Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a behavioural condition characterised by persistent and substantial antagonism and defiance, often accompanied by chronic anger or irritability.

Commonly first identifiable in childhood, ODD is typically present through adolescence and into adulthood. Symptoms are categorised by subdimensions of chronic irritability and oppositional behaviour.

Refer all patients with suspected ODD to a mental health professional (who ideally specialises in ODD) to undertake a comprehensive assessment.

ODD is a clinical diagnosis, confirmed by a detailed history and clinical interview of the patient, any available familial informants, and other close contacts of the patient, such as teachers in children of school age. Behavioural observation is also recommended alongside history-taking, particularly for younger children in whom clinical interview can be difficult in practice.

Refer all children and adolescents with ODD (and their families) for evidence-based behavioural interventions; parents should be involved throughout treatment, and behavioural parent training is a key component of management in these age groups.

Evidence for the treatment of adults with ODD is scarce. In practice, referral to a specialist is recommended for consideration of interventions such as psychotherapy.

Oppositional defiant disorder (ODD) is typified by persistent and substantial antagonism and defiance. These difficulties manifest across all contexts, and individuals with ODD often struggle in interpersonal contexts with parents, peers, teachers, employers, and co-workers.[1]Bussing R, Gary FA, Mason DM, et al. Child temperament, ADHD, and caregiver strain: exploring relationships in an epidemiological sample. J Am Acad Child Adolesc Psychiatry. 2003 Feb;42(2):184-92. http://www.ncbi.nlm.nih.gov/pubmed/12544178?tool=bestpractice.com [2]Ding W, Lin X, Hinshaw SP, et al. Reciprocal influences between marital quality, parenting stress, and parental depression in Chinese families of children with oppositional defiant disorder symptoms. Child Youth Serv Rev. 2022 May;136:106389.​ https://www.sciencedirect.com/science/article/abs/pii/S0190740922000251 [3]Evans SC, Pederson CA, Fite PJ, et al. Teacher-reported irritable and defiant dimensions of oppositional defiant disorder: social, behavioral, and academic correlates. School Ment Health. 2016;8(2):292-304. https://link.springer.com/article/10.1007/s12310-015-9163-y [4]França MH, Pereira FG, Wang YP, et al. Individual and population level estimates of work loss and related economic costs due to mental and substance use disorders in Metropolitan São Paulo, Brazil. J Affect Disord. 2022 Jan 1;296:198-207. http://www.ncbi.nlm.nih.gov/pubmed/34610514?tool=bestpractice.com [5]Leadbeater BJ, Ames ME. The longitudinal effects of oppositional defiant disorder symptoms on academic and occupational functioning in the transition to young adulthood. J Abnorm Child Psychol. 2017 May;45(4):749-63. http://www.ncbi.nlm.nih.gov/pubmed/27469319?tool=bestpractice.com

ODD is commonly first observed in childhood (often before the age of 8) and is typically persistent throughout development into adulthood.[6]Burke JD, Waldman I, Lahey BB. Predictive validity of childhood oppositional defiant disorder and conduct disorder: implications for the DSM-V. J Abnorm Psychol. 2010 Nov;119(4):739-51. http://www.ncbi.nlm.nih.gov/pubmed/20853919?tool=bestpractice.com [7]Gomez R, Stavropoulos V. Oppositional defiant disorder dimensions: associations with traits of the Multidimensional Personality Model among adults. Psychiatr Q. 2019 Dec;90(4):777-92. http://www.ncbi.nlm.nih.gov/pubmed/31407123?tool=bestpractice.com [8]Johnston OG, Derella OJ, Burke JD. Identification of oppositional defiant disorder in young adult college students. J Psychopathol Behav Assess. 2018 Dec;40(4):563-72.​ https://einstein.elsevierpure.com/en/publications/identification-of-oppositional-defiant-disorder-in-young-adult-co [9]Hawes DJ, Gardner F, Dadds MR, et al. Oppositional defiant disorder. Nat Rev Dis Primers. 2023 Jun 22;9(1):31. http://www.ncbi.nlm.nih.gov/pubmed/37349322?tool=bestpractice.com ODD poses a substantial risk for functional impairments and future psychopathology.[10]Copeland WE, Shanahan L, Costello EJ, et al. Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Arch Gen Psychiatry. 2009 Jul;66(7):764-72. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/483134 http://www.ncbi.nlm.nih.gov/pubmed/19581568?tool=bestpractice.com [11]Burke JD, Rowe R, Boylan K. Functional outcomes of child and adolescent oppositional defiant disorder symptoms in young adult men. J Child Psychol Psychiatry. 2014 Mar;55(3):264-72. https://pmc.ncbi.nlm.nih.gov/articles/PMC3944082 http://www.ncbi.nlm.nih.gov/pubmed/24117754?tool=bestpractice.com

Evidence for distinct dimensions of symptoms suggests that elevations of symptoms on the chronic irritability dimension are particularly predictive of depression, anxiety, and suicidality, and elevations of the oppositional behavioural dimension are predictive of future antisocial behaviour, including conduct disorder.[12]Evans SC, Burke JD, Roberts MC, et al. Irritability in child and adolescent psychopathology: an integrative review for ICD-11. Clin Psychol Rev. 2017 Apr;53:29-45. http://www.ncbi.nlm.nih.gov/pubmed/28192774?tool=bestpractice.com