otherwise normal patients.  ODD and CD patients have higher levels of testosterone than other patients.  However, measuring levels will probably not change your treatment plan.  
    • 4-point salivary cortisol testing may be useful for patients with chronic stress. 
    • Strongly consider organic acid testing (OAT)

Studies show that anemia, iron deficiency and B12 deficiency are linked to “externalizing behaviors:”  https://pubmed.ncbi.nlm.nih.gov/29897579/ 

Studies show that vitamin D deficiency in middle childhood is associated with behavior problems in adolescence. https://pubmed.ncbi.nlm.nih.gov/31429909/ 

 Studies show an inverse relationship between magnesium and zinc levels and behavior problems in children. https://pubmed.ncbi.nlm.nih.gov/38388752/ 

Assessing the stability of the parent/caregiver-child bond, and assessing the impact of defiant behaviors on the parent

To assess how well a parent is connecting with a defiant child, a clinician or primary care provider can ask a series of questions that explore the parent’s understanding, empathy, and communication strategies with their child. These questions can help identify areas where the parent might need additional support or guidance. 

Here are some example questions. Note that I do not typically ask ALL of these questions.  It is important to ask about specific examples of recent situations where the child was defiant.  It is also important to ask support and self-care questions, as well as examples of recent positive encounters with their child.  Encouraging parents/caregivers in what IS working is very helpful and raises their parenting confidence. 

General questions:

1. Can you describe a typical day with your child?
   • This question helps understand the daily dynamics and interactions.
2. How do you usually respond when your child becomes defiant or acts out?
   • This gives insight into the parent’s immediate reactions and strategies.
3. Can you give an example of a recent situation where your child was defiant? How did you handle it?
   • This helps in assessing specific incidents and the parent’s response.

Understanding and Empathy:

4. How do you think your child feels when they are being defiant?
   • This question gauges the parent’s empathy and ability to understand their child’s perspective.
5. What do you believe are the reasons behind your child’s defiant behavior?
   • Understanding the parent’s insight into potential triggers and underlying causes.

Communication Strategies

6. How do you communicate with your child when they are calm and not acting out?
   • This assesses the baseline communication skills and relationship.
7. What techniques do you use to calm your child down during a defiant episode?
   • Understanding the strategies employed for de-escalation.

Consistency and Structure

8. How consistent are you with rules and consequences?
   • Consistency is key in managing defiant behavior, and this question assesses how well the parent maintains it.
9. What kind of routine or structure do you have in place for your child?
   • A structured environment can help manage defiance, and this assesses the presence of such structures.

Support and Self-Care (***Always ask these questions! Having a defiant child seriously affects the mental health of the caregiver.***)

10. How do you take care of yourself when dealing with your child’s challenging behavior?
    • Parental self-care is crucial for effective parenting, and this question checks if the parent is looking after their own well-being.

11. Do you have support from family, friends, or professionals when dealing with your child’s behavior?
    • Understanding the support system available to the parent.

Positive Interactions

12. Can you share some positive interactions you have had with your child recently?
    • Focusing on positive experiences to assess if there is a balance in the relationship.
13. How do you praise or reward your child for good behavior?
    • This explores the reinforcement strategies used by the parent.

Behavioral Management

14. What are some strategies you have tried in the past to manage your child’s defiant behavior? How effective were they?
    • Assessing the parent’s experience with different behavioral management techniques.
15. Are there any specific challenges you face in connecting with your child?
    • Identifying unique or specific barriers the parent might be facing.

Reflective and Insightful Questions

16. How do you feel after dealing with a defiant episode with your child?
    • This assesses the emotional impact on the parent.
17. What do you think your child needs most from you during moments of defiance?
    • Encourages the parent to reflect on their child’s needs.

Treatment strategies for ODD

Parenting strategies for Oppositional Defiant Disorder

Parenting strategies are evidence-based and have been shown to significantly improve ODD symptoms. 

