Oppositional Defiant Disorder (ODD)

The etiology of oppositional defiant disorder is influenced by a combination of various biological, psychological, and social risk and protective factors. It is probably most common among children from families in which the adults engage in loud, argumentative, interpersonal conflicts (1). This diagnosis should not be viewed as a circumscribed disorder but rather as an indication of underlying problems that may require further investigation and treatment. Oppositional defiant disorder has been associated with attention deficit/hyperactivity disorder (ADHD), antisocial personality disorder, substance use disorders, and to a lesser extent with mood and anxiety disorders.

Factors that predispose youth to oppositional defiant disorder share much in common with those for conduct disorder and antisocial personality disorder. Although oppositional defiant disorder has sometimes been viewed as a mild version of conduct disorder, similarities between the 2 disorders are only superficial. The hallmark of this disorder is an interpersonal style characterized by irritability and defiance. In contrast, children with a conduct disorder seemingly lack a conscience and repeatedly violate the rights of others (eg, bullying, threatening or causing harm, being cruel to animals), sometimes without any evidence of irritability.

Typically, children with oppositional defiant disorder tend to frequently do the following:

• Lose their temper easily and repeatedly

• Argue with adults

• Defy adults

• Refuse to obey rules

• Deliberately annoy people

• Blame others for their own mistakes or misbehavior

• Be easily annoyed and angered

• Be spiteful or vindictive

Many affected children also lack social skills.

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria

Oppositional defiant disorder is diagnosed if children have had ≥ 4 of the above symptoms for at least 6 months (1). Symptoms must also be severe and disruptive.

Oppositional defiant disorder must be distinguished from the following, which may cause similar symptoms:

• Mild to moderate oppositional behaviors: Such behaviors occur periodically in nearly all children and adolescents.

• Untreated attention-deficit/hyperactivity disorder (ADHD): The symptoms that resemble those of oppositional defiant disorder often resolve when ADHD is adequately treated.

• Mood disorders: Irritability caused by depression can be distinguished from oppositional defiant disorder by the presence of anhedonia and neurovegetative symptoms (eg, sleep and appetite disruption); these symptoms are easily overlooked in children.

• Anxiety disorders and obsessive-compulsive disorder: In these disorders, the oppositional behaviors occur when children have overwhelming anxiety or when they are prevented from carrying out their rituals.

• Behavior modification therapy

• Sometimes medications

Initially, the treatment of choice for oppositional defiant disorder is a rewards-based behavior-modification program designed to make the child’s behaviors more socially appropriate (1). Many children can benefit from group-based therapy that builds social skills. Family-based approaches are also effective.

Sometimes medications used to treat depressive or anxiety disorders (see table Medications For Long-Term Treatment of Anxiety, Depression, and Related Disorders may be beneficial.

Underlying problems (eg, family dysfunction) and coexisting disorders (eg, ADHD) should be identified and corrected. However, even without corrective measures or treatment, most children with oppositional defiant disorder gradually improve over time. The persistence of symptoms into adolescence and adulthood occurs in a substantial minority of patients and is associated with poor functional outcomes. Children with oppositional defiant disorder may have difficulty forming adult relationships, and struggle in educational and professional settings. They may also be at higher risk of developing conduct disorder in adulthood (with a much higher risk in males) (1).