History and exam
Key diagnostic factors
common
often loses temper
A person with ODD may display one or more of the following symptoms of angry/irritable mood: often loses temper; often touchy or easily annoyed; often angry and resentful.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
often touchy or easily annoyed
A person with ODD may display one or more of the following symptoms of angry/irritable mood: often touchy or easily annoyed; often loses temper; often angry and resentful.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
often angry and resentful
A person with ODD may display one or more of the following symptoms of angry/irritable mood: often angry and resentful; often touchy or easily annoyed; often loses temper.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
argumentative/defiant behaviour
A person with ODD may display one or more of the following symptoms of oppositional behaviour: being argumentative, defiant, or vindictive; deliberately annoying others; refusing to comply with requests or rules; blaming peers for mistakes/misbehaviour; behaving provocatively or spitefully.[14]
Examples of argumentative or defiant behaviour include often arguing with authority figures (adults, if the patient is a child or adolescent), and often actively defying or refusing to comply with rules or requests from others.
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
deliberately annoying others
A person with ODD may display one or more of the following symptoms of oppositional behaviour: deliberately annoying others; being argumentative, defiant, or vindictive; refusing to comply with requests or rules; blaming peers for mistakes/misbehaviour; behaving provocatively or spitefully.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
refusing to comply with requests or rules
A person with ODD may display one or more of the following symptoms of oppositional behaviour: refusing to comply with requests or rules; deliberately annoying others; being argumentative, defiant, or vindictive; blaming peers for mistakes/misbehaviour; behaving provocatively or spitefully.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
blaming peers for mistakes/misbehaviour
A person with ODD may display one or more of the following symptoms of oppositional behaviour: blaming peers for mistakes/misbehaviour; refusing to comply with requests or rules; deliberately annoying others; being argumentative, defiant, or vindictive; behaving provocatively or spitefully.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
provocative behaviour
A person with ODD may display one or more of the following symptoms of oppositional behaviour: behaving provocatively or spitefully; blaming peers for mistakes/misbehaviour; refusing to comply with requests or rules; deliberately annoying others; being argumentative, defiant, or vindictive.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
spiteful behaviour
A person with ODD may display one or more of the following symptoms of oppositional behaviour: behaving spitefully or provocatively; blaming peers for mistakes/misbehaviour; refusing to comply with requests or rules; deliberately annoying others; being argumentative, defiant, or vindictive.[14]
Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria, and typically occur on most days in a child under 5 years, or at least once a week in those aged 5 years and over, or at a frequency and intensity that is outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
vindictive behaviour
A person with ODD may display one or more of the following symptoms of oppositional behaviour: behaving vindictively; behaving spitefully or provocatively; blaming peers for mistakes/misbehaviour; refusing to comply with requests or rules; deliberately annoying others; being argumentative or defiant.[14]
To fulfil the diagnostic criteria, vindictive behaviours should occur at least twice in the past 6 months or at a frequency and intensity outside a normal range for the individual's development level, sex, and culture.[14]
The DSM-5-TR further specifies that symptoms should be exhibited during interaction with at least one person who is not a sibling of the individual.[14]
Pay particular attention to symptoms that cause distress to the patient or to people that they interact with, or have a negative impact on important areas of the patient's life, including social, educational, and occupational settings.[14] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode or of depressive or bipolar disorder.[14]
Risk factors
strong
genetic predisposition
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Although there are few supporting data from genome-wide studies, estimates from behavioural genetics analyses of twin studies suggest that heritability may contribute to the development of ODD, potentially alongside non-shared environmental factors. Factors commonly experienced by both twins are typically found to explain very little of the manifestation of ODD.[2][22][23]
history of ADHD
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Prospective and retrospective data identify ADHD as one of the few comorbid mental health conditions likely to precede ODD in onset, and predict year over year increases in the level of ODD.[25][40] ODD may co-exist in up to 60% of people with ADHD.[41]
weak
child hyporeactivity to stress
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Some empirical data support an association between ODD and low basal cortisol, low resting heart rate, and low skin conductance, although no definitive conclusions have been drawn.[36]
child deficits in learning from punishment
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Some evidence suggests that beyond the effects of ADHD, ODD may contribute to difficulties in behavioural control.[37][42] The salience of rewards and of punishments may also be altered among youth with ODD.[37][38]
difficulties in recognising angry facial expressions
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Atypical facial expression recognition for some kinds of emotion has been found for youths with ODD, with limited evidence for some distinctions relative to conduct disorder and ADHD.[39]
parental history of behavioural psychopathology and irritability
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Studies have found disproportionately higher rates of parental histories of antisocial personality disorder (APD) or conduct disorder, and chronic irritability, among youth with ODD. In one clinic sample of boys, paternal (but not maternal) APD was present for 23% of boys with ODD, compared to 8% for boys without, a relationship that was significant even after controlling for demographic factors.[43] The odds ratio (OR) for child ODD given parental externalising psychopathology was 1.32 in one Swedish national cohort study.[44]
maternal tobacco use, alcohol consumption, substance use, and/or stress during pregnancy
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Antenatal tobacco use, alcohol consumption, substance use, and/or maternal stress during pregnancy may contribute to the development of ODD.[9][45] Although some studies have found maternal smoking during pregnancy to be a potential predictor for developing ODD (especially in the presence of comorbidities such as ADHD), other studies have found no association.[27][45][46][47][48] This illustrates the complexities that may arise due to confounding risk factors, confounding outcomes, and the influences of varying measurement approaches.
maladaptive parenting (timid discipline, aggressive parenting, low maternal warmth)
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Many studies have examined parenting behaviours, mostly with insufficient attention to covariates and to developmental processes. It is clear that undesirable parenting behaviours are at least associated with ODD.[49][50] Further, the implications of the effectiveness of treatments for ODD, which consistently depend on parent management training, suggest that increasing specific parenting behaviours leads to improvements regardless of the sources of risk.
One study of data taken from 926 participants of a longitudinal cohort study demonstated that adolescents with ODD were more likely to have been raised in home environments that were subject to multiple social, economic, and related adversities including parental adjustment problems and exposure to child abuse and family violence.[27]
parental divorce
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Family-level stressors contribute to child functional difficulties, including ODD.[9][51]
exposure to abuse and family violence
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Environmental risk factors for the development of ODD are thought to include childhood exposure to abuse or violence.[27][50][52] Data from 926 participants of a longitudinal birth cohort support the hypothesis that adolescents with ODD are more likely to have been raised in home environments that were subject to multiple social, economic, and related adversities.[27]
socioeconomic adversity and low household income
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Environmental risk factors for the development of ODD are thought to include low socioeconomic status and low household income.[27] In data from 926 participants of a longitudinal birth cohort, adolescents with ODD were more likely to have been raised in home environments that were subject to multiple social, economic, and related adversities.[27]
interpersonal conflict
Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorised beyond a general and suggestive level of confidence. While a number of factors have been more frequently studied, no individual risk factors have been subject to sufficient empirical testing to be considered specific and reliable.
Children with ODD experience higher levels of peer rejection and more conflict with peers.[3][9] The effects appear potentially reciprocal, but studies are inconsistent with regards to ODD as both a cause and a consequence of peer conflict.
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