Oppositional defiant disorder

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Oppositional defiant disorder
Classification and external resources
ICD-10 F91.3
ICD-9 313.81
MedlinePlus 001537
MeSH D019958

Oppositional defiant disorder (ODD) is defined by the DSM-5 as a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, and exhibited during interaction with at least one individual whom is not a sibling. Individuals must display at least four symptoms defined under any of the three categories outlined as angry/irritable mood, argumentative/defiant behavior, or vindictiveness. 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.[1] A diagnosis of ODD cannot be given if the child presents with conduct disorder.[2] ODD is not restricted to childhood and may extend into adulthood as evidenced by behaviors such as unpopular dissent, non-aggressive resistance, deliberate disobedience to authority, abstaining from widely accepted norms, or refusal to comply with any request in a particular setting.

Signs and symptoms[edit]

Previously, DSM-IV-TR (that is now replaced by DSM-5) stated that the child must exhibit four out of the eight signs and symptoms listed below in order to meet the diagnostic threshold for oppositional defiant disorder.[3] Furthermore, they must be perpetuated for longer than six months and must be considered beyond normal child behavior to fit the diagnosis.[4][5]

  • Actively refuses to comply with majority's requests or consensus-supported rules.[6]
  • Performs actions deliberately to annoy others.[6]
  • Angry and resentful of others.[5]
  • Argues often.[5]
  • Blames others for their own mistakes.[7]
  • Frequently loses temper.[7]
  • Spiteful or seeks revenge.[7]
  • Touchy or easily annoyed.[7]

These patterns of behavior result in impairment at school and/or other social venues.[5]

Common features of oppositional defiant disorder (ODD) include excessive, often persistent anger, frequent temper tantrums or angry outbursts, as well as disrespect of authority. Children and adolescents with ODD often purposely annoy others, blame others for their own mistakes, and are easily disrupted. Parents often observe more rigid and irritable behaviors than in siblings.[8] In addition, these young people may appear resentful of others, and when someone does something they don't like they prefer revenge over more sensitive solutions.[9]

For a child or adolescent to qualify for a diagnosis of ODD, these behaviors 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 behaviors must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD.[10] Other common comorbid disorders include depression and substance use disorders.[11]


The exact cause of ODD is unknown, but it is believed that a combination of biological, psychological, and environmental factors may contribute to the condition. However it has been part of human behavior for some time, as evidenced by historical figures such as Socrates, Jesus, Galileo, Mahatma Gandhi, Thomas Jefferson, and Martin Luther King, Jr.

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. This 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.[12]

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, and mother’s use of nicotine, marijuana, alcohol or other substances during pregnancy may increase the risk of developing ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.[12]

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. Children with ODD are thought to have an overactive behavioral activation system (BAS), and underactive behavioral inhibition system (BIS). 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. As well as this, if neurotransmitters in the brain are out of balance, or not working properly, they may not be able to communicate to each other in the brain effectively, causing behavioral deficits. Many children with ODD also have other mental illnesses, such as ADHD, learning disorders, depression, or an anxiety disorders which could also be strong contributors.[12]

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.[12]

Family factors[edit]

A child has reciprocal influence, meaning that the child’s behavior is both influenced by and influences the behavior of others. Negative parenting practices and parent–child conflict may lead to antisocial behavior, but they may also be a reaction to the oppositional and aggressive behaviors of their 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.

Coercion theory describes another hypothesis for how the family might contribute to development of ODD. Coercion theory contends that parent–child interactions provide a training ground for the development of antisocial behavior. According to this theory, through a 4-step, escape-conditioning sequence, the child learns to use increasingly intense forms of noxious behavior to avoid unwanted parental demands.

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.[12]

Societal factors[edit]

Low socioeconomic status is associated with poor parenting, specifically with inconsistent discipline and poor parental monitoring, which are then associated with an early onset of aggression and antisocial behaviors.[12]

Cultural factors[edit]

Socialization across cultures is one of the strongest predictors of aggressive acts. Externalizing problems are reported to be more frequent among minority-status youth, a finding that is likely related to things like economic hardship, limited employment opportunities, and living in high-risk urban neighborhoods.[12]


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 CD is present.[13] 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”.[11]


One of the key factors in the development and maintenance of the negative behaviors associated with ODD symptoms is reinforcement, whether intentional or not, of the unwanted behaviors. The most effective way of treating disruptive behavior disorders is behavioral therapies.[14] Behavioral therapy for children and adolescents focuses primarily on how to prevent problematic thoughts or behaviors from accidentally getting reinforced unknowingly within a young person's environment.

