Oppositional defiant disorder

From Wikipedia, the free encyclopedia
Jump to navigation Jump to search
Oppositional defiant disorder
SpecialtyPsychiatry Edit this on Wikidata
Usual onsetchildhood or adolescence
TreatmentCognitive behavioral therapy, family therapy, intervention (counseling)

Oppositional defiant disorder (ODD) [1] is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness" in children and adolescents.[2] Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit.[3]


Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when conduct disorder is present.[4] According to Dickstein, the DSM-5 attempts to:

"redefine ODD by emphasizing a 'persistent pattern of angry and irritable mood along with vindictive behavior,' rather than DSM-IV's focus exclusively on 'negativistic, hostile, and defiant behavior.' Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is 'angry/irritable mood'—defined as 'loses temper, is touchy/easily annoyed by others, and is angry/resentful.' This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD".[5]


Oppositional defiant disorder has a prevalence of 1% to 11%.[6] The average prevalence is approximately 3.3%.[6] Gender and age play an important role in the rate of the disorder.[6] In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old.[6][7][8] However, it is very unlikely to emerge following early adolescence.[9] There is difference in prevalence between boys and girls. The ratio of this prevalence is 1.4 to 1 in favor of boys being more prevalent than girls before adolescence.[6] On the other hand, girls' prevalence tends to increase after puberty.[7] When researchers observed the general prevalence of oppositional defiant disorder throughout cultures, they noticed that it remained constant.[8] However, the sex difference in ODD prevalence is only significant in Western cultures.[8] There are two possible explanations for this difference which are that in non-Western cultures there is a decrease prevalence of ODD in boys or an increase prevalence of ODD in girls.[8] There are other factors that can influence the prevalence of the disorder. One of these factors is the socioeconomic status. Youths living in families of low socioeconomic status have a higher prevalence.[10] Another factor is based on the criteria used to diagnose an individual. When the disorder was first included in the DSM-III, the prevalence was 25% higher than when the DSM-IV revised the criteria of diagnosis.[10] The DSM-V made more changes to the criteria grouping certain characteristics together in order to demonstrate that ODD display both emotional and behavioral symptomatology.[11] In addition, criteria were added to help guide clinicians in diagnosis because of the difficulty found in identifying whether the behaviors or symptoms are directly related to the disorder or simply a phase in a child's life.[11] Consequently, future studies may obtain results indicating a decline in prevalence between the DSM-IV and the DSM-V due to these changes.

Signs and symptoms[edit]

The fourth revision of the Diagnostic and Statistical Manual (DSM-IV-TR) (now replaced by DSM-5) stated that the child must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder.[4] These symptoms include:

  1. Often loses temper
  2. Is often touchy or easily annoyed
  3. Is often angry and resentful
  4. Often argues with authority figures or for children and adolescents, with adults
  5. Often actively defies or refuses 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. Has been spiteful or vindictive at least twice within the past 6 months.[12][13]

These behaviors are mostly directed towards an authority figure such as a teacher or a parent. Although these behaviors can be typical among siblings they must be observed with individuals other than siblings for an ODD diagnosis.[12] Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behavior observed in conduct disorder.[13] Furthermore, they must be perpetuated for longer than six months and must be considered beyond a normal child's age, gender and culture to fit the diagnosis.[14][12] For children under 5 years of age, they occur on most days over a period of 6 months. For children over 5 years of age they occur at least once a week for at least 6 months.[12] It is possible to observe these symptoms in only 1 setting, most commonly home. Thus the severity would be mild. If it is observed in two settings then it would be characterized as moderate and if the symptoms are observed in 3 or more settings then it would be considered severe.[12]

These patterns of behavior result in impairment at school and/or other social venues.[14][15]


There is no specific element that has yet been identified as directly causing ODD. Researchers looking precisely at the etiological factors linked with ODD are limited. The literature often examines common risk factors linked with all disruptive behaviours, rather than specifically about ODD. Symptoms of ODD are also often believed to be the same as CD even though the disorders have their own respective set of symptoms. When looking at disruptive behaviours such as ODD, research has shown that the causes of behaviours are multifactorial. However, disruptive behaviours have been identified as being mostly due either to biological or environmental factors.[16]

Genetic influences[edit]

Research indicates that parents pass on a tendency for externalizing disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. Research has also shown that there is a genetic overlap between ODD and other externalizing disorders. Heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behavior is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolizing enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behavior following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.[17]

Prenatal factors and birth complications[edit]

