Etiology

Heritability may explain approximately 40% to 60% of ODD, with the remainder thought to be explained by non-shared environmental factors (influences that differ for siblings, such as having different friends, different teachers, or being treated differently by parents).[22][23][24] Onset of the disorder is often preceded by the presence of ADHD and subclinical levels of ODD.[25][26] Most studies of risk factors have failed to distinguish ODD from other behavioral disorders, but environmental risk factors include low socioeconomic status, smoking during pregnancy, and childhood exposure to abuse or violence.[27] Child temperament, sociocognitive development, and emotion regulation predict ODD onset.[9][28][29] Parental psychopathology, family functioning and interparental relationship quality, and parenting behaviors contribute to the onset and maintenance of ODD over time.[30]

ODD may elicit undesirable parenting, peer rejection, and conflict with teachers, and can, in turn, be worsened by conflictual relationships in all areas. ODD is also predictive of parental stress, interparental conflict, and divorce.[31][32] The condition may therefore impact both immediate and more diffuse reciprocal maladaptive cause-effect relationships in interpersonal domains.

Pathophysiology

There is no clear evidence for specific linkages between pathophysiologic processes and ODD. Some initial suggestive evidence links ODD with atypical morphology or function in certain brain regions associated with social and emotional functioning, neuroendocrine function, and psychophysiologic measures.[33][34] These are typically concordant with impairments in reinforcement learning, social cognition, problem solving, emotion regulation, and response to stressors; however, the degree of specificity to ODD is ambiguous and the consistency of such findings across studies is either low or not clear. No translation of this basic research to reliable clinical and assessment practices has yet been done.

Behavior genetics studies show that ODD, conduct disorder (CD), and ADHD (among other comorbidities) share common genetic influence, but also show unique genetic influence for ODD.[22][24][35] Studies assessing risk factors for ODD are generally insufficiently controlled for comorbid conditions to identify which are shared and which are unique; the historic tendency for researchers to combine ODD and CD (and sometimes ADHD) into a single construct has worsened the problem. As a result, the literature on risk factors for ODD is substantially limited by confounding among both the predictors and the outcomes.

Some empiric 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] The salience of rewards and of punishments may also be altered among youth with ODD.[37][38]

Atypical facial expression recognition for some kinds of emotions has been found for youths with ODD, with limited evidence for some distinctions relative to CD and ADHD.[39]

Classification

Diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR)[13]​

The DSM-5-TR includes severity specifiers of mild, moderate, and severe.

These are distinguished by the number of settings in which ODD symptoms are shown (one, two, and three or more, respectively) including at home, work, school, and/or with peers.

International classification of diseases 11th revision (ICD-11)[14]​

The ICD-11 classification for ODD is listed under the parent group of disruptive behavior or dissocial disorders. The ICD-11 includes subtypes for ODD with and without chronic irritability.

ODD with chronic irritability is distinguished by prevailing anger and resentment, being touchy or easily annoyed, and often losing temper. ODD without chronic irritability is defined as diagnostic criteria being met for ODD, but instead of a persistently angry and irritable mood, anger and temper loss are more transitory, less severe, and less often out of proportion to any provocation.

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