Positive reinforcement often unintentionally contributes to an increase in the frequency of ODD behaviors. Behavior therapies can be applied to a wide range of psychological symptoms among children, adolescents, and adults with ODD. Behavior therapists encourage children and adolescents to try new behaviors and not to allow unwanted reinforcement to dictate the ways in which they act. Furthermore, therapists may work with parents to discontinue ways in which they are unintentionally reinforcing unwanted behaviors. An example of how positive reinforcement can occur is when the patient is rewarded with attention when performing ODD behaviors. Attention is reinforcing itself and the reinforcing attention could be accidentally given, ironically, when trying to create a negative consequence to their behavior.[15] Positive Punishment occurs when the patient is inadvertently punished by aversive stimuli for not performing the ODD behaviors (of revenge, dis-cooperation, and frequent anger). These aversive stimuli that punish patients for not performing ODD behaviors can include humiliation, isolation, not being told the reason of rules (e.g. being told "the reason you should is because I said so"), not having opinions taken seriously, as well as "being pushed around."

Researchers have found that the use of positive reinforcement and praise for appropriate behaviors are two key elements in effective interventions. If the majority of interactions with the child are focused around correcting their negative behaviors, a cycle of negative interactions is created where the child expects attention after misbehaving. On the contrary, positive reinforcement and praise not only builds a child's self-esteem but also serves to strengthen the bond between a child and their caregiver. To accomplish this the positive reinforcement should occur immediately after a child has exhibited an appropriate behavior. The behaviors outlined for the child to be reinforced should be easy to evaluate and have very clear and easy to understand instructions. The type of reinforcement used should always depend on the child and should be developed together with both the family and the therapist.[16]

Other approaches to the treatment of ODD include parent training programs, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training.[17][18] 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.[19] Several preventative programs have had a positive effect on those at high risk for ODD. Both home visitation and programs such as Head Start have shown some effectiveness in preschool children. Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD. For adolescents at risk for ODD, cognitive interventions, vocational training, and academic tutoring have shown preventative effectiveness.[11]

An approach developed by Russell Barkley[20][21][22] uses a parent training model and begins by focusing on positive approaches to increase compliant behaviours.


ODD has an estimated lifetime prevalence of 10.2% (11.2% for males, 9.2% for females).[11] According to a 1992 article, if left untreated, about 52% of children with ODD will continue to meet the DSM-IV criteria up to three years later, and about half of those 52% will progress into conduct disorder.[23] CD may progress into antisocial personality disorder. This strong correlation between strong defiance in childhood and adulthood may suggest similar mechanisms for hostility toward established authority by children and by adults.


According to The American Journal of Psychiatry, several sources of controversy exist around the diagnosis of ODD. One concerns the fact that the DSM-IV criteria differ slightly from those of the World Health Organization's criteria, as outlined in the ICD-10. Diagnosis of ODD is further complicated by the high occurrence of comorbidity with other disorders such as ADHD,[24] though a 2002 study provided additional support for the validity of ODD as an entity distinct from conduct disorder.[25]

In another study, the utility of the DSM-IV criteria to diagnose preschoolers has been questioned because the criteria were developed using school-age children and adolescents. The authors concluded that the criteria could be used effectively when developmental level was factored into assessment.[26]

See also[edit]