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead,[18] and mother's use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance abuse prior to birth have also been associated with developing disruptive behaviours such as ODD.[19][20][21][22] Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological factors[edit]

Deficits and injuries to certain areas of the brain can lead to serious behavioral problems in children. Brain imaging studies have suggested that children with ODD may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control.[medical citation needed] Children with ODD are thought to have an overactive behavioral activation system (BAS), and underactive behavioral inhibition system (BIS).[medical citation needed] The BAS stimulates behavior in response to signals of reward or nonpunishment. The BIS produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of nonreward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.[17]

Social-cognitive factors[edit]

As many as 40 percent of boys and 25 percent of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behavior, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act.[17] Children with ODD have difficulty controlling their emotions or behaviors. In fact, students with ODD have limited social knowledge that is based only on individual experiences, which shapes how they process information and solve problems cognitively. This information can be linked with the social information processing model (SIP) that describes how children process information in order to respond appropriately or inappropriately in social settings. This model explains that children will go through five stages before displaying behaviors: encoding, mental representations, response accessing, evaluation and enactment. However, children with ODD have cognitive distortions and impaired cognitive processes. This will therefore directly impact their interactions and relationship negatively. It has been shown that social and cognitive impairments result in negative peer relationships, loss of friendship and an interruption in socially engaging in activities. Children learn through observational learning and social learning. Therefore, observations of models have a direct impact and greatly influence children's behaviors and decision-making processes. Children often learn through modeling behavior. Modeling can act as a powerful tool to modify children’s cognition and behaviours.[16]

Environmental factors[edit]

Negative parenting practices and parent–child conflict may lead to antisocial behaviour, but they may also be a reaction to the oppositional and aggressive behaviors of children. Factors such as a family history of mental illnesses and/or substance abuse as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behavior disorders.[medical citation needed] Parenting practices not providing adequate or appropriate adjustment to situations as well as high ratio of conflicting events within a family have been shown to be causal factors of risk for developing ODD.[16]

Insecure parent–child attachments can also contribute to ODD. Often little internalization of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance abuse. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.[17]

In a number of studies, low socioeconomic status has also been associated with disruptive behaviours such as ODD.[23][24]

Other social factors such as neglect, abuse, uninvolved parents and lack of supervision can also contribute to ODD.[25]

Externalizing problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighbourhoods.[17] Studies have also found that the state of being exposed to violence was also a contribution factor for externalizing behaviours to occur.[23][24][26]


For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD.[medical citation needed] Other common comorbid disorders include depression and substance use disorders.[5]


Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training.[27][28] According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents.[27]

Psychopharmacological treatment[edit]

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medication to control ODD include mood stabilizers, antipsychotics, and stimulants. In two controlled randomized trials, it was found that between administered lithium and the placebo group, administering lithium decreased aggression in children with conduct disorder in a safe manner. However, in a third study it found the treatment of lithium over a period of two weeks invalid.[29] Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

Effectiveness of drug and medication treatment is not well established. Effects that can result in taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention.[29]

Individual interventions[edit]

Individual interventions are focused on child specific individualized plans. These interventions include anger control/stress inoculation, assertiveness training, and child-focused problem solving skills training program, and self-monitoring skills.[29]

Anger control and stress inoculation helps prepare the child for possible upsetting situations or events that may cause anger and stress. It includes a process of steps they may go through.

Assertiveness training educates individuals in keeping balance between passivity and aggression. It is about creating a response that is controlled, and fair.

Child- focused problem solving skills training program aims to teach the child new skills and cognitive processes that teach how deal with negative thoughts, feelings and actions.

Parent and family treatment[edit]

According to randomized trials evidence shows that parent management training is most effective.[30] It has strong influences over a longer period of time and in various environments.[29]

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases. The first phase being child-directed interaction, whereby it is focused on teaching the child non directive play skills. The second phase is parent directed interaction, where the parents are coached on aspects including clear instruction, praise for compliance, and time-out noncompliance. The parent-child interaction training is best suited for elementary aged children.[29]

Parent and family treatment has a low financial cost, that can yield an increase in beneficial results.[29]

Multimodal intervention[edit]

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighbourhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behaviour program. The intervention is intensive and addresses barriers to individuals improvement such as parental substance abuse or parental marital conflict.[29]

An impediment to treatment includes the nature of the disorder itself, whereby treatment is often not complied with and is not continued or stuck with for adequate periods of time.[29]


Oppositional defiant disorder can be described as a term or disorder with lots of different pathways in regard to comorbidity. A high importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.[31]

