Approach

Oppositional defiant disorder (ODD) is characterized by persistent and substantial antagonism and defiance, often accompanied by chronic anger or irritability. ODD is commonly - but not always - first identified in childhood (often before the age of 8). The condition typically continues through adolescence and into adulthood. Be aware that ODD may be misdiagnosed, for example as a form of conduct disorder (CD), or dismissed as a product of ineffective parenting; the resulting delay in initiating effective treatment may lead to poorer patient outcomes.

Refer all patients with suspected ODD to a mental health professional (who ideally specializes in ODD) to undertake a comprehensive assessment. ODD is a clinical diagnosis determined by an assessment of symptoms and behaviors, which is most commonly performed by a mental health professional. The diagnosis is confirmed via a detailed history, observation, and clinical interview of any available family members or caregivers. Note that there are no known physical indicators of ODD. Diagnosis may be supported by information provided by other close contacts of the patient, such as teachers of school-age children.

ODD is an early-emerging risk factor for, and often co-occurs with, affective and behavioral disorders.[40] Its presence in the context of other disorders is highly salient to prognosis and treatment and should not be dismissed. It is important that symptoms suggestive of ODD are not disregarded or assumed to be the result of another condition.

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 predictive of parental stress, interparental conflict, and divorce, and may engender both immediate and more diffuse reciprocal maladaptive cause-effect relationships in interpersonal domains.

Initial history

Take a comprehensive history and obtain information from family members, caregivers, and/or other close contacts as appropriate to identify pertinent symptoms of ODD and to consider comorbid or alternative diagnoses.[53][54][55] Enquire about:

  • Symptoms that have occurred in the last 6 months, with a focus on symptoms that are atypical for the patient's age, level of development, sex, and culture.[13][55] Symptoms typically suggestive of ODD are categorized by subdimensions of:

    • Chronic irritability, such as frequent loss of temper, often being touchy, or frequently being angry or resentful.

    • Oppositional behavior, such as being argumentative, defiant, or vindictive, refusing to comply with requests or rules, deliberately annoying others or blaming peers for mistakes or misbehavior, behaving provocatively or spitefully.

  • Medical/psychiatric history

    • Enquire about past diagnoses, and specifically history of learning disabilities, history of substance abuse, and coexisting mental health issues, as part of the assessment.[53][55]

  • Family and psychosocial history including assessment of:

    • Relationship with family members and/or caregivers (and particularly parents if the patient is a child), with a focus on parenting strategies, tensions in the home, and detail regarding peer relationships.[53]

    • Family history of medical conditions, including psychiatric conditions affecting family members.

  • Developmental history and school/work performance

    • Determining developmental milestones may help to detect any primary cognitive or developmental disorders that may be an alternative diagnosis or exist alongside ODD.

If you suspect ODD based on the initial history, refer the patient to a mental health professional who is competent to undertake a comprehensive assessment of the patient's symptoms and behaviors.[53]

Specialist assessment: structured clinical interview

A mental health professional, who ideally specializes in ODD, should take a thorough history from the patient and their family members, caregivers, teachers, and/or other close contacts as appropriate to identify pertinent symptoms of ODD and to consider comorbid or alternative diagnoses.[53][54][55] Behavioral observation is also recommended alongside history-taking, particularly for younger children in whom clinical interview can be difficult in practice.

Several well-validated semi-structured clinical interviews exist and may be administered as part of the specialist assessment. These tools generate diagnoses algorithmically, typically taking impairment and other diagnostic rules into account. However, they should not be regarded as a substitute for clinical judgment. A commonly used instrument is the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version DSM-5 (K-SADS-PL DSM-5).[56]

Specialist assessment should cover:

  • Symptoms

  • Medical/psychiatric history

  • Family and psychosocial history

  • Risk factors.

Symptoms

Assessment of symptoms should focus on symptoms that have occurred in the past 6 months and are atypical for the patient's age, level of development, sex, and culture.[13][55] Symptoms typically suggestive of ODD are categorized by subdimensions of:

  • Chronic irritability, as demonstrated by:

    • Frequent loss of temper

    • Often touchy

    • Frequently angry or resentful

  • Oppositional behavior, as demonstrated by the patient:

    • Being argumentative

    • Being defiant

    • Refusing to comply with requests or rules

    • Deliberately annoying others

    • Blaming peers for mistakes/misbehavior

    • Being vindictive

    • Behaving provocatively

    • Behaving spitefully.