  1. ^ Nolen-Hoeksema, Susan (2014). (ab)normal psychology. New York, NY: McGraw Hill. p. 323. ISBN 978-0-07-803538-8. 
  2. ^ Pardini, D.A., Frick, P.J., & Moffitt, T.E. (2010) Building an Evidence base for DSM-5 Conceptualizations of Oppositional Defiant Disorder and Conduct Disorder: Introduction to the Special Section. Journal of Abnormal Psychology. 119(4) 683–688
  3. ^ Pardini, D.A., Frick, P.J., & Moffitt, T.E. (2010) Building an Evidence base for DSM-5 Conceptualizations of Oppositional Defiant Disorder and Conduct Disorder: Introduction to the Special Section. Journal of Abnormal Psychology. 119(4) 683–688
  4. ^ "Q 00 Oppositional Defiant Disorder". DSM-5. American Psychiatric Association. Retrieved 5 November 2011. 
  5. ^ a b c d Kaneshiro, Neil. "Oppositional Defiant Disorder". A.D.A.M. Medical Encyclopedia. Retrieved 5 November 2011. 
  6. ^ a b "Oppositional Defiant Disorder: Symptoms". Psych Central. Retrieved 5 November 2011. 
  7. ^ a b c d http://behavenet.com/oppositional-defiant-disorder
  8. ^ "Children With Oppositional Defiant Disorder".
  9. ^ Phelan, Thomas. 1-2-3 Magic. Glen Ellyn: ParentMagic, Inc., 2003.
  10. ^ Chandler, Jim. "Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in Children and Adolescents: Diagnosis and Treatment". Web. Retrieved 11/4/11.  Check date values in: |accessdate= (help)
  11. ^ a b c d 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. 
  12. ^ a b c d e f g Mash, E. J., & Wolfe, D. A. (2013). Abnormal Child Psychology (5th ed.). Belmont, CA: Wadsworth Cengage Learning. pp. 182–191. 
  13. ^ Pardini, D.A., Frick, P.J., & Moffitt, T.E. (2010) Building an Evidence base for DSM-5 Conceptualizations of Oppositional Defiant Disorder and Conduct Disorder: Introduction to the Special Section. Journal of Abnormal Psychology. 119(4) 683–688
  14. ^ Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008).
  15. ^ "Be Aware of Negative Reinforcement". campus.dyc.edu. Retrieved 2011-12-20. 
  16. ^ Kledzik, A.M., Thorne, M.C., Prasad, V., Hayes, K.H., & Hines, L. (2011). Challenges in Treating Oppositional Defiant Disorder in a Pediatric Medical Setting: A case study. Journal of Pediatric Nursing. 2011. Article in Press
  17. ^ "Children With Oppositional Defiant Disorder". www.aacap.org. Retrieved 2008-07-15. 
  18. ^ AACAP Workgroup On Quality Issues, Steiner, H, Remsing, L.: Practice Parameter For The Assessment And Treatment Of Children And Adolescents With Oppositional Defiant Disorder. Journal of the American Academy Of Child And Adolescent Psychiatry, 46(1): 126–141, 2007
  19. ^ "FAQs on Oppositional Defiant Disorder". www.aacap.org. Retrieved 2008-07-15. 
  20. ^ Barkley, R., (1997) Defiant Children: A Clinician's Manual for Assessment and Parent Training, NY: Guilford Press
  21. ^ Barkley, R., & Benton, C., (1998), Your Defiant Child, NY: Guilford Press
  22. ^ Barkley, R., Edwards, G., & Robin, A., (1999), Defiant Teens: A Clinician's Manual for Assessment and Family Intervention, NY: Guilford Press
  23. ^ Lahey, B., Loeber, R., Quay, H., Frick, P., & Grimm, J., (1992) Oppositional defiant and conduct disorders: Issues to be resolved for the DSM-IV. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 539–546.
  24. ^ Volkmar, Fred (2002). "Considering Disruptive Behaviors". Am J Psychiatry 159 (3): 349–350. doi:10.1176/appi.ajp.159.3.349. PMID 11869994. 
  25. ^ Greene, Ross W.; Biederman, Joseph; Zerwas, Stephanie; Monuteaux, Michael C.; Goring, Jennifer C.; Faraone, Stephen V. (2008). "Psychiatric comorbidity, family dysfunction, and social impairment in referred youth with Oppositional Defiant Disorder". Am J Psychiatry 159 (7): 1214–1224. doi:10.1176/appi.ajp.159.7.1214. PMID 12091202. 
  26. ^ Keenan, Kate; Wakschlag, Lauren S. (2002). "Can a Valid Diagnosis of Disruptive Behavior Disorder Be Made in Preschool Children?". Am J Psychiatry 159 (3): 351–358. doi:10.1176/appi.ajp.159.3.351. PMID 11869995. 

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