Oppositional defiant disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Oppositional defiant disorder is a controversial psychiatric category listed in the Diagnostic and Statistical Manual of Mental Disorders where it is described as an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures which supposedly goes beyond the bounds of normal childhood behavior.

Differential Diagnosis

• Attention-deficit/hyperactivity disorder
• Bipolar disorder
• Conduct disorder
• Depressive disorder
• Disruptive mood dysregulation disorder
• Intellectual disability (intellectual developmental disorder)
• Intermittent explosive disorder
• Language disorder
• Social anxiety disorder (social phobia)

Epidemiology and Demographics

Prevalence

The prevalence of oppositional defiant disorder is 1,000-11,000 per 100,000 (1%-11%) of the overall population.

Risk Factors

• Abnormalities in amygdala
• Abnormalities in the prefrontal cortex
• High levels of emotional reactivity
• Lower heart rate
• Neglectful child-rearing practices
• Poor frustration tolerance
• Reduced basal cortisol reactivity
• Skin conductance reactivity

Natural History,Complications,and Prognosis

Prognosis

Childhood oppositional defiant disorder is strongly associated with later developing conduct disorder. Untreated, about 52% of children with ODD will continue to meet the DSM-IV criteria up to three years later and about half of those 52% will progress into conduct disorder.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Oppositional Defiant Disorder

“

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. Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful. Argumentative/Defiant Behavior 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. Vindictiveness 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 AS). 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. AND 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. AND 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: Some symptoms are present in three or more settings.

”

Treatment

There are a variety of approaches to the treatment of Oppositional Defiant Disorder (ODD). One evidence-based approach with empirical support is an approach developed by Russell A. Barkley, Ph.D. This approach uses a parent training model and begins by focusing on positive approaches to increase compliant behaviours. Only later in the program are methods introduced to extinguish negative or noncompliant behaviours.

Controversy

The category of Oppositional Defiant Disorder as outlined in the DSM has attracted criticism and controversy since DSM III-R where it was established that while Oppositional Defiant Disorder was one of only seven categories (out of more than 300) in that revision for which field trials had taken place, the results of those field trials are not reported in the DSM III-R and do not seem to be available for examination elsewhere .

In the course of trying to determine the possible extent of the effects of gender bias on the precision of categories in the DSM, Psychologist Paula J. Caplan, PhD and graduate student Kaye Lee Pantony wrote about whether the research confirmed the existence of such mental disorders as those represented by the labels of the categories they had chose to study, whether research had made it possible to discover the actual elements, or criteria, of each disorder; and whether research had made it possible to discover exactly how many criteria a person had to meet in order to belong clearly to a particular category.

Aiming for a wide variety of diagnoses, they chose to examine three categories that could be applied to people of either sex. One of the categories they selected was Oppositional Defiant Disorder. Their opinion was that, "In view of all of that research, we were frankly amazed to find that not a single empirically based article included any evidence of what the cutoff point for any of these three categories ought to be. In other words, there was no research on which to base the DSM's prescriptions about many criteria a person had to meet in order to be given any of those three labels: AD, ODD, or OCD. Those prescriptions cannot be said to have been derived from any scientific work whatsoever." They could only find seven articles that mentioned Oppositional Defiant Disorder at all, and none of them mentioned the selection of criteria, or the cutoff point, for ODD. Their opinion was that, "All told, then, there was little or no scientific evidence to justify the ways the criteria and cutoff points were chosen for a wide variety of DSM categories. It seems possible but highly unlikely that more rigorous standards were used for the categories that we happened not to study."

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