Oppositional Defiant Disorder (ODD)

Primer

Oppositional Defiant Disorder (ODD) is a mental disorder characterized by frequent and persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness.[1]

Epidemiology
  • The prevalence of ODD ranges anywhere from 1 to 11%, with an average prevalence of 3.3%.[2]
  • ODD appears to be more prevalent in males than in females (1.4:1 ratio) prior to adolescence, but the predominance is less evident in adolescents/adults.[3]
Prognosis
  • Symptoms of ODD usually begin in the preschool years (rarely later than early adolescence).
  • The symptoms of ODD can result in frequent conflicts between the individual and parents, teachers, supervisors, peers, and/or romantic partners.[4]
  • Children and adolescents with ODD are at an increased risk for antisocial behavior, impulse-control problems, substance abuse, anxiety, and depression, when they enter adulthood.[5]
  • ODD is also associated with increased risk for suicide attempts.[6]
Comorbidity
  • Attention-deficit/hyperactivity disorder (ADHD) and conduct disorder are the two most common comorbidities.[7]
  • ODD often precedes the development of conduct disorder, especially for those with the childhood-onset type of conduct disorder.
    • However, most children and adolescents with ODD do not go on to develop conduct disorder.
  • Individuals with ODD are also at increased risk for anxiety and depressive disorders, and are thought to be related to the presence of the angry-irritable mood symptoms seen in ODD.[8]
Risk Factors
  • ODD is more common in families where child care is disrupted by a the presence of multiple different caregivers or in families in which harsh, inconsistent, or neglectful child-rearing practices are common.[9]

DSM-5 Diagnostic Criteria

Criterion A

A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 months as evidenced by at least 4 symptoms from any of the following categories, and exhibited during interaction with at least 1 individual who is not a sibling.

Argumentative/Defiant Behaviour
  1. Often argues with authority figures or, for children and adolescents, with adults.
  2. Often actively defies or refuses to comply with requests from authority figures or with rules.
  3. Often deliberately annoys others.
  4. Often blames others for his or her mistakes or misbehaviour
Angry/Irritable Mood
  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
Vindictiveness
  1. Has been spiteful or vindictive at least twice within the past 6 months.

Mnemonic

The mnemonic REAL BADS can be used to remember the symptoms of ODD:
  • R - Resentful
  • E - Easily annoyed
  • A - Argues with adults
  • L - Loses temper
  • B - Blames others
  • A - Annoys people deliberately
  • D - Defies rules or requests
  • S - Spiteful
Note: The persistence and frequency of these behaviours should be used to distinguish a behaviour that is within normal limits from a behaviour that is symptomatic. For children younger than 5 years, the behaviour should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8 - Vindictiveness). For individuals 5 years or older, the behaviour should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8 - Vindictiveness). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviours are outside a range that is normative for the individual’s developmental level, gender, and culture.
Criterion B

The disturbance in behaviour is associated with distress in the individual or others in his or her immediate social context (e.g. - family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

Criterion C

The behaviours do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Specifiers

Severity Specifier

Specify current severity:

  • Mild: Symptoms are confined to only 1 setting (e.g. - at home, at school, at work, with peers).
  • Moderate: Some symptoms are present in at least 2 settings.
  • Severe: Some symptoms are present in 3+ settings.

Signs and Symptoms

  • Individuals with ODD may only show symptoms at home and only with family members.[10] In more severe cases, the symptoms of the disorder are present in multiple settings.

Screening Tools and Scales

Pathophysiology

Differential Diagnosis

  • Conduct disorder
    • Conduct disorder and ODD are both related to conduct problems that bring the individual in conflict with adults and other authority figures (e.g. - parents, teachers, work supervisors). ODD symptoms are less severe than conduct disorder and do not include aggression toward people or animals, pattern of theft or deceit, or destruction of property. ODD also includes problems of emotional dysregulation (i.e. - angry and irritable mood) that are not included in the diagnostic criteria for conduct disorder.
  • Attention-deficit/hyperactivity disorder (ADHD)
    • ADHD is often comorbid with ODD. If there are ODD symptoms that are not related to the need for sustained effort and attention or demand that the individual sit still, then a diagnosis of ODD may be considered.
  • Depressive and bipolar disorders
    • Both depressive and bipolar disorders may involve negative affect and irritability. Thus, ODD should not be diagnosed if the symptoms occur exclusively during the course of a mood disorder.
  • Social anxiety disorder (social phobia)
    • ODD should be distinguished from defiance due to fear of negative evaluation associated with social anxiety disorder.
  • Disruptive mood dysregulation disorder (DMDD)
    • ODD and DMDD both have symptoms of chronic negative mood and temper outbursts. However, the severity, frequency, and chronicity of temper outbursts are more severe in individuals with DMDD than in those with ODD. Thus, only a minority of children and adolescents whose symptoms meet criteria for ODD would also be diagnosed with DMDD. When the mood disturbance is severe enough to meet criteria for DMDD, a diagnosis of ODD is not given, even if all criteria for ODD are met.
  • Intermittent explosive disorder (IED)
    • IED also involves high rates of anger. However, individuals with this disorder show serious aggression toward others that is not part of the diagnostic criteria for ODD.
  • Intellectual disability (intellectual developmental disorder)
    • In individuals with intellectual disability, a diagnosis of ODD is given only if the oppositional behaviour is markedly greater than what is commonly expected among individuals of comparable mental age and severity of intellectual disability.
  • Language disorder
    • ODD must also be distinguished from an inability or failure to follow directions that is due to impaired language comprehension (e.g. - hearing loss).

Investigations

Hold the blood tests and medications! A biopsychosocial “investigation” to understanding aggressive behaviour is important. A child diagnosed with ODD or ADHD may all have these factors contribute to their symptoms:

  • Parenting and family factors:
    • Parenting behaviour
    • Parent-child attachment
  • Peer relationships:
    • Peer rejection
    • Deviancy “training” (getting trained to be “unliked” by others)
  • Child-level mental processes:
    • Callous-unemotional traits (degree of empathy in the child)
    • Emotional regulation
    • Executive functions and language (think learning disorders)
    • Social cognition
  • Predisposing Factors:
    • Trauma
    • Raised up in the orphanage
  • Precipitating Factors:
    • Recently punched by student
    • Recently moved
    • Recent death in family
  • Perpetuating Factors:
    • Recurring social/family/school conflicts

Treatment

Prognosis

Resources

For Patients

For Providers

Articles
Research

References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.