In the context of oppositional defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-occurs with an attention deficit hyperactivity disorder (ADHD), anxiety disorders, emotional disorders as well as mood disorders.[32] Those mood disorders can be linked to major depression or bipolar disorder. Indirect consequences of ODD can also be related or associated with a later mental disorder. For instance, conduct disorder is often studied in connection with ODD. A strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relations to ODD can be seen.[32] For instance, children or adolescents who have ODD with coexistence of ADHD will usually be more aggressive, will have more of the negative behavioral symptoms of ODD and thus, inhibit them from having a successful academic life. This will be reflected in their academic path as students.[33]

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments in regard to the academic area and language disorders in which problems can be observed related to language production and/or comprehension.[33]

See also[edit]


  1. ^ "A Guide For Families" (PDF). www.AACAP.org. 2009.
  2. ^ Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Diagnostic Criteria 313.81 (F91.3): American Psychiatric Association.
  3. ^ Nolen-Hoeksema, Susan (2014). (ab)normal psychology. New York, NY: McGraw Hill. p. 323. ISBN 978-0-07-803538-8.
  4. ^ a b Pardini DA, Frick PJ, Moffitt TE (November 2010). "Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section". J Abnorm Psychol. 119 (4): 683–8. doi:10.1037/a0021441. PMC 3826598. PMID 21090874.
  5. ^ a b Dickstein DP (May 2010). "Oppositional defiant disorder". J Am Acad Child Adolesc Psychiatry. 49 (5): 435–6. doi:10.1097/00004583-201005000-00001. PMID 20431460.
  6. ^ a b c d e American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Publishing. ISBN 978-0890425558.
  7. ^ a b Fraser, Anna (April 2008). "Oppositional defiant disorder". Australian Family Physician. 37: 402–405.
  8. ^ a b c d Nock, Matthew K. (2007). "Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication". Journal of Child Psychology and Psychiatry. 48 (7): 703–713. CiteSeerX doi:10.1111/j.1469-7610.2007.01733.x. PMID 17593151.
  9. ^ Rowe, Richard (2010). "Developmental pathways in oppositional defiant disorder and conduct disorder". Journal of Abnormal Psychology. 119 (4): 726–738. doi:10.1037/a0020798. PMC 3057683. PMID 21090876.
  10. ^ a b Loeber, Rolf; Burke, Jeffrey (December 2000). "Oppositional Defiant and Conduct Disorder: A Review of the Past 10 Years, Part 1". Journal of the American Academy of Child & Adolescent Psychiatry. 39 (12): 1468–1484. doi:10.1097/00004583-200012000-00007. PMID 11128323 – via Ovid.
  11. ^ a b American Psychiatric Association (2013). "Highlights of Changes from DSM-IV-TR to DSM-5" (PDF). pp. 1–19.
  12. ^ a b c d e Disruptive, Impulse-Control, and Conduct Disorders. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.
  13. ^ a b Oppositional defiant disorder. (2004). In W. E. Craighead, & C. B. Nemeroff (Eds.), The concise Corsini encyclopedia of psychology and behavioral science (3rd ed.). Hoboken, NJ: Wiley. Retrieved from https://proxy.library.mcgill.ca/login?url=https://search.credoreference.com/content/entry/wileypsych/oppositional_defiant_disorder/0?institutionId=899
  14. ^ a b Kaneshiro, Neil. "Oppositional Defiant Disorder". A.D.A.M. Medical Encyclopedia. US: National Center for Biotechnology Information, U.S. National Library of Medicine, National Institutes of Health. Retrieved 5 November 2011.
  15. ^ Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, D.C: American Psychiatric Association. 2013.
  16. ^ a b c Goldstein, S., & In DeVries, M. (2017). Handbook of DSM-5 Disorders in Children and Adolescents.
  17. ^ a b c d e Mash EJ, Wolfe DA (2013). Abnormal Child Psychology (5th ed.). Belmont, CA: Wadsworth Cengage Learning. pp. 182–191.
  18. ^ Gump, Brooks B.; Dykas, Matthew J.; MacKenzie, James A.; Dumas, Amy K.; Hruska, Bryce; Ewart, Craig K.; Parsons, Patrick J.; Palmer, Christopher D.; Bendinskas, Kestutis (2017). "Background lead and mercury exposures: Psychological and behavioral problems in children". Environmental Research. 158: 576–582. Bibcode:2017ER....158..576G. doi:10.1016/j.envres.2017.06.033. PMC 5562507. PMID 28715786.
