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 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; this can be supported by pharmacotherapy, depending on the severity of symptoms.

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Overview

Epidemiology

  • Prevalence: 
    • Lifetime prevalence is estimated to be 10%.  
    • Before 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 have oppositional defiant disorder (ODD).

Etiology

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

  • Biological factors: 
    • Family history of:
      • Disruptive behavior disorder
      • Mood disorder
      • Alcohol or substance abuse 
    • Impairment in brain 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, as well as decreased cortisol 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

  • 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 symptomsPharmacology options
Depressive mood, irritability, anxietySelective serotonin reuptake inhibitors (e.g., fluoxetine)
Severe aggression2nd-generation antipsychotics (e.g., risperidone)
Impulsivity, hyperactivity, inattentionStimulants (e.g., methylphenidate) or nonstimulants (e.g., guanfacine)

Differential Diagnosis

  • Conduct disorder: a pediatric mental disorder characterized by 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 a duration of at least 1 year. An important risk factor is parental rejection and neglect. Management includes family therapy, behavioral modification, and pharmacotherapy.
  • ADHD: 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. Onset is usually before the age of 12. Attention deficit hyperactivity disorder is a common comorbidity of ODD; however, those with ADHD will have difficulty carrying out tasks that require attention or remaining still. Symptoms associated with ODD will manifest outside of tasks requiring focus. 
  • Disruptive mood dysregulation disorder (DMDD): a pediatric mental disorder that involves chronic negative mood, irritability, and severe recurrent temperamental outbursts. Oppositional defiant disorder cannot be diagnosed if DMDD is present; if criteria for both conditions are met, only the diagnosis of DMDD should be established. The distinguishing clinical feature is the disproportional emotional outbursts relative to the developmental/maturity stage in DMDD.
Table: Features of ODD compared with important differential diagnoses
CharacteristicsODDDMDDConduct disorder
OnsetPreschool ageAges 6–10 years
  • Childhood onset: < 10
  • Adolescent onset: > 10
MoodAngry/irritableAngry/irritableNo mood component
Impairment in interpersonal relationshipsExhibits continued and frequent argumentative/defiant behaviors inconsistent with developmental levelExhibits outbursts of emotion inconsistent with developmental level
  • Initiates aggressive behavior
  • Reacts aggressively
Psychological features
  • Behavior secondary to threat to one’s autonomy
  • Patient considers behavior to be justified.
Extreme and disproportionately angry response to stimulusLack of empathy, remorse, guilt
Behavioral features
  • Defies rules and authority figures
  • Not physically aggressive
  • Elevated mood without meeting criteria for bipolar disorders
  • Verbally or physically aggressive
  • Violates rules of society (thievery, vandalism)
  • Aggressive to people and animals
Exclusion diagnosisNot diagnosed if patient meets criteria for DMDDMay co-occur with ADHD, conduct disorder, depressive disorders, and substance use disorders
  • May co-occur with ODD
  • Consider antisocial personality disorder 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/ 

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