Online or in-person training programs for parents: 

• Incredible Years
  • Up to 8 years
  • www.IncredibleYears.com
    • Includes teachers, parents and child curriculum
    • Evidence-based program
    • Available through IncredibleYears.com, but it is very expensive, $550 for one year.  
• Triple p-positive parenting program
  • Baby program, under 12 program and teen program
  • https://www.triplep-parenting.com/us/triple-p/
    • $93.45 for 12 months
• Parent-child Interaction Therapy
  • Up to 8 years
  • www.pcit.org
    • Requires in-person parent “coaching”
    • See the website and click on “find a provider” 

Pamphlets: 

This pamphlet from American Academy of Child & Adolescent Psychiatry can be very helpful for parents: 

https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_odd_guide.pdf

Book recommendations:

• The Defiant Child: A Parent’s Guide to Oppositional Defiant Disorder by Douglas Riley, PhD.  Published 1997, but parents still find it helpful.  Some of the information is dated. 
• The Kazdin Method for Parenting the Defiant Child, by Alan Kazdin. This is an excellent book that gives very useful parenting strategies to avoid power struggles. 
• The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children.
• Also consider:
  • No Drama Discipline: The Whole Brain Way to Calm the Chaos and Nurture Your Child’s Developing Mind, from the writers of the Whole Brain Child
  • Oppositional Defiant Disorder Activities: 100 Exercises Parents and Kids Can Do Together to Improve Behavior, Build Self-Esteem, and Foster Connection, by Laura McLaughlin

I also strongly recommend TBRI, which is an attachment-based, trauma-informed intervention. It is best for children with toxic stress, traumas, or children who have experienced adversity. 

A note regarding Promoting First Relationships (PFR)

I highly recommend all naturopathic & integrative medicine pediatric providers get training in PFR. Promoting First Relationships (PFR) is an evidence-based program designed to enhance the relationship between caregivers and young children. “Nurturing parents & caregivers to nurture their young children.” The program focuses on strengthening the caregiver’s ability to read and respond to a child’s cues in a sensitive and nurturing manner.

Addressing Pathological Demand Avoidance

See “Pathological Demand Avoidance Treatment Plan” link in the documents section.

These handouts from PDA society is helpful: For teachers: https://www.pdasociety.org.uk/wp-content/uploads/2021/10/PDA-for-teaching-professionals.pdf 

For parents: 

Demand-Anxiety Cycle PDF in documents section 

Addressing potential MAOA 

See the “MAOA Treatment Plan” link in the documents section.  

Nutritional strategies

Blood-sugar balancing diet

See the “Balancing your child’s blood sugar” parent handout in the documents section. 

Balancing blood sugar is crucial in managing childhood behavior problems because blood sugar levels can significantly impact a child’s mood, energy levels, and cognitive function. Fluctuations in blood sugar can lead to irritability, difficulty concentrating, hyperactivity, and mood swings, which can exacerbate behavior problems. I cannot overstate the importance of a blood-sugar balancing diet for children with defiant behaviors.  The reasons for this include: 

• Mood Stability: Stable blood sugar levels help maintain a more consistent mood. Sudden spikes and drops can lead to irritability, anxiety, and aggression.
• Energy Levels: Consistent blood sugar levels ensure a steady supply of energy, reducing fatigue and hyperactivity, which can both affect behavior.
• Cognitive Function: Stable blood sugar supports better concentration, memory, and overall cognitive performance, helping children manage their emotions and behavior more effectively.
• Hormonal Balance: Blood sugar levels influence the release of stress hormones like cortisol and adrenaline, which can impact behavior.

Foods to Include and Avoid:

Include:

• Complex Carbohydrates: Whole grains (e.g., brown rice, quinoa, oats), vegetables, and fruits (especially high-fiber options like apples and pears).
• Protein: Lean meats, fish, eggs, dairy products, nuts, seeds, and legumes. 
• Healthy Fats: Avocados, nuts, seeds, olive oil, and fatty fish like salmon. 
• High-Fiber Foods: Vegetables, fruits, whole grains, and legumes. 

Avoid:

• Sugary Foods and Drinks: Candy, soda, fruit juices with added sugar, and desserts like cakes and cookies.
• Refined Carbohydrates: White bread, white rice, pastries, and other processed foods made with white flour.
• High-Glycemic Foods: Foods that cause rapid spikes in blood sugar, such as sugary cereals and white pasta.

Summary: PROTEIN, FIBER, FAT at most meals. No refined carbs or sugary foods without protein, fiber or fat. 

