Oppositional Defiant Disorder

Descriptive Characteristics and Phenomenology

File photo. [Credit: Hillscrest Adolescent Training CentreOpens in new window]

ODD is a diagnosis for persons who exhibit negativistic, hostile, defiant, and disobedient behaviors towards others. ODD is mostly a diagnosis for children and adolescents but may also be used in adults.

The diagnosis is made on the basis of angry or irritable, defiant, or vindictive behavior of at least 6 months’ duration, with a minimum of four of eight symptoms in three categories: angry/irritable mood, argumentative/defiant behavior, and vindictiveness.

• Symptoms of angry/irritable mood include losing temper, being easily annoyed, and acting angry and resentful.
• Argumentative/defiant behavior includes arguing with adults, defying rules or adults, deliberately annoying others, and blaming others for own mistakes.
• And finally, vindictiveness, is manifested as being spiteful or vindictive at least twice in a six-month period.

DSM-5 considers ODD to be a developmental antecedent for some youth with conduct disorderOpens in new window, thereby suggesting that they may reflect different stages of a spectrum of disruptive behaviors.

The diagnosis received its current name with DSM-III-R.

The diagnosis had many commonalities with DSM-II’s unsocialized aggressive reaction, a diagnosis used to describe loners with a pattern of hostile disobedience, aggressiveness, stealing, and lying, behaviors thought to result from inconsistent discipline and parental rejection.

The prevalence of ODD has ranged in studies from 1% to 11%, with an average of 3.3%. The disorder is more common in boys than girls prior to adolescence. ODD has a mean age of onset of 6 years and may precede the onset of conduct disorder.

Youth with ODD are also at risk for developing mood and anxiety disorders. The defiant, argumentative, and vindictive symptoms carry most of the risk for conduct disorder. Angry/irritable mood symptoms carry most of the risk for internalizing disorders.

While all children show oppositional behavior from time to time, the diagnosis is given to those with frequent, recurrent, and problematic behaviors, for example temper outbursts, arguments with parents or other authority figures, and a refusal to obey orders.

The disorder tends to be stable over time.

There appears to be a genetic overlap of ODD with other disruptive disorders, including conduct disorder and attention-deficit/hyperactivity disorder.

Other disorders need to be ruled out. Unlike conduct disorderOpens in new window which specifies that the child must have violated personal rights and social rules, ODD is defined on the basis of difficult and disruptive behavior. Attention-deficit/hyperactivity disorderOpens in new window may be comorbid with ODD but is a diagnosis used in those with problems of sustained effort and attention.

ODD shares many features with disruptive mood dysregulation disorder, such as negative mood and temper outbursts, but the severity, frequency, and chronicity of temper outbursts are more severe in children with disruptive mood dysregulation disorderOpens in new window than in those with ODD. (In DSM-5, the diagnosis of disruptive mood dysregulation disorder takes precedence over ODD, if the criteria for both disorders are met.) Intermittent explosive disorder (IED)Opens in new window also involves high rates of anger, but people with this disorder show serious aggression towards others that is not part of the definition of ODD.

Etiology

There has been little neurobiologic research with regard to ODD. One study showed elevated levels of dehydroepiandrosterone sulfate in children with ODD, in contrast to children with attention-deficit/hyperactivity disorder and controls, suggesting to the authors that stress or genetic factors have led to a shift in adrenocorticotrophic hormone (ACTH)-β-endorphin functioning in the hypothalamic-pituitary-adrenal axis.

Another study found a specific pattern of single-nucleotide polymorphisms associated with attention-deficit/hyperactivity disorder comorbid with ODD, compared with attention-deficit/hyperactivity disorder alone, especially for measures of argumentative and defiant behaviors.

Treatment

There is no standard treatment for ODD, but common sense suggests that because most patients with ODD are children, clinical management should emphasize individual and family therapy, with treatment of co-occurring attention-deficit/hyperactivity disorder or other disorders with medications, as needed, such as stimulants, guanfacine, or clonidine.

Family-based interventions include parental management training and child problem skills training.

• The former aims to teach parents to better manage their child’s behavior, as well as to promote desired behaviors.
• The latter is cognitively based and aims to help children learn to manage anger, improve problem-solving ability, delay impulsive responses, and improve social interactions.

School-based programs, such as those aimed at resisting negative peer influences and reducing bullying and antisocial behavior, may also be helpful.