Oppositional defiant disorder

Oppositional defiant disorder (ODD)

redefine ODD by emphasizing a "persistent pattern of angry and irritable mood along with vindictive behavior," rather than DSM-IV's focus exclusively on "negativistic, hostile, and defiant behavior." Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is "angry/irritable mood"—defined as "loses temper, is touchy/easily annoyed by others, and is angry/resentful." This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD.^[10]

Epidemiology

ODD is a pattern of negative, defiant, disobedient, and hostile behavior, and it is one of the most prevalent disorders from preschool age to adulthood.^[11] This can include frequent temper tantrums, excessive arguing with adults, refusing to follow rules, purposefully upsetting others, getting easily irked, having an angry attitude, and vindictive acts.^[12] Children with ODD usually begin showing symptoms around age 6 to 8, although the disorder can emerge in younger children too. Symptoms can last throughout teenage years.^[12] The pooled prevalence is 3.6% up to age 18.^[13]

Oppositional defiant disorder has a prevalence of 1–11%.^[2] The average prevalence is approximately 3%.^[2] Gender and age play an important role in the rate of the disorder.^[2] ODD gradually develops and becomes apparent in preschool years, often before the age of eight years old.^[2][14][15] However, it is very unlikely to emerge following early adolescence.^[16]

There is a difference in prevalence between boys and girls, with a ratio of 1.4 to 1 before adolescence.^[2] Other research suggests a 2:1 ratio.^[17] Prevalence in girls tends to increase after puberty.^[14] Researchers have found that the general prevalence of ODD throughout cultures remains constant. However, the gendered disparities in diagnoses is only seen in Western cultures. It is unknown whether this reflects underlying differences in incidence or under-diagnosis of girls.^[18] Physical abuse at home is a significant predictor of diagnosis for girls only, and emotional responsiveness of parents is a significant predictor of diagnosis for boys only, which may have implications for how gendered socialization and received gender roles affect ODD symptoms and outcomes.^[19]

Children from lower-income backgrounds are more likely to be diagnosed with ODD.^[20][21] The correlative link between low income and ODD diagnosis is direct in boys, but in girls, the link is more complex; the diagnosis is associated with specific parental techniques such as corporal punishment which are in turn linked to lower income households. This disparity may be linked to a more general tendency of boys and men to display more externalized psychiatric symptoms, and girls to display more internalized ones (such as self-harm or anorexia nervosa).^[21]

Prevalence of ODD and conduct disorder are significantly higher among children in foster care. One survey in Norway found that 14 percent met the criteria, and other studies have found a prevalence of up to 17 or even 29 percent.^[23][24] Low parental attachment and parenting style are strong predictors of ODD symptoms.

Earlier conceptions of ODD had higher rates of diagnosis. When the disorder was first included in the DSM-III, the prevalence was 25% higher than when the DSM-IV revised the criteria of diagnosis.^[20] The DSM-V made more changes to the criteria, grouping certain characteristics together in order to demonstrate that people with ODD display both emotional and behavioral symptoms.^[25] In addition, criteria were added to help guide clinicians in diagnosis because of the difficulty found in identifying whether the behaviors or other symptoms are directly related to the disorder or simply a phase in a child's life.^[25] Consequently, future studies may find that there was also a decline in prevalence between the DSM-IV and the DSM-V.

Signs and symptoms

The fourth revision of the Diagnostic and Statistical Manual (

• Often loses temper
• Is often touchy or easily annoyed
• Is often angry and resentful
• Often argues with authority figures or, for children and adolescents, with adults
• Often actively defies or refuses to comply with requests from authority figures or with rules
• Often deliberately annoys others
• Often blames others for their mistakes or misbehavior
• Has been spiteful or vindictive at least twice within the past six months[2]^[26]