Particular attention should be paid 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.[13] It is important to confirm that these symptoms do not occur exclusively during substance abuse, or during the course of a psychotic episode, or depressive or bipolar disorder.[13]

The evidence regarding the relative prevalence of subtypes (chronic irritability and oppositional behavior) is limited, but available data suggest a modest likelihood for a lower prevalence of ODD with chronic irritability compared to without.[57]

  • The ICD-11 represents these dimensions through codified subtypes of ODD either with or without chronic irritability/anger.[14]

  • DSM-5 does not distinguish subtypes but defines the criteria for diagnosis of the condition as the presence of 4 or more symptoms/patterns of mood or behavior, which should occur during interaction with at least one person who is not a sibling of the individual.[13]

Subclinical levels of ODD symptoms (i.e., 3 or fewer symptoms of ODD rather than 4 symptoms as per Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision [DSM-5-TR] diagnostic criteria) often precede the onset of ODD; symptoms of behavioral disorders commonly wax and wane over time.[15][16]

Age of onset of symptoms should be determined, as well as frequency and duration. Typically, ODD emerges in childhood (often before the age of 8) and generally shows a stable course over time.[58][59] Onset in adolescence or adulthood is possible, but there is not enough robust evidence to support an estimate of how frequently this occurs. If diagnostic criteria are met for ODD, it is recommended that the diagnosis is not discounted solely on the basis of the age of onset.

  • Symptoms should be present for at least 6 months to meet the DSM-TR diagnostic criteria.[13][14][55] Symptoms should typically occur:[13]

    • on most days in children under 5 years, or

    • at least once a week in those ages 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, or

    • in the case of vindictive behavior, 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.

The DSM-5-TR further specifies that these symptoms should be exhibited during interaction with one or more people who are not a sibling of the individual.[13] See Criteria.

Medical/psychiatric history

Past diagnoses, and specifically history of learning disabilities, history of substance abuse, and coexisting mental health issues, should be enquired about as part of the assessment.[53][55]

Although ODD can occur as a single entity, the condition is often comorbid with other mood, anxiety, and neurodevelopmental disorders.

  • If there is an uncertainty about a diagnosis of ODD in the presence of comorbid psychopathology, a careful developmental history is recommended.

  • One study assessing the lifetime prevalence of ODD and 18 other DSM-IV disorders (the relevant DSM version at time of publication of study) in 3199 adults found 92.4% of patients with lifetime ODD to meet criteria for at least one other lifetime DSM-IV disorder, including mood disorders (45.8%), anxiety disorders (62.3%), impulse-control disorders (68.2%), and substance use disorders (47.2%).[40]

ADHD and ODD commonly co-occur; prevalence estimates of their comorbidity range between 13.6% and 29.5%.[19][60][61] Developmentally, ADHD typically precedes ODD and may predict higher severity of ODD over time.[25][40]

  • The diagnoses of both ADHD and ODD should be made if criteria for both conditions are present, because best practices for treatment of the two disorders differ markedly. ODD and ADHD are each associated with distinct risks for poor outcomes and require specific targeted intervention.

  • Primary symptoms of ADHD do not include irritability or anger (although it is important to note that the experience of ADHD can lead to frustration stemming from, and resistance to, activities that may be taxing to the patient, given their limited attentional capacities).

  • If ADHD is present and the diagnosis of ODD is ambiguous or if ODD symptoms occur only in the context of impairments linked to ADHD, it may be appropriate to refrain from assigning ODD as a co-occurring diagnosis. For more detail on ADHD, see Attention deficit hyperactivity disorder in children and Attention deficit hyperactivity disorder in adults.

