Perhaps the most commonly diagnosed of all disruptive behavior disorders,1 Oppositional Defiant Disorder (ODD) involves a pattern of problematic relationships with others characterized by argumentativeness and rule violations.2 Primarily, individuals with ODD demonstrate difficulties with emotional and/or behavioral regulation. Treatment typically involves behavioral and parent management therapies, which has been proven to reduce behavioral issues and improve family function.
Those diagnosed with Oppositional Defiant Disorder are characterized by having difficulty regulating both their emotions and their behaviors. Specifically, difficulties with emotion regulation often manifest as frequent anger and irritation, whereas behavioral dysregulation is evident in episodes of argumentativeness and defiance.3 ODD tends to be more commonly diagnosed in males than females, and evidence of the disorder tends to present in childhood or early adolescence.
Signs of Oppositional Defiant Disorder
Signs of ODD tend to be overt, persistent, and functionally impairing. These individuals demonstrate periods of argumentative and/or defiant behavior, often coupled with a quickness to anger or become irritable. Unlike other diagnostic categories which require evidence of the behavior across settings, individuals with ODD may only display impairing behavior in a single setting (usually in the home). However, the presence of challenging behavior with siblings alone is not sufficient to meet the criteria for a diagnosis; rather, these individuals often display marked difficulty in their relationships with adults (perhaps even to the point of parental abuse) and/or same-aged peers.
Behaviors characteristic of ODD do occur, to a degree, in individuals without the disorder. For instance, challenging behaviors can be a common feature across development: tantrums commonly occur in preschool children and adolescents are prone to limit-testing. However, the persistence and frequency of these behaviors are the keys to meeting the criteria for a diagnosis of Oppositional Defiant Disorder. In other words, challenging behaviors are only considered symptoms of the disorder if they occur more days than not, and to the degree that they significantly impact functioning (i.e. behavior resulting in property destruction or dismissal from organized activities).
Furthermore, individuals with Oppositional Defiant Disorder often do not regard their mood as being irritable or their behavior as being problematic. More often, they report that their responses are reasonable reactions to unjust expectations or unreasonable circumstances.2
When Is Oppositional Defiant Disorder Diagnosed?
In order to meet the criteria for ODD, individuals must demonstrate a pattern of angry/irritable mood, argumentative and/or defiant behavior, or vindictiveness for at least 6 months. In addition, at least 4 of the following symptoms must occur during interaction with another person other than a sibling:2
Angry or Irritable Mood:
- Loses temper often
- Easily annoyed
- Often angry or resentful
Argumentativeness or Defiance:
- Frequent arguing with authority figures and/or adults
- Willingly defies or refuses to comply with stated rules or demands from authority figures
- Seeks to annoy others
- Blames others for mistakes/misbehavior
Vindictiveness:
- Evidence of spiteful or vindictive behavior at least twice in the last 6 months
In order to meet the criteria for the diagnosis, these behaviors need to persist beyond that which would be expected for others of the same age. Delineating symptomatic behaviors in childhood can be particularly challenging, as some problematic behavior is expected in typical development. For children younger than 5, the problematic behaviors need to occur on most days for a period of at least 6 months. For children older than 5, problematic behaviors need to occur at least once per week for the same 6 month period.
In addition to receiving a diagnosis, individuals who meet the criteria for ODD will also receive one of the following three specifiers:
- Mild – symptoms occur in only one setting
- Moderate – Symptoms present in at least two settings
- Severe – Symptoms present in three or more settings
Risk Factors for Oppositional Defiant Disorder
Symptoms of ODD are often apparent early in childhood and are rarely first observed later than early adolescence. Early problems related to emotional regulation have been shown to predict a later diagnosis with ODD. Specifically, evidence of emotional reactivity and low frustration tolerance can be early indicators.
Different categories of risk factors for oppositional defiant disorder include:
Environmental Risk Factors
There is some evidence that inconsistent, and/or neglectful early learning environments are associated with individuals diagnosed with ODD. Harsh parenting practices are strongly linked to the development of the disorder. ODD is also more common among children who live in poverty and who are exposed to community violence.4
Biologic Factors
There are some suggested links between prenatal exposure to nicotine, marijuana, and other illicit substances among children later diagnosed with ODD. In addition, prenatal nutritional deficiencies have also been correlated with the development of behavioral issues later in childhood.
Genetic & Physiological Factors
There are several associated features of ODD, including lower heart rates and skin conductance, and basal cortisol under-reactivity. In addition, individuals with abnormalities in the prefrontal cortex and amygdala are also implicated in the disorder. Parental psychopathology is also associated with the disorder, particularly maternal frustration tolerance and aggression.
Psychological Factors
Research on attachment theory has suggested that some of the behaviors associated with ODD may be related to insecure attachment and reactive attachment disorder.1
Specifically, this type of attachment is characterized by a fear-based bond with caregivers. Young children may demonstrate reluctance in their early relationships, as well as experiences of rejection. Other research has examined individuals’ social information processing, or their ability to understand the intent of others’ behaviors. Individuals with ODD have been thought to have some difficulty understanding important social cues and display weak problem-solving skills in unclear situations.
Co-Occurring Conditions & Oppositional Defiant Disorder
ODD often co-occurs with other types of mental health conditions. These commonly include Attention-deficit/hyperactivity disorder (ADHD) and Conduct Disorder. ADHD is the condition most associated with ODD, with 14-40% of children meeting criteria for both disorders. It is described as a developmental condition of inattention and distractibility, with or without accompanying hyperactivity.
