Oppositional defiant disorder (ODD) is defined by the DSM-5 as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months". Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. A diagnosis of ODD is also no longer applicable if the individual is diagnosed with reactive attachment disorder (RAD).
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Signs and symptoms
The fourth revision of the Diagnostic and Statistical Manual (DSM-IV-TR) (now replaced by DSM-5) stated that the child must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder. Furthermore, they must be perpetuated for longer than six months and must be considered beyond normal child behavior to fit the diagnosis. Signs and symptoms were: actively refuses to comply with majority's requests or consensus-supported rules; performs actions deliberately to annoy others; is angry and resentful of others; argues often; blames others for their own mistakes; frequently loses temper; is spiteful or seeks revenge; and is touchy or easily annoyed.
These patterns of behavior result in impairment at school and/or other social venues.
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Causes
The cause of ODD is unknown.
Genetic influences
Research indicates that parents pass on a tendency for externalizing disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. This heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behavior is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolizing enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behavior following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.
Prenatal factors and birth complications
Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning, and mother's use of alcohol or other substances during pregnancy may increase the risk of developing ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.
Neurobiological factors
Deficits and injuries to certain areas of the brain can lead to serious behavioral problems in children. Brain imaging studies have suggested that children with ODD may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control. Children with ODD are thought to have an overactive behavioral activation system (BAS), and underactive behavioral inhibition system (BIS). The BAS stimulates behavior in response to signals of reward or nonpunishment. The BIS produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of nonreward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.
Social-cognitive factors
As many as 40 percent of boys and 25 percent of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behavior, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act.
Environmental factors
Negative parenting practices and parent-child conflict may lead to antisocial behavior, but they may also be a reaction to the oppositional and aggressive behaviors of children. Factors such as a family history of mental illnesses and/or substance abuse as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behavior disorders.
Insecure parent-child attachments can also contribute to ODD. Often little internalization of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance abuse. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.
Low socioeconomic status is associated with poor parenting, specifically with inconsistent discipline and poor parental monitoring, which are then associated with an early onset of aggression and antisocial behaviors.
Externalizing problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighborhoods.
Diagnosis
For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends, or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.
Management
Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioral therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents. Several preventative programs have had a positive effect on those at high risk for ODD. Both home visitation and programs such as Head Start have shown some effectiveness in preschool children. Social skills training, parent management training, and anger management programs have been used as prevention programs for school-age children at risk for ODD. For adolescents at risk for ODD, cognitive interventions, vocational training and academic tutoring have shown preventative effectiveness. There is also limited evidence that the atypical antipsychotic medication risperidone decreases aggression and conduct problems in youth with disruptive behavioral disorders, such as ODD.
Epidemiology
ODD has an estimated lifetime prevalence of 10.2% (11.2% for males, 9.2% for females).
History
Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when conduct disorder is present. According to Dickstein, the DSM-5 attempts to:
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