Conduct disorder (CD) also commonly occurs in association with ODD. General population prevalence estimates of their comorbidity vary substantially, ranging from 8% to 60%.[20][60] Higher levels of the oppositional behavioral symptom dimension (rather than the irritability dimension) in patients with ODD may increase the risk for future CD.[12]

  • The symptoms of CD are very distinct from ODD. CD symptoms include significant and repeated aggression, acts of physical harm or cruelty toward people and animals, criminal behaviors such as theft and property destruction, status offenses such as truancy and curfew violations.

  • Aggressive behavior is not indicative of ODD, although it is possible that during an outburst of temper in a patient with ODD, minor damage or inadvertent harm to another could occur. To resolve diagnostic ambiguity between ODD and CD regarding aggression, consider whether aggression is limited to incidents of tantrums, is generally mild, or if damage/harm caused is accidental - these features are more suggestive of ODD. If criteria for both ODD and CD are met, both diagnoses should be given.

Family and psychosocial history

A family and psychosocial history should be obtained, which includes assessment of:

  • The patient's relationship with their family members and/or caregivers (and particularly parents if the patient is a child), with a focus on parenting strategies, tensions in the home, and detail regarding peer relationships.[53]

  • Family history of medical conditions, including psychiatric conditions affecting family members.

Risk factors

Note that presence or absence of any risk factor does not rule ODD in or out, and no individual risk factor can be categorized 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 empiric testing to be considered specific and reliable.

Potential contributors to the development of ODD include:[1][2][22][23][24][27][32]

  • Genetic predisposition

  • History of ADHD

  • Child hyporeactivity to stress

  • Child deficits in learning from punishment

  • Difficulties in recognizing angry facial expressions

  • Parental history of behavioral psychopathology and irritability

  • Prenatal tobacco, alcohol, or substance use; maternal stress during pregnancy

  • Maladaptive parenting (timid discipline, aggressive parenting, low maternal warmth)

  • Parental divorce

  • Exposure to abuse and family violence

  • Socioeconomic adversity and low household income.

Although there are few supporting data from genome-wide association studies, estimates from behavioral 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 (also known as shared environment) typically explain very little of the variation in ODD in behavioral genetics studies.[2][22][23][24]

Specialist assessment: behavioral checklists

Behavioral checklists may be used as part of the specialist assessment.[55]

  • Behavioral checklists are typically easy to administer and relatively brief.

  • In contrast to structured clinical interviews, behavioral checklists rarely include assessment of any impairment criteria, nor do they address exclusion criteria regarding comorbid conditions.

Administration of behavioral checklists to people involved in the patient's care or who see the patient on a regular basis should also be considered, and especially to teachers if the patient is still in school.[55] Many checklists have separate parent-, teacher-, or self-rated versions to facilitate the collection of multiple informant observations.

Information from multiple sources can be very useful for assessment. However, different informants (i.e., teachers, parents, parent self-report) may substantially disagree with one another. This is not indicative of error or false reporting on the part of any one informant, but more likely reflects differing windows of observation; significant discordance among informants may point to symptoms being environment-specific and therefore might not support a diagnosis of ODD. There is no clear guidance on how to integrate dissonant information from multiple informants; clinical judgment is key.

While multiple informants are generally preferred, a diagnosis can also be made if criteria are met based on a single informant's report. Evidence supports the stability of ODD and the risk for poor outcomes being equally predicted by parent report or teacher report, independent of one another and true even in the presence of significant discrepancies between the two informants.[62][63]

Flawed retrospective recall may bias the accuracy of the history provided by any informant. Thus, ODD may be first diagnosed in adolescence or adulthood if criteria are met, even if an informant denies any history of ODD in childhood.

Commonly used behavioral checklists for the assessment of ODD include:

  • the Child and Adolescent Symptom Inventory-5 (CASI-5)[64]

  • the Vanderbilt[65]

  • the Conners[66]

  • The Child Behavior Checklist.[67]

Most commonly used behavioral checklists do not map clearly onto DSM criteria, therefore reducing their efficiency for diagnostic purposes. However, the Child Behavior Checklist includes proxy measures of DSM diagnoses and may aid in collecting informant reports if symptom-based checklists are not available.[67]

The Kiddie Computerized Adaptive Test (K-CAT) has been subject to limited empiric scrutiny, but may also be used due to its potential to enhance assessment practices.[68]

