Oppositional defiant disorder

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Oppositional defiant disorder
SpecialtyPsychiatry, clinical psychology 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".[2] This behavior is usually targeted toward peers, parents, teachers, and other authority figures.[3] Unlike with conduct disorder (CD), those 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.[4] It has certain links to attention deficit hyperactivity disorder (ADHD) and as much as one half of children with ODD also fulfill the diagnostic criteria for ADHD.[5][6][7]


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 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.[8] 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".[9]


ODD is a pattern of negativistic, defiant, disobedient and hostile behaviour, and is one of the most prevalent disorders from preschool age to adulthood.[10] ODD is marked by defiant and disobedient behaviour towards authority figures. This can include: frequent temper tantrums, excessive arguing with adults, refusing to follow rules, acting in a way to purposely upset others, getting easily irked, having an angry attitude, and acting vindictive.[11] Children with ODD usually begin showing symptoms around 6 to 8, although the disorder can emerge in younger children, too. Symptoms can last throughout the teen years.[11] The pooled prevalence is 3.6% up to age 18 (Ezpeleta, et al. 2019). While adults can be affected by ODD, adults with ODD who were not diagnosed as children often go undiagnosed.[12] There has been research to support that ODD is more common in boys than girls with a 2:1 ratio.[13]

Oppositional defiant disorder has a prevalence of 1% to 11%.[2] The average prevalence is approximately 3.3%.[2] Gender and age play an important role in the rate of the disorder.[2] In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old.[2][14][15] However, it is very unlikely to emerge following early adolescence.[16] There is a difference in prevalence between boys and girls. The ratio of this prevalence is 1.4 to 1 with it being more prevalent in boys than in girls, before adolescence.[2] However, girls' prevalence tends to increase after puberty.[14] When researchers observed the general prevalence of ODD throughout cultures, they noticed that it remained constant.[15] However, the sex difference in ODD prevalence is only significant in Western cultures.[15] There are several possible explanations for this difference; it is possible that in non-Western cultures there is a decreased prevalence of ODD in boys or an increased prevalence of ODD in girls; or it is also possible that the disorder is either over- or under-diagnosed in boys or girls, respectively, in Western cultures.[15] Other factors 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.[17] 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.[17] The DSM-V made more changes to the criteria grouping certain characteristics together in order to demonstrate that ODD display both emotional and behavioural symptomatology.[18] 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.[18] 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 a person must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for ODD.[8] These symptoms include:

  • Often loses temper
  • Is often touchy or easily annoyed
  • Is often angry and resentful
  • Often argues with authority figures or, for children and adolescents, with adults
  • Often actively defies or refuses to comply with requests from authority figures or with rules
  • Often deliberately annoys others
  • Often blames others for his or her mistakes or misbehavior
  • Has been spiteful or vindictive at least twice within the past six months[2][19]

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.[2] Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behaviour observed in conduct disorder.[19] 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.[20][2] For children under five years of age, they occur on most days over a period of six months. For children over five years of age they occur at least once a week for at least six months.[2] If symptoms are confined to only one setting, most commonly home, it is considered mild in severity. If it is observed in two settings, then it is characterized as moderate and if the symptoms are observed in three or more settings, then it is considered severe.[2]

These patterns of behaviour result in impairment at school or other social venues.[20][2]


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 behaviors, 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 behaviors are multifactorial. However, disruptive behaviours have been identified as being mostly due either to biological or environmental factors.[21]

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.[22]

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,[23] and mother's use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance use prior to birth has also been associated with developing disruptive behaviors such as ODD.[24][25][26][27] 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 behavioural problems in children. Brain imaging studies have suggested that children with ODD may have hypofunction in the part of the brain responsible for reasoning, judgment, and impulse control.[28] Children with ODD are thought to have an overactive behavioral activation system (BAS), and an underactive behavioural inhibition system (BIS).[medical citation needed] The BAS stimulates behavior in response to signals of reward or non-punishment. The BIS produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of non-reward 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.[22]

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.[22] 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 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 behaviors.[21]

Environmental factors[edit]

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 children. Factors such as a family history of mental illnesses and/or substance use disorders as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behavior disorders.[29] Parenting practices not providing adequate or appropriate adjustment to situations as well as a high ratio of conflicting events within a family are causal factors of risk for developing ODD.[21]

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 use. 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.[22]

