Oppositional Defiant Disorder

What is oppositional defiant disorder?

Oppositional defiant disorder (ODD) is a disruptive disorder characterized by frequent and persistent angry or irritable mood, argumentative or defiant behavior, or vindictiveness. The average prevalence of ODD is 3.3% and is more common in men than women.

What does ODD look like?

Signs & Symptoms

Having frequent temper tantrums
Arguing a lot with adults
Refusing to do what an adult asks
Always questioning rules and refusing to follow rules
Doing things to annoy or upset others, including adults
Blaming others for the child’s own misbehaviors or mistakes
Being easily annoyed by others
Often having an angry attitude
Speaking harshly or unkindly
Seeking revenge or being vindictive

DSM-5 Criteria

Criterion A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual that is not a sibling:

Angry/Irritable Mood

Often loses temper.
Is often touchy or easily annoyed.
Is often angry and resentful.

Argumentative/Defiant Behavior

Often argues with authority figures or, for children and adolescents, with adults.
Often actively defies or refuses to comply with requests from authority figures or with rules.
Often deliberately annoys others.
Often blames others for his or her mistakes or misbehavior.

Vindictiveness

Has been spiteful or vindictive at least twice within the past 6 months.

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture.

Criterion B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g. family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

Criterion C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Risk Factors

Harsh, inconsistent, or neglectful child-rearing practices
Childcare disrupted by the presence of multiple caregivers

Prognosis

Symptoms usually begin in early preschool years and rarely later than early adolescence
Can result in frequent conflicts with peers, parents, and other adults
Increased risk for antisocial behavior, impulse-problems, substance abuse, anxiety, and depression in adulthood
Increased risk for suicide attempts

Differential Diagnosis

Conduct disorder
Attention-deficit/hyperactivity disorder
Depressive disorders
Bipolar disorders
Social anxiety disorder
Disruptive mood dysregulation disorder
Intermittent explosive disorder
Intellectual disability
Language disorder

How is ODD investigated?

A biopsychosocial investigation is key to understanding aggressive behavior:

Parenting and family factors:
- Parenting behaviour
- Parent-child attachment
Peer relationships:
- Peer rejection
- Deviancy “training” (getting trained to be “unliked” by others)
Child-level mental processes:
- Callous-unemotional traits (degree of empathy in the child)
- Emotional regulation
- Executive functions and language (learning disorders)
- Social cognition
Predisposing Factors:
- Trauma
- Raised up in the orphanage
Precipitating Factors:
- Recently punched by student
- Recently moved
- Recent death in family
Perpetuating Factors:
- Recurring social/family/school conflicts

How is ODD treated?

Behavioral modification
Parent management training

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.