Oppositional defiant disorder (ODD) 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. 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.

Signs and Symptoms

The DSM-5 states that the child must exhibit four out of the following eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder (ODD):

• 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 their mistakes or misbehavior
• has been spiteful or vindictive at least twice within the past six months

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 oppositional defiant disorder (ODD) diagnosis. Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behavior observed in conduct disorder. 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.

For children under five years of age, these behaviors 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. It is possible to observe these symptoms in only one setting, most commonly home. Thus the severity would be mild. If it is observed in two settings, then it would be characterized as moderate; if the symptoms are observed in three or more settings, then it would be considered severe. These patterns of behavior result in impairment at school and/or other social venues.

Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Etiology

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 ODD. Symptoms of ODD are also often believed to be the same as conduct disorder even though the disorders have their own respective set of symptoms. When looking at disruptive behaviors such as ODD, research has shown that the causes of behaviors are multifactorial. However, disruptive behaviors have been identified as being mostly due either to biological or environmental factors.

Genetic Influences

Figure 1. There has been little research on the genetics of ODD, perhaps, because this disorder has been viewed primarily as the result of ineffective parenting. Nevertheless, the heritability of ODD has been estimated to be around 0.60 and ODD is familial among families of ADHD youth.

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 and 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.

Prenatal Factors and Birth Complications

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead, 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 has also been associated with developing disruptive behaviors such as ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological Factors

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 an underactive behavioral inhibition system (BIS). The behavioral activation system (BAS) stimulates behavior in response to signals of reward or non-punishment. The behavioral inhibition system (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.

Social-Cognitive Factors

As many as 40% of boys and 25% 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 their behavior, and cognitive distortions such as interpreting a neutral event as an intentional hostile act. 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. Social information processing model (SIP) 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 impairment 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.

Environmental Factors

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 abuse as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behavior disorders. Parenting practices not providing adequate or appropriate adjustment to situations as well as a high ratio of conflicting events within a family have been shown to be causal factors of risk for developing ODD.

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. In a number of studies, low SES has also been associated with disruptive behaviors such as ODD. Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.

Externalizing problems are reported to be more frequent among marginalized youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk, urban neighborhoods. Studies have also found that the state of being exposed to violence was also a contributing factor for externalizing behaviors to occur.

Epidemiology

Oppositional defiant disorder has a wide prevalence range, from one to 11%. The average prevalence is approximately 3.3%. Gender and age play an important role in the rate of the disorder. In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old. However, it is very unlikely to emerge following early adolescence. There is a difference in prevalence between boys and girls with the ratio being 1.4 (boys) to 1 (girls). On the other hand, girls’ prevalence tends to increase after puberty. When researchers observed the general prevalence of oppositional defiant disorder throughout cultures, they noticed that it remained constant. However, the sex difference in ODD prevalence is only significant in Western cultures. Two possible explanations for this difference are that in non-Western cultures there is a decreased prevalence of ODD in boys or an increased prevalence of ODD in girls. Another factor is based on the criteria used to diagnose an individual. When the disorder was first included in the DSM-3, the prevalence was 25% higher than when the DSM-4 revised the criteria of diagnosis. The DSM-5 made more changes to the criteria, grouping certain characteristics together in order to demonstrate that ODD displays both emotional and behavioral symptomatology. 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. Consequently, future studies may obtain results indicating a decline in prevalence between the DSM-4 and the DSM-5 due to these changes.

Management

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, CBT, and social skills training. 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 preschoolers and adolescents.

Psychopharmacological Treatment

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medication 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. 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 for ODD is not well established. Effects that can result in taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and an increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention. 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; he developed gynecomastia and required breast reduction surgery as a result.

Individual Interventions

Figure 2. Parent and family treatment has a low financial cost that can yield an increase in beneficial results.

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. Anger control and stress inoculation help 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 a 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 to deal with negative thoughts, feelings, and actions.

Parent and Family Treatment

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

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.