These behaviors are mostly directed towards an authority figure such as a teacher or a parent. Although these behaviors can be typical among siblings, they must be observed with individuals other than siblings for an ODD diagnosis.^[2] Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behavior observed in conduct disorder.^[26] Furthermore, they must be perpetuated for longer than six months and must be considered beyond a normal child's age, gender and culture to fit the diagnosis.^[27][2] For children under five years of age, they must occur on most days over a period of six months. For children over five years of age, they must occur at least once a week for at least six months.^[2] If symptoms are confined to only one setting, most commonly home, it is considered mild in severity. If it is observed in two settings, it is characterized as moderate, and if the symptoms are observed in three or more settings, it is considered severe.^[2]

These patterns of behavior result in impairment at school or other social venues.^[27][2]

Etiology

There is no specific element that has yet been identified as directly causing ODD. Research looking precisely at the

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead,^[30] and mother's use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance use prior to birth has also been associated with developing disruptive behaviors such as ODD.^{[31][32][33][34]} Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological factors

Deficits and injuries to certain areas of the brain can lead to serious behavioral problems in children. Brain imaging studies have suggested that children with ODD may have hypofunction in the part of the brain responsible for reasoning, judgment, and

As many as 40 percent of boys and 25 percent of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behavior, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act.^[29] Children with ODD have difficulty controlling their emotions or behaviors. In fact, students with ODD have limited social knowledge that is based only on individual experiences, which shapes how they process information and solve problems cognitively. This information can be linked with the social information processing model (SIP) that describes how children process information to respond appropriately or inappropriately in social settings. This model explains that children will go through five stages before displaying behaviors: encoding, mental representations, response accessing, evaluation, and enactment. However, children with ODD have cognitive distortions and impaired cognitive processes. This will therefore directly impact their interactions and relationship negatively. It has been shown that social and cognitive impairments result in negative peer relationships, loss of friendship, and an interruption in socially engaging in activities. Children learn through observational learning and social learning. Therefore, observations of models have a direct impact and greatly influence children's behaviors and decision-making processes. Children often learn through modeling behavior. Modeling can act as a powerful tool to modify children's cognition and behaviors.^[28]

Environmental factors

Negative parenting practices and parent–child conflict may lead to

Insecure parent–child attachments can also contribute to ODD. Often little internalization of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance use. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.[29]

School is also a significant environmental context besides family that strongly influences a child's maladaptive behaviors.^[38] Studies indicate that child and adolescent externalizing disorders like ODD are strongly linked to peer network and teacher response.^[39][40] Children with ODD present hostile and defiant behavior toward authority including teachers which makes teachers less tolerant toward deviant children.^[39] The way in which a teacher handles disruptive behavior has a significant influence on the behavior of children with ODD.^[41] Negative relationships from the socializing influences and support network of teachers and peers increases the risk of deviant behavior. This is because the child consequently gets affiliated with deviant peers that reinforce antisocial behavior and delinquency.^[42] Due to the significant influence of teachers in managing disruptive behaviors, teacher training is a recommended intervention to change the disruptive behavior of ODD children.^[43][44]

In a number of studies, low socioeconomic status has also been associated with disruptive behaviors such as ODD.^[45][46]

Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.^[1]

Externalizing problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighborhoods.^[29] Studies have also found that the state of being exposed to violence was a contribution factor for externalizing behaviors to occur.^[45][46][47]

Diagnosis

For a child or adolescent to qualify for a diagnosis of ODD, behaviors must cause considerable distress for the family or interfere significantly with academic or social functioning. Such interference might manifest as challenges in learning at school, making friends, or placing the individual in harmful situations. These behaviors must also persist for at least six months. It is crucial to consider the bio-socio complexity in the expression and management of ODD. Biological factors such as genetics and neurodevelopmental variations interact with social factors like family dynamics, educational practices, and societal norms to influence the manifestation and recognition of ODD symptoms. The effects of ODD can be amplified by other disorders in comorbidity such as ADHD, depression, and substance use disorders. This intricate interplay between biological predispositions and social factors can lead to diverse clinical presentations, affecting the approaches to treatment and support.

Additionally, it has been observed that adults who were diagnosed with ODD as children tend to have a higher chance of being diagnosed with other mental illnesses in their lifetime, as well as being at a higher risk of developing social and emotional problems. This suggests that longitudinal support and intervention, taking into account the individual's biological makeup and social context, are vital for improving long-term outcomes for those with ODD.