Oppositional Defiant Disorder often precedes a later diagnosis of Conduct Disorder. Conduct disorder is defined as a continual pattern of aggression toward others as well as intentional rule-breaking behavior. Conduct disorder is also a childhood disorder, like oppositional defiant disorder. The DSM-5 characterizes a conduct disorder as a condition where a child intentionally violates rules and the rights of others.
Conduct disorder is often viewed as a more severe form of ODD as children with conduct disorder continually harm others and break the law whereas individuals with ODD usually have a difficult time with authority and rules. Research across the lifespan of children carrying an ODD diagnosis has found that approximately 42% go on to meet the criteria for Conduct Disorder.4
In addition, anxiety and depression are closely linked with ODD. Symptoms of these mood disorders can be evident as early as preschool age. Individuals with internalizing behaviors (e.g. anger and irritability) have been found to be at high risk for mood disorders, and those demonstrating more externalizing behaviors (e.g. defiance, vindictiveness) have been found to be more likely to receive a Conduct Disorder diagnosis.
Although the outcomes of individuals diagnosed with Oppositional Defiant Disorder are not always clear, some research suggests that 70% no longer meet the criteria by the time they are 18 years old.6 However, it is evident that the earlier the onset of symptoms the more likely individuals are to have more severe mental health issues into adulthood. A diagnosis of ODD in childhood or adolescence increases the chance of being diagnosed with another mental health illness, including substance use disorders. For those that don’t meet the criteria for a formal diagnosis, there is evidence that they are at higher than average risk for social and emotional problems in adulthood.
Treatment of Oppositional Defiant Disorder
Individuals with ODD typically experience difficulties in their interpersonal relationships as a result of challenging behavior. For young children, symptoms are best addressed through behavioral and parent management therapies. These approaches help parents and family members reduce problem behavior by minimizing the reinforcement that may be maintaining the behaviors themselves.
In other words, parents may be inadvertently contributing to the occurrence of problem behavior through accommodation, negotiation, or poor follow-through. Instead, parents are taught to be consistent in rewarding appropriate behavior and punishing maladaptive behavior. Research on the use of these interventions has established that they are largely effective in reducing conduct problems and increasing family functioning.1
For adolescents, traditional behavior-based parent management training may be less effective, as these children have longer histories of challenging behavior. These older individuals often benefit from cognitive-behavioral therapies, social skills, and vocational training.
Treatment approaches involving exposure to frightening situations (e.g., “Scared Straight,” boot camps, etc.), which are intended to motivate adolescents away from poor choices, have been shown to be both ineffective and have a high risk of escalating the intensity and severity of problem behavior.
While medication is not typically used as a primary tool for treating Oppositional Defiant Disorder, some research suggests that it can be most helpful for individuals with co-occurring disorders.8 Specifically, stimulants are often helpful in children with ADHD and ODD.9 In addition, some blood pressure medications such as clonidine can be helpful in addressing externalizing behaviors. Finally, antidepressants have been shown to be effective in reducing challenges for individuals who have a mood disorder diagnosis in addition to ODD.11
6 Tips for Parenting a Child With Oppositional Defiant Disorder
Working with a trained mental health professional is the best way to manage the symptoms of ODD and improve family functioning. Often this process begins by addressing concerns from your child’s pediatrician. From there, referrals can be provided to psychologists or other mental health workers trained in managing challenging behaviors. In addition to formal therapy, there are some simple parenting strategies that can be useful to minimize frustrating interactions and behaviors.
Here are six strategies that can be used to help parent children with challenging behavior:11
1. Catch Them Being Good
Often, challenging behavior can become the focus of parental attention. However, for many children who are motivated for their parents’ attention, the focus on the negative can turn into a difficult cycle that maintains problems. Taking the time to acknowledge and attend to small instances of appropriate behavior can go a long way toward undoing the cycle of challenging interactions.
2. Establish Clear Routines
Many children benefit from structure throughout the day. Creating consistent expectations for what needs to be accomplished each day can be extremely helpful in minimizing confrontations between caregivers and their children.
3. Use Predictable, Matter-of-Fact Consequences
Bad choices should result in consequences that reduce the likelihood that similar behavior will occur again. Parents and caregivers should deliver discipline that has been previously established with their children in an even mannered way. Yelling and lecturing are not useful tools to mitigating challenging behavior.
4. Model the Behavior You Want to See
Children are extremely observant, and will often take their cues from those around them. One of the best ways to ensure that your child engages in a certain behavior is to do it yourself.
5. Supervise
Bad behavior can often be the product of increased opportunity. Minimize the chances of bad choices by remaining close by during activities where kids are likely to run into trouble.
6. Set Limits on use of Electronics & Social Media
Research is underway to understand the best (and worst) of screen time during the day. Encourage moderation of screen usage by selecting specific times when screens can be available. In addition, make sure that children are using screens in an age-appropriate manner.
Oppositional Defiant Disorder Statistics
The prevalence of ODD in the general public ranges from about 1% to 11%, with an average of approximately 3.3%. Approximately 14% of individuals with ODD also meet criteria for an anxiety disorder and 9% show evidence of depressive disorders.4 The disorder tends to occur more commonly in males than females (1.4:1), though that ratio reflects samples of adolescents and adults. In other words, the diagnosis is fairly evenly distributed among younger children. In addition, rates of diagnosis of the disorder are consistent across different races and ethnicities.
