Condition

Oppositional Defiant Disorder

Editors: Sergio Zaderenko MD; Esther Jolanda van Zuuren MD; Alexander Rae-Grant MD, FRCPC, FAAN

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Background Information

Description

  • Oppositional defiant disorder is a type of disruptive behavior disorder in children that is characterized by a recurrent pattern of developmentally inappropriate levels of argumentative, defiant, vindictive, and hostile behavior toward authority figures for > 6 months.
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  • The disorder negatively affects the child’s social, academic, or occupational functioning and is not caused by underlying psychosis, substance use, or mood disorder.
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Also Called

  • ODD

Epidemiology

Incidence/Prevalence

  • The mean reported prevalence of oppositional defiant disorder (ODD) is about 3%, but prevalence ranges from 1% to 16% based on varying definitions used and depth of informant interviews.
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    • Among adolescents in juvenile justice settings, prevalence varies from about 11% to ≤ 55% based on age and sex.
    • Among patients in clinical settings, the prevalence ranges from 28% to 65%. Clinics specializing in treatment of attention deficit hyperactivity disorder (ADHD) or behavioral issues tend to report higher prevalence.
  • Characteristic behaviors are generally evident by age 8 years, but usually present in late preschool or early school years.
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  • ODD may be slightly more common in male children than female children, although findings are inconsistent due to variations in the criteria used to diagnose the disorder. Prevalence in adolescents does not appear to differ by sex.
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  • ODD is reported to be more common in children with chronic obesity and children in low-income households.
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  • Children of ethnic/racial minoritized backgrounds are more likely to be diagnosed with ODD than ADHD compared to White, non-Hispanic children. This may be a result of unconscious bias, particularly if ADHD or other relevant diagnoses are not considered as part of the differential diagnosis.
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  • STUDY SUMMARY
    4.2% estimated prevalence of oppositional defiant disorder in school children in Spain using Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria by teacher report
    CROSS-SECTIONAL STUDY: Actas Esp Psiquiatr 2015 Nov-Dec;43(6):213

Risk Factors

  • The overall combination of a child's biologic vulnerabilities and protective factors appears more important than any single risk factor.
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  • The estimated heritability of oppositional defiant disorder (ODD) is 34%-73% (moderate to high). However, identifying genetic risk factors has been challenging due to the genetic overlap with other externalizing disorders.
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  • Environmental risk factors include:
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    • Harsh parenting styles, particularly low parental warmth and involvement
    • Parental malnutrition and/or smoking during pregnancy
    • Parental maladaptive behavior
    • Exposure to abuse or interparental violence
    • Poverty and/or food insecurity
    • Lead exposure
    • Affiliation with deviant peers during adolescence
  • STUDY SUMMARY
    maternal distress pre- and postnatally may be associated with increased risk of oppositional defiant disorder at age 3 years
    COHORT STUDY: J Atten Disord 2020 May;24(7):1057

  • STUDY SUMMARY
    negative discipline styles may be associated with oppositional defiant disorder in children without peer acceptance, but not in children with peer support
    CROSS-SECTIONAL STUDY: Aggress Behav 2014 Jan;40(1):79

Associated Conditions

  • Oppositional defiant disorder (ODD) has been associated with:
    • Attention deficit hyperactivity disorder (ADHD) (reported in about 14%, and up to 40% of children with ADHD meet the criteria for ODD)
    • Anxiety disorders (reported in about 14%)
    • Depressive disorders (reported in about 9%)
    • Conduct disorder
    • Learning disabilities and language disorders
    • Substance abuse
    • Suicide attempts
    • Disruptive mood dysregulation disorder
    • References -
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      , Am J Psychiatry 2013 Feb;170(2):173
  • STUDY SUMMARY
    preschoolers meeting criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th ed. diagnosis of attention deficit hyperactivity disorder appear to have increased rates of oppositional defiant disorder and conduct disorder
    CROSS-SECTIONAL STUDY: J Atten Disord 2017 Jul;21(9):741

Etiology and Pathogenesis

Causes

  • The exact cause of oppositional defiant disorder (ODD) is unknown but is most likely a conglomeration of biologic vulnerabilities and protective factors interacting with environmental factors.
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Pathogenesis

  • No single neurotransmitter (such as serotonin, norepinephrine, or dopamine) or neurologic pathway has been identified as root cause of oppositional defiant disorder (ODD).
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  • Children with ODD may have deficits in a discrete skill set, such as affective modulation or executive function, which lead to oppositional behavior.
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    • A child who explodes in response to a parental demand may lack the cognitive or emotional skills required to comply with their parent's request.
      • Lack of or deficits in affective modulation may lead to emotional overreaction and/or losing capacity to reason.
      • Deficits in executive cognitive skills, such as working memory, ability to change tasks, or organized problem solving may undermine the ability to comply with adult demands.
    • Hypothesized skill deficits support the transactional conceptualization of ODD, which emphasizes the roles of behavioral context and interaction with others in the initiation of the child's disruptive behavior.
  • Smaller cortical structures and lower brain activity have been found in areas associated with executive functioning in individuals with ODD or conduct disorder.
    • Executive functioning involves motivational and affective aspects of cognitive processing, including reinforcement learning, affective decision-making, and emotional processing.
    • Areas reported to be smaller or less active in structural and functional imaging studies include:
      • Bilateral amygdala
      • Bilateral insula
      • Right striatum
      • Left medial/superior frontal gyrus
      • Left precuneus
    • Reference - Neuropsychol Rev 2016 Mar;26(1):44
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