  • When delivered on a computer tablet, with parent- and child-report versions, K-CAT has been shown to assess ODD in 64 seconds, and to assess a set of seven common categories of psychopathology in 8 minutes.[68]

Although validation studies of most well-established checklists and structured interviews commonly have lower bounds of approximately 6 years of age, some experts recommend measures specifically for diagnosis of ODD in children of preschool age.​[26][69][70] Examples include:

  • The Diagnostic Interview Schedule for Children Adolescents and Parents-5 (DISCAP-5); validated for use in children as young as 2.[71]

  • The Diagnostic Infant and Preschool Assessment; validated for use in children between 1.5 and 7 years of age in US, Danish, and Dutch samples.[72][73][74]

Similarly, although ODD typically persists into adulthood, validation data for most measures have an upper bound of 18 years of age.[4][7][8] Several measures for ODD in adults have been put forward but are largely awaiting more substantial validation evidence for their use.[8][75][76]

Diagnostic pitfalls

Missed/delayed diagnosis

Delayed diagnosis and misdiagnosis of ODD is common, leading to increased exposure to harmful outcomes and to the accumulation of stressors for the patient and family.[54]

The worldwide prevalence of ODD in children up to the age of 18 is estimated to be approximately 3% to 4%.[17][18][19][20] Therefore, meeting the symptom criteria for ODD is relatively rare. However, when present, the disorder is typically stable over the patient's lifespan and can exert a heavy toll. In practice, clinicians may attribute clinical levels of ODD to other phenomena (e.g., trauma, poor parenting, environmental stressors) and consequently dismiss it as a benign condition. There may also be reluctance by some practitioners to diagnose ODD due to concerns regarding perceptions of stigma arising from the diagnosis.

  • Withholding the diagnosis when suspected is likely to increase the likelihood of the well-known poor outcomes of ODD (including depression, anxiety, aggression, conduct disorder, and functional impairments across interpersonal contexts such as academic achievement, workplace performance, and romantic/marital relationships) due to lack of intervention with available management options.

ODD is often misdiagnosed because other conditions can cause similar behaviors.

  • It is important to be aware that ODD commonly co-occurs with other psychopathology such as ADHD and anxiety disorders. ODD is an early-emerging risk factor for, and is often comorbid with, affective and behavioral disorders.[40] Its presence in the context of other disorders is highly salient to prognosis and treatment, and should not be dismissed.

  • The diagnosis of the somewhat controversial conditions of disruptive mood dysregulation disorder (DMDD) or pathologic demand avoidance (PDA) may be wrongly applied to some patients with ODD.

    • The symptoms of DMDD (temper outbursts in the context of chronically irritable mood) overlap almost completely with the chronic irritability dimension of ODD symptoms, making it difficult to distinguish between the two conditions. While the criteria for DMDD describe potentially higher intensity of outbursts of temper, in practice extraordinarily high rates of overlap of ODD and DMDD have been found in clinical and community samples.[77]

    • Patients with PDA are described to demonstrate resistance to and/or avoidance of everyday demands, excessive mood swings, and obsessive behavior that is often focused on other people. Note that PDA is not represented in the DSM-5 or the ICD-11, and was originally described following observations of children with what was described as atypical autism.[78] Interest in and discussion of PDA is confined largely to the UK.

Misdiagnosis may also be driven by implicit racial bias.[79] Clinicians may misapply the diagnosis of ODD to children of color when other diagnoses are more appropriate; studies have indicated that children who are not white are more likely to receive a diagnosis of a disruptive behavior disorder rather than a diagnosis of ADHD when compared with white children, with treatment disparities being present even when adjusted for confounding.[80][81]

Misinterpretation of risk factors

Overstating the role of any individual risk factor for ODD should be avoided because:

  • Very little evidence exists to distinguish true risks for ODD from confounded covariates.[48]

    • Behavior genetics studies show that ODD, 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.

  • The literature on risk factors for ODD involves the reciprocity between ODD and the environment.

    • The behaviors associated with ODD exert impacts on, and are themselves modified by, the behaviors of others, including parenting behaviors and peer interactions.[82][83] Relatively few risk factors have been evaluated via reciprocal developmental study designs.

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