Assessment

There are two periods of developmentally normal oppo-sitional behavior: the "terrible twos," between 18 and 24 months of age, when the toddler behaves negatively as an expression of developing autonomy, and sometimes in adolescence, when the teenager is trying to separate from the parents and establish an autonomous identity. Unlike ODD, these stages usually last less than 6 months (see eBox 24-1).

A child with ODD reported by the parents may not show much oppositional behavior while being examined in the office. The symptoms of ODD that these children display are much more evident in interactions with people and situations that they know well. The child takes a self-defeating position in arguments with adults. The struggle becomes more important than the reality of the situation, such that the child may be willing to risk losing the object or activity rather than lose the argument. Even a significant delay by the child in complying with a parental request is seen as a victory by the child. The assessment of ODD should include direct information from the child and parents regarding symptoms, age of onset, duration, and degree of functional impairment.

If oppositional behavior is confined mostly to school and not much at home (except as it relates to schoolwork), additional diagnoses must be considered in the differential, including mental retardation, borderline intellectual functioning, a specific developmental disorder (e.g., learning disability), and most often, ADHD. No specific laboratory tests or pathologic findings can assist the clinician in making the specific diagnosis of ODD.

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