• At least ¼ of the child’s plate should be protein. Consider increasing this to ½ of the child’s meals and snacks.
• Include a source of fat at most meals. 
• Include fiber-containing foods at each meal and snack.  Nearly all vegetables contain fiber, and almost all fruits do as well, especially fruits with the skin left on (e.g., unpeeled apples).

Remember “avoid” does not mean that these children can never have refined carbohydrates, crackers, pastries, or candies. As long as there is not a medical reason to 100% eliminate these foods, it is always better to let kids have periodic access.  We know that children who have severely restricted diets often end up with inappropriate relationships with food.  These children are more likely to develop binge eating disorders.  “Avoid” means to limit on a day-to-day basis, and allow periodic unrestricted access.  I describe this to patients as follows: “In my house we talk about these foods as ‘party’ foods.  ‘Party’ foods are for party days.  For example, Christmas, Halloween, birthdays, etc.  Go ahead and let your child have unrestricted access on these days.  Don’t limit the amount that they have, but instead tell them to listen to their tummies and be done when their tummies tell them they have had enough.” 

Okay (but not great) handout on the Mediterranean Diet. See also “How to Balance Your Child’s Blood Sugar” handout. https://www.health.qld.gov.au/__data/assets/pdf_file/0032/946049/cardiac-meddiet.pdf

The Feingold Diet

The Feingold Diet is an elimination diet designed to manage hyperactivity and behavioral issues by removing certain artificial additives and naturally occurring substances. Developed by Dr. Benjamin Feingold in the 1970s, this diet primarily excludes artificial colors, artificial flavors, and certain preservatives such as BHA, BHT, and TBHQ. It also eliminates foods containing salicylates, which are naturally occurring compounds found in various fruits, vegetables, and other foods. The Feingold Diet does not currently have any evidence to support its use in Oppositional Defiant Disorder.  However, given the comorbidity of ADHD in patients with ODD, it is reasonable to give a Feingold Diet a try.  A Feingold Diet also limits preservatives and colorings typically found in highly processed foods.  Given that highly processed foods are associated with a number of long-term health consequences, I think it is reasonable to request parents to eliminate these foods. 

The Feingold Diet works by eliminating specific additives and chemicals that are believed to affect behavior and cognitive function. The theory is that some children are sensitive to these substances, which can exacerbate symptoms of hyperactivity, inattention, and oppositional behaviors. By removing these potential triggers, the diet aims to reduce behavioral problems and improve overall functioning. Potential benefits of a Feingold Diet for children with Oppositional Defiant Disorder include: 

1. Reduction in Behavioral Symptoms: Some studies and anecdotal reports suggest that children on the Feingold Diet show a reduction in oppositional and defiant behaviors. The removal of artificial additives may decrease irritability and impulsiveness, leading to better emotional regulation and compliance with rules. 
2. Improved Focus and Attention: By reducing the intake of substances that can negatively impact brain function, children may experience improved concentration and focus, which can help them better respond to everyday demands and reduce oppositional behaviors.
3. Enhanced Emotional Stability: The diet may help stabilize mood swings and reduce anxiety, contributing to fewer outbursts and aggressive responses to demands.

https://pubmed.ncbi.nlm.nih.gov/21127082

https://pubmed.ncbi.nlm.nih.gov/28121994

“Artificial food colors (AFCs) have not been established as the main cause of attention-deficit hyperactivity disorder (ADHD), but accumulated evidence suggests that a subgroup shows significant symptom improvement when consuming an AFC-free diet and reacts with ADHD-type symptoms on challenge with AFCs. Of children with suspected sensitivities, 65% to 89% reacted when challenged with at least 100 mg of AFC. Oligoantigenic diet studies suggested that some children in addition to being sensitive to AFCs are also sensitive to common nonsalicylate foods (milk, chocolate, soy, eggs, wheat, corn, legumes) as well as salicylate-containing grapes, tomatoes, and orange. Some studies found “cosensitivity” to be more the rule than the exception. Recently, 2 large studies demonstrated behavioral sensitivity to AFCs and benzoate in children both with and without ADHD. A trial elimination diet is appropriate for children who have not responded satisfactorily to conventional treatment or whose parents wish to pursue a dietary investigation.”

