DSM Definition: Oppositional defiant disorder
Diagnostic Criteria 313.81 (F91.3)
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
8. Has been spiteful or vindictive at least twice within the past 6 months.
Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture.
B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.
Specify current severity:
- Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
- Moderate: Some symptoms are present in at least two settings.
- Severe: Son\e symptoms are present in three or more settings.
It is not uncommon for individuals with oppositional defiant disorder to show symptoms only at home and only with family members. However, the pervasiveness of the symptoms is an indicator of the severity of the disorder.
The essential feature of oppositional defiant disorder is a frequent and persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness (Criterion A). It is not unusual for individuals with oppositional defiant disorder to show the behavioral features of the disorder without problems of negative mood. However, individuals with the disorder who show the angry/irritable mood symptoms typically show the behavioral features as well.
The symptoms of oppositional defiant disorder may be confined to only one setting, and this is most frequently the home. Individuals who show enough symptoms to meet the diagnostic threshold, even if it is only at home, may be significantly impaired in their social functioning. However, in more severe cases, the symptoms of the disorder are present in multiple settings. Given that the pervasiveness of symptoms is an indicator of the severity of the disorder, it is critical that the individual's behavior be assessed across multiple settings and relationships. Because these behaviors are common among siblings, they must be observed during interactions with persons other than siblings. Also, because symptoms of the disorder are typically more evident in interactions with adults or peers whom the individual knows well, they may not be apparent during a clinical examination.
The symptoms of oppositional defiant disorder can occur to some degree in individuals without this disorder. There are several key considerations for determining if the behaviors are symptomatic of oppositional defiant disorder. First, the diagnostic threshold of four or more symptoms within the preceding 6months must be met. Second, the persistence and frequency of the symptoms should exceed what is normative for an individual's age, gender, and culture. For example, it is not unusual for preschool children to show temper tantrums on a weekly basis. Temper outbursts for a preschool child would be considered a symptom of oppositional defiant disorder only if they occurred on most days for the preceding 6months, if they occurred with at least three other symptoms of the dis order, and if the temper outbursts contributed to the significant impairment associated with the disorder (e.g., led to destruction of property during outbursts, resulted in the child being asked to leave a preschool).
The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder from the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child's behavior caused the parents to act in a more hostile manner toward the child, if the parents' hostility led to the child's problematic behavior, or if there was some combination of both. Whether or not the clinician can separate the relative contributions of potential causal factors should not influence whether or not the diagnosis is made. In the event that the child may be living in particularly poor conditions where neglect or mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful.
Associated Features Supporting Diagnosis
In children and adolescents, oppositional defiant disorder is more prevalent in families in which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or neglectful child-rearing practices are common. Two of the most common co-occurring conditions with oppositional defiant disorder are attention-deficit/ hyperactivity disorder (ADHD) and conduct disorder (see the section "Comorbidity" for this disorder). Oppositional defiant disorder has been associated with increased risk for suicide attempts, even after controlling for comorbid disorders.
The prevalence of oppositional defiant disorder ranges from 1% to 11%, with an average prevalence estimate of around 3.3%. The rate of oppositional defiant disorder may vary depending on the age and gender of the child. The disorder appears to be somewhat more prevalent in males than in females (1.4:1) prior to adolescence. This male predominance is not consistently found in samples of adolescents or adults.
Development and Course
The first symptoms of oppositional defiant disorder usually appear during the preschool years and rarely later than early adolescence. Oppositional defiant disorder often precedes the development of conduct disorder, especially for those with the childhood-onset type of conduct disorder. However, many children and adolescents with oppositional defiant disorder do not subsequently develop conduct disorder. Oppositional defiant disorder also conveys risk for the development of anxiety disorders and major depressive disorder, even in the absence of conduct disorder. The defiant, argumentative, and vindictive symptoms carry most of the risk for conduct disorder, whereas the angry-irritable mood symptoms carry most of the risk for emotional disorders.
Manifestations of the disorder across development appear consistent. Children and adolescents with oppositional defiant disorder are at increased risk for a number of problems in adjustment as adults, including antisocial behavior, impulse-control problems, substance abuse, anxiety, and depression.