School is also a significant environmental context besides family that strongly influences a child's maladaptive behaviours.[30] Studies indicate that child and adolescent externalising disorders like ODD are strongly linked to peer network and teacher response.[31] [32] Children with ODD present hostile and defiant behaviour toward authority including teachers which makes teachers less tolerant toward deviant children.[33] The way in which a teacher handles disruptive behaviour has a significant influence on the behaviour of children with ODD.[34] Negative relationships from the socialising influences and support network of teachers and peers increases the risk of deviant behaviour. This is because the child consequently gets affiliated with deviant peers that reinforce antisocial behaviour and delinquency.[35] Due to the significant influence of teachers in managing disruptive behaviours, teacher training is a recommended intervention to change the disruptive behaviour of ODD children.[36] [37]

In a number of studies, low socioeconomic status has also been associated with disruptive behaviors such as ODD.[38][39]

Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.[1]

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 neighborhoods.[22] Studies have also found that the state of being exposed to violence was a contribution factor for externalizing behaviors to occur.[38][39][40]


For a child or adolescent to qualify for a diagnosis of ODD, 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.[41][42][43] Other common comorbid disorders include depression and substance use disorders.[9] Adults who were diagnosed with ODD as children tend to have a higher chance of being diagnosed with other mental illness in their lifetime, as well as being at higher risk of developing social and emotional problems. [44]


Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training.[45][46] 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.[45]

Children with oppositional defiant disorder tend to exhibit problematic behavior that can be very difficult to control.[47] An occupational therapist can recommend family based education referred to as Parent Management Training (PMT) in order to encourage positive parents and child relationships and reduce the child's tantrums and other disruptive behaviors. [48] Since ODD is a neurological disorder that has biological correlates, an occupational therapist can also provide problem solving training to encourage positive coping skills when difficult situations arise, as well as offer cognitive behavioral therapy. [49]

Psychopharmacological treatment[edit]

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medications to control ODD include mood stabilizers, anti-psychotics, 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, a third study found the treatment of lithium over a period of two weeks invalid.[50] Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

The effectiveness of drug and medication treatment is not well established. Effects that can result from 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.[50]

In one case, a 16-year-old boy was given estrogen at an L. A. juvenile jail due to allegedly having ODD due to somewhat elevated testosterone levels, developing gynecomastia and requiring breast reduction surgery as a result.[51]

Individual interventions[edit]

Individual interventions are focused on child-specific individualized plans. These interventions include anger control/stress inoculation, assertiveness training, a child-focused problem-solving skills training program, and self-monitoring skills.[50]

Anger control and stress inoculation help prepare the child for possible upsetting situations or events that may cause anger and stress. They include a process of steps the child may go through.

Assertiveness training educates individuals in keeping a balance between passivity and aggression. It aims to help the child respond in a controlled and fair manner.

A child-focused problem-solving skills training program aims to teach the child new skills and cognitive processes that teach how to 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.[46] It has strong influences over a long period of time and in various environments.[50]

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases; the first phase is child-directed interaction, where the focus is to teach 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 for noncompliance. The parent-child interaction training is best suited for elementary-aged children.[50]

Parent and family treatment has a low financial cost, which can yield an increase in beneficial results.[50]

Multimodal intervention[edit]

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighborhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behavior programs. The intervention is intensive and addresses barriers to individuals' improvement such as parental substance use or parental marital conflict.[50]

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.[50]


Oppositional defiant disorder can be described as a term or disorder with a variety of pathways in regard to comorbidity. High importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.[52]

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.[53] 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. Strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relation to ODD can be seen.[53] For instance, children or adolescents who have ODD with coexisting ADHD will usually be more aggressive and have more of the negative behavioral symptoms of ODD, which can inhibit them from having a successful academic life. This will be reflected in their academic path as students.[1]

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments with academics and language disorders, in which problems can be observed related to language production and/or comprehension.[1]

See also[edit]


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  53. ^ a b Maughan B, Rowe R, Messer J, Goodman R, Meltzer H (March 2004). "Conduct disorder and oppositional defiant disorder in a national sample: developmental epidemiology". Journal of Child Psychology and Psychiatry, and Allied Disciplines. 45 (3): 609–21. doi:10.1111/j.1469-7610.2004.00250.x. PMID 15055379.

Further reading[edit]

  • Latimer K, Wilson P, Kemp J, Thompson L, Sim F, Gillberg C, et al. (September 2012). "Disruptive behaviour disorders: a systematic review of environmental antenatal and early years risk factors". Child. 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". Clinical Child and Family Psychology Review. 15 (3): 234–46. doi:10.1007/s10567-012-0118-7. hdl:1874/386223. PMID 22790712. S2CID 3951467.

External links[edit]