How to Implement the Feingold Diet

First, assess the ability of the parent to make major dietary changes.  In many cases these parents are overwhelmed already, and adhering to a strict dietary plan for their child may be very challenging.  Secondly, assess the child’s willingness to adhere to the diet, and any obstacles that may prevent adherence (e.g., schools giving kids candy as rewards).  I typically recommend a 30-day trial elimination diet followed by a challenge portion.  

1. Eliminate: the Feingold diet recommends eliminating the following food groups.  Note that I find the Salicylate elimination optional, as it limits some extremely healthy foods and can be somewhat confusing for parents.
   1. Artificial Colors: Synthetic dyes, such as Red 40, Yellow 5, and Blue 1.
   2. Artificial Flavors: Synthetic flavoring agents found in various processed foods.
   3. Artificial Sweeteners: Such as aspartame, saccharin, and sucralose.
   4. Preservatives: Including butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), and tert-butylhydroquinone (TBHQ).
   5. Certain Artificial Additives: Such as monosodium glutamate (MSG) and sodium benzoate.
   6. Optional: Salicylates: Naturally occurring compounds found in certain fruits, vegetables, and other foods. High-salicylate foods include apples, berries, grapes, oranges, tomatoes, almonds, and certain spices.
2. Start by identifying foods and products that contain artificial colors, flavors, preservatives, and salicylates. Create a list of these items and eliminate them from the child’s diet. Eliminate these foods for a full 30 days. 
3. Reintroduction: After a period of elimination, reintroduce foods one at a time to observe any changes in behavior. This can help identify specific triggers.
4. Monitor and Adjust: Keep a detailed food and behavior diary to track improvements and setbacks. Adjust the diet as necessary based on observed reactions.

Low salicylate diet:

As a part of a Feingold Diet, a low salicylate diet can be recommended in some circumstances. I should also note that I could not find any scientific evidence supporting a low salicylate diet.   It should ONLY be continued if a patient is truly sensitive to these foods. High salicylate foods to avoid include: 

• Fruits:
  • Apples

• Apricots
• Berries (all types, including strawberries, raspberries, blackberries, blueberries)
• Cherries
• Grapes and raisins
• Oranges
• Peaches
• Plums and prunes
• Tomatoes

• Vegetables
  • Alfalfa sprouts
  • Broccoli
  • Cucumbers (and pickles)
  • Peppers (bell and chili)
  • Spinach
  • Zucchini
• Nuts and Seeds
  • Almonds
  • Peanuts
  • Pine nuts
• Spices and Herbs
  • Curry powder
  • Paprika
  • Thyme
  • Oregano
  • Dill
  • Turmeric

• Other Foods:
  • Honey
  • Cider and cider vinegar
  • Wine
  • Orange Juice
  • Tea (herbal and regular)
• Beverages
  • Fruit juices from high-salicylate fruits

Gluten-free, dairy-free Elimination Diet

A gluten-free, dairy-free elimination diet has no direct evidence for use in Oppositional Defiant Disorder.  However, increasing evidence suggests that a GF/DF diet may be helpful for patients with autism and ADHD.  Note that the evidence is still mixed, and it appears that only a subset of children are sensitive to either gluten or dairy.  I would strongly recommend a trial of this diet for kids who have autism AND defiant behaviors, or who have Pathological Demand Avoidance.  As always, discuss with the parent the ability of the family to accomplish this diet, including the financial resources, how picky the child is, and the ability of the caregiver to understand and comply with this diet. 

The rationale for a GF/DF diet is in reducing gluteomorphins and caseomorphins, which are opioid peptides derived from the incomplete digestion of gluten and casein, respectively. Casein is a protein found in dairy products. These peptides can cross the intestinal barrier and enter the bloodstream, potentially affecting brain function by mimicking the action of opioid peptides and binding to opioid receptors. This interaction can exacerbate neurological effects, leading to increased irritability, reduced attention, heightened anxiety, and other behavioral issues. 

A gluten-free, dairy-free diet may also help modify the gastrointestinal microbiome, which has also been implicated in autism. Children with autism and other sensitivities often have increased intestinal permeability, which allows these peptides to enter the bloodstream more easily. This can further amplify their effects on the brain and behavior, contributing to symptoms such as aggression, hyperactivity, and social withdrawal. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11001083/ – Positive study on GF/DF diets for autism spectrum disorder. 

https://pubmed.ncbi.nlm.nih.gov/12223079/ – discussion of opiates in autism. 