Many of the behaviors associated with oppositional defiant disorder increase in frequency during the preschool period and in adolescence. Thus, it is especially critical during these development periods that the frequency and intensity of these behaviors be evaluated against normative levels before it is decided that they are symptoms of oppositional defiant disorder.
Risk and Prognostic FeaturesTemperamental
Temperamental. Temperamental factors related to problems in emotional regulation (e.g., high levels of emotional reactivity, poor frustration tolerance) have been predictive of the disorder.
Environmental. Harsh, inconsistent, or neglectful child-rearing practices are common in families of children and adolescents with oppositional defiant disorder, and these parenting practices play an important role in many causal theories of the disorder.
Genetic and physiological. A number of neurobiological markers (e.g., lower heart rate and skin conductance reactivity; reduced basal cortisol reactivity; abnormalities in the pre- frontal cortex and amygdala) have been associated with oppositional defiant disorder. However, the vast majority of studies have not separated children with oppositional defiant disorder from those with conduct disorder. Thus, it is unclear whether there are markers specific to oppositional defiant disorder.
Culture-Related Diagnostic Issues
The prevalence of the disorder in children and adolescents is relatively consistent across countries that differ in race and ethnicity.
Functional Consequences of Oppositional Defiant Disorder
When oppositional defiant disorder is persistent throughout development, individuals with the disorder experience frequent conflicts with parents, teachers, supervisors, peers, and romantic partners. Such problems often result in significant impairments in the individual's emotional, social, academic, and occupational adjustment.
Conduct disorder. Conduct disorder and oppositional defiant disorder are both related to conduct problems that bring the individual into conflict with adults and other authority figures (e.g., teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of conduct disorder and do not include agression toward people or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder.
Attention-deficit/hyperactivity disorder. ADHD is often comorbid with oppositional defiant disorder. To make the additional diagnosis of oppositional defiant disorder, it is important to determine that the individual's failure to conform to requests of others is not solely in situations that demand sustained effort and attention or demand that the individual sit still.
Depressive and bipolar disorders. Depressive and bipolar disorders often involve negative affect and irritability. As a result, a diagnosis of oppositional defiant disorder should not be made if the symptoms occur exclusively during the course of a mood disorder.
Disruptive mood dysregulation disorder. Oppositional defiant disorder shares with disruptive mood dysregulation disorder the symptoms of chronic negative mood and temper outbursts. However, the severity, frequency, and chronicity of temper outbursts are more severe in individuals with disruptive mood dysregulation disorder than in those with oppositional defiant disorder. Thus, only a minority of children and adolescents whose symptoms meet criteria for oppositional defiant disorder would also be diagnosed with disruptive mood dysregulation disorder. When the mood disturbance is severe enough to meet criteria for disruptive mood dysregulation disorder, a diagnosis of oppositional defiant disorder is not given, even if all criteria for oppositional defiant disorder are met.
Intermittent explosive disorder. Intermittent explosive disorder also involves high rates of anger. However, individuals with this disorder show serious aggression toward others that is not part of the definition of oppositional defiant disorder.
Intellectual disability (intellectual developmental disorder). In individuals with intellectual disability, a diagnosis of oppositional defiant disorder is given only if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable mental age and with comparable severity of intellectual disability.
Language disorder. Oppositional defiant disorder must also be distinguished from a failure to follow directions that is the result of impaired language comprehension (e.g., hearing loss).
Social anxiety disorder (social phobia). Oppositional defiant disorder must also be distinguished from defiance due to fear of negative evaluation associated with social anxiety disorder.
Rates of oppositional defiant disorder are much higher in samples of children, adolescents, and adults with ADHD, and this may be the result of shared temperamental risk factors. Also, oppositional defiant disorder often precedes conduct disorder, although this appears to be most common in children with the childhood-onset subtype. Individuals with oppositional defiant disorder are also at increased risk for anxiety disorders and major depressive disorder, and this seems largely attributable to the presence of the angry-irritable mood symptoms. Adolescents and adults with oppositional defiant disorder also show a higher rate of substance use disorders, although it is unclear if this association is independent of the comorbidity with conduct disorder.