Oppositional Defiant Disorder

Aka: Oppositional Defiant Disorder

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II. Epidemiology

  1. Prevalence: 3.3%
  2. Slightly more common in males until adolescence (then equal between genders)

III. Pathophysiology

  1. Behavior disorder in children with onset in preschool or elementary school
  2. On spectrum of behavior continuum
    1. Children
      1. Normal defiance in childhood (exercising autonomy)
      2. Oppositional Defiant Disorder (develops in 1-16% of children, 3.3% on average)
      3. Conduct Disorder (develops in 33-42% of Oppositional Defiant Disorder children)
    2. Adults
      1. Antisocial Personality Disorder (develops in 40% of Conduct Disorder children)

IV. Risk Factors

  1. Poverty
  2. Parental Nicotine use
  3. Prenatal nutritional deficiency
  4. Developmental Delay
  5. Detached or unresponsive parenting
  6. Maternal aggression
  7. Harsh punishment or abuse
  8. Inconsistent Discipline
  9. Lack of structured environment
  10. Community Violence

V. Symptoms

  1. Children and adolescents with disobedience and difficulty controlling their temper
  2. Usual onset by early elementary school

VI. Diagnosis: DSM V Criteria

  1. Six month or more of negative, hostile, argumentative, vindictive or defiant behavior
  2. Occurs during interaction with at least one person who is not a sibling
  3. Criteria: Requires 4 or more behaviors (any category) that the child demonstrates frequently
    1. Angry irritable Mood
      1. Loses temper
      2. Easily annoyed by others ("touchy")
      3. Angry and resentful
    2. Argumentative or defiant behavior
      1. Argues with authority figures (includes adults when occurring in children)
      2. Actively defies or refuses to comply with authority figure's requests or rules
      3. Deliberately annoys people
      4. Blames others for the child's own mistakes or Misbehavior
    3. Vindictiveness
      1. Spiteful or vindictive at least twice in the last 6 months
  4. Severity: Related to number of settings affected (home, school, work, peers)
    1. Mild: 1 setting
    2. Moderate: 2 settings
    3. Severe: 3 or more settings
  5. Behaviors occur on most days in age <5 years, and at least weekly in age >5 years
  6. Behaviors are not consistent with typical behavior (esp. <5 years old), developmental level, gender, culture
  7. Results in distress in patient or others or signficantly impairs social, academic or occupational functioning
  8. Behaviors not limited to Psychosis, Substance Abuse, Bipolar Disorder or Mood Disorder episodes
  9. Does not meet criteria for disruptive mood dysregulation disorder (DMDD)
  10. References
    1. (2013) DSM V, APA, Washington D.C., p. 462-3

VII. Diagnosis: Screening Tools

  1. Free scales
    1. NICHQ Vanderbilit Assessment Scale
      1. http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-assessment-scales
    2. SNAP-IV Teacher and Parent Rating Scale (Swanson, Nolan, Pelham)
      1. https://www.attentionpoint.com/x_upload/media/images/snap_description_with_questions-1.pdf
  2. Commercial scales (fee charged for use)
    1. Child behavior checklist
    2. Connors 3

VIII. Associated Conditions

  1. Attention Deficit Disorder (up to 40%)
  2. Conduct Disorder (42%)
  3. Anxiety Disorder (14%)
  4. Major Depression (9%)

IX. Differential Diagnosis

  1. Difficulty following rules or oppositional behavior
    1. Attention Deficit Disorder
    2. Conduct Disorder
    3. Developmental Delay or Intellectual Disability
    4. Language disorder
    5. Social Phobia
  2. Irritability or negative affect
    1. Major Depression
    2. Bipolar Disorder
  3. Anger outbursts
    1. Disruptive mood dysregulation disorder (DMDD)
    2. Intermittent explosive disorder

X. Management

  1. Treat comorbid Attention Deficit Disorder
    1. Stimulant Medications and Clonidine improve both Attention Deficit Disorder and comorbid ODD
  2. Treat comorbid Mood Disorders
    1. Fluoxetine has been shown effective for comorbid depression and ODD
      1. Jacobs (2010) J Clin Child Adolesc Psychol 39(4): 559-67 [PubMed]
    2. Atypical Antipsychotics (esp. Risperidone) may be effective for aggression and conduct problems
      1. Loy (2012) Cochrane Database Syst Rev (9):CD008559 [PubMed]
  3. Mental health referral (often group therapy, see programs below)
    1. Child therapy (including CBT)
      1. Problem solving skill training
      2. Collaborative problem solving (child problem solves with parents)
    2. Parent Training (parent management therapy)
      1. Teaches more positive and less harsh responses to child
      2. Disruptive behavior management
        1. Avoiding reinforcement of behaviors
        2. Timely and appropriate consequences

XI. Prevention

  1. See Parenting Resources
  2. Preschool programs such as Head Start
  3. Parent Management Strategy programs
    1. Triple-P-Positive Parenting Program
    2. Incredible Years
    3. Parenting Through Change

XII. Complications

  1. See pathophysiology above
  2. Conduct Disorder (children)
  3. Antisocial Personality Disorder (adults)
  4. Substance Use Disorder

XIII. References

  1. Hamilton (2008) Am Fam Physician 78:861-8 [PubMed]
  2. Maughan (2004) J Child Psychol Psychiatry 45(3): 609-21 [PubMed]
  3. Riley (2016) Am Fam Physician 93(7): 586-91 [PubMed]
  4. Steiner (2007) J Am Acad Child Adolesc Psychiatry 46(1):126-41 [PubMed]

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