Management

Approaches to the treatment of ODD include

Children with oppositional defiant disorder tend to exhibit problematic behavior that can be very difficult to control.[50] An occupational therapist can recommend family based education referred to as parent management training (PMT) in order to encourage positive parents and child relationships and reduce the child's tantrums and other disruptive behaviors.^[51] Since ODD is a neurological disorder that has biological correlates, an occupational therapist can also provide problem solving training to encourage positive coping skills when difficult situations arise, as well as offer cognitive behavioral therapy.^[52]

Psychopharmacological treatment

The effectiveness of drug and medication treatment is not well established. Effects that can result from taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention.^[53]

Individual interventions

Individual interventions are focused on child-specific individualized plans. These interventions include anger control/stress inoculation, assertiveness training, a child-focused problem-solving skills training program, and self-monitoring skills.^[53]

Anger control and stress inoculation help prepare the child for possible upsetting situations or events that may cause anger and stress. They include a process of steps the child may go through.

Assertiveness training educates individuals in keeping a balance between passivity and aggression. It aims to help the child respond in a controlled and fair manner.

A child-focused problem-solving skills training program aims to teach the child new skills and cognitive processes that teach how to deal with negative thoughts, feelings, and actions.

Parent and family treatment

According to randomized trials, evidence shows that parent management training is most effective.^[49] It has strong influences over a long period of time and in various environments.^[53]

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases; the first phase is child-directed interaction, where the focus is to teach the child non-directive play skills. The second phase is parent-directed interaction, where the parents are coached on aspects including clear instruction, praise for compliance, and time-out for noncompliance. The parent-child interaction training is best suited for elementary-aged children.^[53]

Parent and family treatment has a low financial cost, which can yield an increase in beneficial results.^[53]

Multimodal intervention

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighborhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behavior programs. The intervention is intensive and addresses barriers to individuals' improvement such as parental substance use or parental marital conflict.^[53]

An impediment to treatment includes the nature of the disorder itself, whereby treatment is often not complied with and is not continued or adhered to for adequate periods of time.^[53]

Comorbidity

Oppositional defiant disorder can be described as a term or disorder with a variety of pathways in regard to comorbidity. High importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.^[54]

In the context of oppositional defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-occurs with an attention deficit hyperactivity disorder (ADHD), anxiety disorders, emotional disorders as well as mood disorders.^[55] Those mood disorders can be linked to major depression or bipolar disorder. Indirect consequences of ODD can also be related or associated with a later mental disorder. For instance, conduct disorder is often studied in connection with ODD. Strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relation to ODD can be seen.^[55] For instance, children or adolescents who have ODD with coexisting ADHD will usually be more aggressive and have more of the negative behavioral symptoms of ODD, which can inhibit them from having a successful academic life. This will be reflected in their academic path as students.^[1]

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments with academics and language disorders, in which problems can be observed related to language production and/or comprehension.^[1]

Criticism

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Oppositional defiant disorder's validity as a diagnosis has been criticized since its inclusion in the

Research has shown that

Latina women may be disproportionately impacted by the diagnosis of ODD because of the difference between Latino and White conceptions of femininity and appropriate feminine behavior.^[24]

African American males are known to be more likely to be suspended or expelled from school, receive harsher sentences for the same offenses as defendants of different races, or be searched, assaulted or killed by police officers.^[66][67][68] The disproportionately high diagnosis of ODD in AA males may be used to rationalize these outcomes.^[61] In this manner, ODD diagnoses can serve as a mechanism of the school-to-prison pipeline. From this viewpoint, the ODD diagnosis frames expected reactions to injustice or trauma as defiant or criminal.^[61][24]

See also

• Antisocial personality disorder
• Attachment disorder
• Attention deficit hyperactivity disorder (ADHD)
• Borderline personality disorder
• Conduct disorder
• Disruptive mood dysregulation disorder (DMDD)
• Pathological demand avoidance

References