  19. ^ Bada, H. S., Das, A., Bauer, C. R., Shankaran, S., Lester, B., LaGasse, L., & Higgins, R. (2007). Impact of prenatal cocaine exposure on child behavior problems through school age. Pediatrics, 119(2), 348–359. doi:10.1542/peds.2006-1404. .
  20. ^ Linares, T. J., Singer, L. T., Kirchner, H., Short, E. J., Min, M. O., Hussey, P., et al. (2006). Mental health outcomes of cocaine-exposed children at 6 years of age. Journal of Pediatric Psychology, 31(1), 85–97. doi:10.1093/jpepsy/jsj020. .
  21. ^ Russel, A., Johnson, C. L., Hamma, A., Ristau, J. I., Zawadzki, S., Alba, V., & Coker, K. L. (2015). Prenatal and neighborhood correlates of oppositional de ant disorder. Child & Adolescent Social Work Journal, 32, 375–388. .
  22. ^ Spears, G. V., Stein, J. A., & Koniak-Griffin, D. (2010). Latent growth trajectories of substance use among pregnant and parenting adolescents. Psychology of Addictive Behaviors, 24(2), 322–332. doi:10.1037/ a0018518.
  23. ^ a b Eiden, R. D., Coles, C. D., Schuetze, P., & Colder, C. R. (2014). Externalizing behavior problems among poly-drug cocaine-exposed children: Indirect pathways via maternal harshness and self-regulation in early childhood. Psychology of Addictive Behaviors, 28(1), 139–153. doi:10.1037/a0032632.
  24. ^ a b Vanfossen, B., Brown, C., Kellam, S., Sokoloff, N., & Doering, S. (2010). Neighborhood context and the development of aggression in boys and girls. Journal of Community Psychology, 38(3), 329–349. doi:10.1002/ jcop.2. .
  25. ^ "ODD A Guide for Families by the American Academy of Child and Adolescent Psychiatry" (PDF).
  26. ^ White, R., & Renk, K. (2012). Externalizing behavior problems during adolescence: An ecological perspective. Journal of Child and Family Studies, 21(1), 158– 171. doi:10.1007/s10826-011-9459-y.0367.
  27. ^ a b "FAQs on Oppositional Defiant Disorder". Manhattan Psychology Group. Retrieved 2015-01-28.
  28. ^ Steiner H, Remsing L, Work Group on Quality Issues (January 2007). "Practice parameters for the assessment and treatment of children and adolescents with oppositional defiant disorder". J Am Acad Child Adolesc Psychiatry. 46 (1): 126–41. doi:10.1097/01.chi.0000246060.62706.af. PMID 17195736.
  29. ^ a b c d e f g h Burke, Jeffrey; Loeber, Rolf; Birmaher, Boris (2002). "Oppositional Defiant Disorder and Conduct Disorder: A Review of the Past 10 years, Part II". Journal of the American Academy of Child & Adolescent Psychiatry. 41 (11): 1275–1293. doi:10.1097/00004583-200211000-00009. PMID 12410070.
  30. ^ Steiner, Hans; Remsing, Lisa (2007). "Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder". Journal of the American Academy of Child & Adolescent Psychiatry. 46 (1): 126–141. doi:10.1097/01.chi.0000246060.62706.af. PMID 17195736.
  31. ^ Nock, Matthew K.; et al. (2007). "Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication". CiteSeerX Cite journal requires |journal= (help)
  32. ^ a b Maughan, Barbara; et al. (April 24, 2003). "Conduct Disorder and Oppositional Defiant Disorder in a national sample: developmental epidemiology". Journal of Child Psychology and Psychiatry. 45 (3): 609–21. doi:10.1111/j.1469-7610.2004.00250.x. PMID 15055379.
  33. ^ a b eAACAP (2009). "ODD: A guide for Families by the American Academy of Child and Adolescent Psychiatry" (PDF). Retrieved February 26, 2018.

Further reading[edit]

  • Latimer K, Wilson P, Kemp J, et al. (September 2012). "Disruptive behaviour disorders: a systematic review of environmental antenatal and early years risk factors". Child Care Health Dev. 38 (5): 611–28. doi:10.1111/j.1365-2214.2012.01366.x. PMID 22372737.
  • Matthys W, Vanderschuren LJ, Schutter DJ, Lochman JE (September 2012). "Impaired neurocognitive functions affect social learning processes in oppositional defiant disorder and conduct disorder: implications for interventions". Clin Child Fam Psychol Rev. 15 (3): 234–46. doi:10.1007/s10567-012-0118-7. PMID 22790712.

External links[edit]