Achieve Mastery of Medical Concepts

Study for medical school and boards with Lecturio

Oppositional Defiant Disorder

Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority Authority Medical Ethics: Basic Principles figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Affected individuals do not show aggressive or violent behavior, and they do not impinge on other persons’ rights. The 1st line of management consists of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy; this can be supported by pharmacotherapy, depending on the severity of symptoms.

Last updated: 15 Jun, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Epidemiology

  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency
    • Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is estimated to be 10%.  
    • Before puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty: more common in boys than girls
    • School-aged children and adolescents: equally common in boys and girls
  • Most common comorbidity: 50% of children affected with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder have oppositional defiant disorder (ODD).

Etiology

A combination of risk factors is considered responsible for the development of ODD.

  • Biological factors: 
    • Family history Family History Adult Health Maintenance of:
      • Disruptive behavior disorder
      • Mood disorder
      • Alcohol or substance abuse 
    • Impairment in brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification areas responsible for impulse control
  • Psychological/social factors:
    • Poverty
    • Abuse
    • Absent or neglectful parenting 
    • Difficulty in forming social relationships
    • Unstable family environment (e.g., divorce or frequent moves)
  • Physical factors: 
    • Low birth weight 
    • Neurological injury during childhood

Pathophysiology

  • The exact pathophysiology of ODD is not understood. 
  • Low resting heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology, as well as decreased cortisol Cortisol Glucocorticoids stress response, are associated with higher levels of aggression in ODD.

Diagnosis

DSM-V diagnostic criteria

  • Duration of at least 6 months
  • Angry/irritable mood:
    • Easily loses temper
    • Easily annoyed
    • Often angry and resentful
  • Argumentative/defiant behavior:
    • Frequently argues with adults
    • Noncompliant with rules
    • Annoys and upsets others
    • Blames others for their misbehavior
  • Vindictiveness:
    • Resentful and revenge-seeking behavior
    • Present at least twice within the past 6 months

Further considerations

  • The disturbance in behavior is associated with distress in the individual or in other persons in their immediate social context.
  • Must exclude: 
    • Other psychotic or mood disorders
    • Substance abuse

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

  • 1st-line treatment
  • The goal is to include and educate both parent and child.
  • May encompass:
    • Interpersonal skills training
    • Anger management
    • Conflict-resolution techniques for the child 
  • CBT may be used to develop coping skills and reduce impulsive behavior.

Pharmacotherapy

  • Only recommended in combination with psychosocial interventions 
  • Indicated if the disorder is associated with other symptoms or conditions
Table: Pharmacotherapy for different target symptoms in ODD
Target symptoms Pharmacology options
Depressive mood, irritability, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants (e.g., fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants)
Severe aggression 2nd-generation antipsychotics (e.g., risperidone Risperidone A selective blocker of dopamine D2 receptors and serotonin 5-HT2 receptors that acts as an atypical antipsychotic agent. It has been shown to improve both positive and negative symptoms in the treatment of schizophrenia. Second-Generation Antipsychotics)
Impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder, inattention Inattention Attention Deficit Hyperactivity Disorder Stimulants Stimulants Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants (e.g., methylphenidate Methylphenidate A central nervous system stimulant used most commonly in the treatment of attention deficit disorder in children and for narcolepsy. Its mechanisms appear to be similar to those of dextroamphetamine. Stimulants) or nonstimulants (e.g., guanfacine)

Differential Diagnosis

  • Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder: a pediatric mental disorder Pediatric mental disorder Conduct Disorder characterized by recurrent behavior in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over a duration of at least 1 year. An important risk factor is parental rejection and neglect Neglect Child Abuse. Management includes family therapy Family therapy A form of group psychotherapy. It involves treatment of more than one member of the family simultaneously in the same session. Psychotherapy, behavioral modification, and pharmacotherapy.
  • ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: a neurodevelopmental disorder characterized by a pattern of inattention Inattention Attention Deficit Hyperactivity Disorder and/or hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder impulsivity Impulsivity Attention Deficit Hyperactivity Disorder that occurs in at least 2 different settings for more than 6 months. Onset is usually before the age of 12.  Attention deficit hyperactivity disorder Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder is a common comorbidity of ODD; however, those with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder will have difficulty carrying out tasks that require attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment or remaining still. Symptoms associated with ODD will manifest outside of tasks requiring focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast
  • Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder ( DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder): a pediatric mental disorder Pediatric mental disorder Conduct Disorder that involves chronic negative mood, irritability, and severe recurrent temperamental outbursts. Oppositional defiant disorder cannot be diagnosed if DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder is present; if criteria for both conditions are met MET Preoperative Care, only the diagnosis of DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder should be established. The distinguishing clinical feature is the disproportional emotional outbursts relative to the developmental/maturity stage in DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder.
Table: Features of ODD compared with important differential diagnoses
Characteristics ODD DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder
Onset Preschool age Ages 6–10 years
  • Childhood onset: < 10
  • Adolescent onset: > 10
Mood Angry/irritable Angry/irritable No mood component
Impairment in interpersonal relationships Exhibits continued and frequent argumentative/defiant behaviors inconsistent with developmental level Exhibits outbursts of emotion inconsistent with developmental level
  • Initiates aggressive behavior
  • Reacts aggressively
Psychological features Extreme and disproportionately angry response to stimulus Lack of empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy, remorse, guilt
Behavioral features
  • Violates rules of society (thievery, vandalism)
  • Aggressive to people and animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic
Exclusion diagnosis Not diagnosed if patient meets criteria for DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder May co-occur with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder, conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder, depressive disorders, and substance use disorders
  • May co-occur with ODD
  • Consider antisocial personality disorder Antisocial Personality Disorder A personality disorder whose essential feature is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The individual must be at least age 18 and must have a history of some symptoms of conduct disorder before age 15. Cluster B Personality Disorders if > 18 years of age.

References

  1. Aggarwal A, Marwaha R. Oppositional Defiant Disorder. (2020). In: StatPearls. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557443/
  2. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 31, Child psychiatry, pages 1244–1247. Philadelphia, PA: Lippincott Williams and Wilkins.
  3. Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders et al. (2015). Mental Disorders and Disabilities Among Low-Income Children. Washington (DC): National Academies Press (US), Prevalence of Oppositional Defiant Disorder and Conduct Disorder. https://www.ncbi.nlm.nih.gov/books/NBK332874/ 

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

Details