(de Magistris et al., 2010; Elder, 2008). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747333/ – high rates of antibodies in autism population. 

Nutritional supplementation

See studies in the laboratory workup section which link low levels of certain nutrients to increased rates of aggression and behavior issues in children. 

Multivitamin/minerals

The study titled “Nutritional supplementation to reduce child aggression: a randomized, stratified, single-blind, factorial trial” published in J Child Psychol Psychiatry, investigated the effects of omega-3, multivitamins, and minerals combined with cognitive behavior therapy (CBT) on childhood aggression. The trial involved 290 children aged 11-12, divided into four groups: Nutrition only, CBT only, Nutrition + CBT, and Control. The children’s aggressive and antisocial behaviors were assessed at baseline, 3 months, 6 months, and 12 months post-treatment. Results showed that the Nutrition only group exhibited reduced externalizing behavior at 3 months, while the Nutrition + CBT group showed reduced behavior at 6 months. However, these effects were not sustained at 12 months, indicating short-term benefits of the interventions. Note that the nutritional supplement stopped at 3 months. Externalizing behavior = aggression, yelling, delinquency, impulsivity, defiance. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10234432/

1. Omega-3 Fatty Acids: Each child received a daily 200 ml drink (SmartFish Recharge) containing 1,000 mg of omega-3. This included:
   • 300 mg of DHA (docosahexaenoic acid)
   • 200 mg of EPA (eicosapentaenoic acid)
   • 400 mg of alpha-linolenic acid
   • 100 mg of DPA (docosapentaenoic acid)
2. Multivitamins: A daily chewable tablet containing 12 vitamins and seven minerals. I was not able to find exactly what was in this product. 
3. Calcium and Vitamin D: An additional fruit-flavored chewable tablet containing:
   • 600 mg of calcium
   • 400 micrograms of vitamin D

Note that the authors also performed a similar study which actually showed that supplementing children with omega-3 fatty acids actually reduced intimate partner violence. https://smartfish1.wpengine.com/wp-content/uploads/2023/07/reductions-of-intimate-partner-violence-resulting-fromsupplementing-children-with-omega-3-fatty-acids-portnoy-j-2018.pdf

Another study found that a mixed multimineral/multivitamin nutrient supplement improved symptoms in aggression. Over a 16-week open-label trial, participants received a micronutrient mix, which significantly improved parent-reported aggressive and violent behaviors, family functioning, and health-related quality of life. The nutrient mix included alpha-tocopherol (vitamin E), ascorbic acid (vitamin C), biotin, chromium, pyridoxal-5-phosphate (P5P), pyridoxine (vitamins B6), selenium, and zinc, The results indicate that micronutrient therapy is well-tolerated and effective, suggesting the need for further research through a double-blinded, randomized controlled trial to confirm these findings. https://pubmed.ncbi.nlm.nih.gov/28481642/  I think it should be noted that B12 and folate were not included in the nutrient supplement. 

Omega 3 fatty acids

See research summary above, Nutritional supplementation to reduce child aggression: a randomized, stratified, single-blind, factorial trial.

A few studies support the use of Omega 3 fatty acids in children with ODD, especially those who also have ADHD:

• This study shows improvement of ODD behaviors in children with ADHD.  Note, however, that the studied dose was 16.2 grams per day!! https://pubmed.ncbi.nlm.nih.gov/17629918/ 
• Children with behavioral problems and depression also benefit from a combination of omega 3 fatty acids and counseling combined, with a superior effect to counseling alone. https://pubmed.ncbi.nlm.nih.gov/27604240/ 
• For prevention, one study found that supplementing fish oil to infants (who were breastfed) decreases behavior problems later in childhood. https://pubmed.ncbi.nlm.nih.gov/32312337/ 
• Omega 3 fatty acids reduce aggression in children: https://pubmed.ncbi.nlm.nih.gov/29743128/ 
• Omega 3 fatty acids reduce antisocial behavior in children: https://pubmed.ncbi.nlm.nih.gov/32222821/ 
• Omega 3 fatty acids reduce behavior problems in children: https://pubmed.ncbi.nlm.nih.gov/25146492/ 
• **Preprint: Omega 3 fatty acids modestly but significantly reduce aggression in children and adults: https://www.sciencedirect.com/science/article/abs/pii/S1359178924000466?fr=RR-2&ref=pdf_download&rr=8876a9a31fd872aa 

Zinc

Research suggests that low zinc levels are associated with aggression in children.  One study showed that 10 mg of zinc supplementation did not significantly reduce aggressive behaviors in children.  However, the authors note that dietary changes were also occurring in the school at the same time as the trial, which could have affected nutrient intake in both the active and placebo groups.  Other trials have mixed data, or do not show a benefit.  However, none of the trial selected patients with baseline low zinc levels.  I strongly recommend zinc supplementation as a trial for children with aggressive behaviors who also have low zinc levels. 

Pharmaceutical Interventions

Stimulant medications (amphetamines like Adderall, Ritalin)

Stimulant medications, primarily prescribed for Attention-Deficit/Hyperactivity Disorder (ADHD), can be beneficial in managing Oppositional Defiant Disorder (ODD) when these conditions co-occur. These medications, including methylphenidate-based options like Ritalin and Concerta, and amphetamine-based options like Adderall and Vyvanse, work by increasing dopamine and norepinephrine levels in the brain. This helps improve attention, focus, and self-control, which can indirectly reduce oppositional and defiant behaviors by addressing the impulsivity and hyperactivity often seen in ADHD.

Though most studies suggest that amphetamines work best in children with co-existing ADHD, one study suggests that extended release amphetamines (adderall XR) improved ODD symptoms even in children without ADHD.  https://pubmed.ncbi.nlm.nih.gov/16750455/

Remember that the use of stimulants is often accompanied by side effects like appetite suppression, insomnia, stomachaches, and headaches, and some children may experience increased irritability or anxiety. Regular monitoring and adjustments by a healthcare provider are essential to manage these side effects and ensure the medication’s effectiveness.

Clonidine

Clonidine, an alpha-2 adrenergic agonist, is used off-label to treat Oppositional Defiant Disorder (ODD), particularly when comorbid with ADHD. It helps reduce symptoms such as hyperactivity, impulsivity, aggression, and emotional over-reactivity by decreasing norepinephrine release in the brain. Some small studies show improvements in behavior and conduct in children with ODD. https://pubmed.ncbi.nlm.nih.gov/12874489/ 

Intranasal oxytocin

Intranasal oxytocin has been suggested as a potential treatment for Oppositional Defiant Disorder (ODD) due to its role in enhancing social bonding and emotional regulation. Oxytocin is a hormone that influences social behaviors, trust, and emotional interactions. A new study indicates that administering oxytocin intranasally can lead to significant improvements in behaviors associated with ODD, such as reducing aggression and increasing prosocial behaviors. This treatment may help children with ODD form better connections with others, increasing empathy and reducing oppositional behaviors. The study suggests that oxytocin’s ability to enhance emotional and social processing could be particularly beneficial in mitigating the challenging behaviors seen in ODD​.  Treatment was with intranasal oxytocin (24 IU daily, or 12 IU daily if the weight is < 40kg). 

Additional considerations:

Neurofeedback

Neurofeedback has been explored as a treatment for Oppositional Defiant Disorder (ODD), focusing on altering brainwave patterns to improve behavior. Neurofeedback involves training individuals to modify their brainwave activity, which can help reduce symptoms of ODD such as aggression, defiance, and irritability. Studies suggest that children with ODD often exhibit dysregulated brainwave patterns similar to those seen in ADHD, with an excess of low-frequency brainwaves. Neurofeedback aims to reduce these low-frequency waves and increase mid-range waves, promoting more balanced brain activity.

Herbal medicine and/or other supplements

I would also consider the following supplements and/or treatment considerations in children with ODD:

• L-Theanine, especially if presenting symptom is anxiety
• St. John’s Wort / Hypericum perfoliatum, especially if presenting symptom is depression
• Resveratrol, to decrease neurological inflammation. Resveratrol has been shown to decrease the need for stimulant medications. https://pubmed.ncbi.nlm.nih.gov/32449130/ 
• NAC, especially if symptoms of OCD are present
• Saffron, especially if presenting with combined depression and anxiety, with cognitive deficits/brain fog
• Medicinal cannabis, as there is one small prospective study: https://pubmed.ncbi.nlm.nih.gov/34661540/