Oppositional Defiant Disorder

Symptoms of oppositional defiant disorder often begin appearing around ages five to eight and decline before reaching adulthood. To meet diagnostic criteria for ODD, symptoms must negatively impact daily life, such as school performance, learning, work, and interpersonal relationships, or cause distress in the child or others in their immediate social context (friends, family members, teachers, etc.). 

At least four symptoms within the following categories must be present when the individual is interacting with other people (not siblings): 

Symptoms of anger and irritable mood: 

• Frequently losing temper
• Becoming easily annoyed, irritated, or bothered
• Acting resentful or angry

Symptoms of defiance and argumentativeness: 

• Arguing repeatedly with adults or authority figures
• Intentionally not obeying rules or requests
• Misplacing blame for their own mistakes on others
• Irritating, annoying, or bothering others on purpose 

Symptoms of vindictiveness: 

• Making mean statements when angry or irritated
• Exhibiting spiteful, revenge-seeking behaviors

These symptoms must not be explained by substance use or another mental health condition (such as depressive or bipolar disorder), and the disorder cannot be diagnosed in individuals with disruptive mood dysregulation disorder. 

Classification 

ODD symptoms can be categorized as mild, moderate, or severe, which are defined as follows: 

• Mild: Symptoms occur in only one setting, such as at home or school. 
• Moderate: Symptoms occur in at least two settings. 
• Severe: Symptoms occur in three or more settings. 

Children may initially exhibit symptoms in one setting, such as at home, but eventually display symptoms in school and peer social settings. For some children with oppositional defiant disorder, symptoms resolve within three years, though others may develop worsening ODD and conduct disorder. Conduct disorder is most likely to develop in children who received an ODD diagnosis at a young age.

There is no one cause of oppositional defiant disorder. It’s believed to be caused by a combination of complex biological, environmental, demographic, and individual factors. Below are many of the risk factors associated with ODD: 

• Genetics: It’s estimated that around 50% of ODD is inherited.   
• Gender: Individuals assigned male at birth are more likely than people assigned female at birth to experience ODD prior to adolescence. This disparity is especially pronounced in Western cultures. 
• Adverse childhood experiences: The impact of trauma on ODD occurrence differs by gender. Amongst people assigned male at birth, interpersonal (e.g., emotional abuse) and non-interpersonal trauma (e.g., experiencing a natural disaster) are risk factors for ODD. In people assigned female at birth, interpersonal—but not non-interpersonal—trauma can be predictive of ODD. 
• Temperament: Some factors present in infants, including low harm avoidance and high novelty seeking, are associated with the later development of ODD. Additionally, high emotional reactivity, impulsivity, and low tolerance are personality traits common in children with ODD. 
• Parenting: Harsh or inconsistent disciplinary practices, neglect, and maltreatment are associated with ODD. 
• Parents' mental health: Parents with depression, substance use disorders, anxiety, or aggression are more likely to have children with symptoms of ODD. 
• Learning disabilities (LD): Children with learning disabilities have a slightly higher prevalence of ODD. However, some ODD symptoms may overlap with behaviors that may be common in children with LD, potentially complicating diagnoses.
• Other factors: Psychosocial factors like poverty, peer rejection, and neighborhood violence may contribute to the development of ODD.

The following treatment options include individual and family therapy, education, medication, and self-care strategies, which can prevent or reduce ODD symptom severity and duration:

Medication

For children with ODD alone, medication has not been proven effective. However, medications may be beneficial for children with comorbid conditions, such as anxiety, depression, substance use disorders, and ADHD. 

Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis.

Other treatment options

Other potentially effective treatments for ODD could include: 

• Parent management training: Educational programs can teach parents how to establish effective disciplinary practices, set healthy boundaries, and develop a nurturing and secure environment for their children. 
• Teacher training: Teacher education may prevent the development of ODD and address symptoms in a more productive manner. 
• School-based programs: Preschool programs such as Head Start can help children learn conflict resolution skills and anger management, which may reduce the risk of developing ODD. Additionally, school-based bullying interventions can reduce antisocial behaviors and ODD symptoms while improving peer social environments.

Self-care

Below are several self-care strategies that may be helpful for children with ODD to learn to manage daily life: 

• Journaling: Journaling may help children express their emotions, manage anxiety, improve mood, and recognize what incites anger. 
• Exercise: Physical activity can improve mood and reduce stress in children and adults. Some studies have found that exercise can improve social conduct, academic achievement, and self-esteem in children with ODD and conduct disorder. Enrolling children in sports, increasing play opportunities, and providing time for exercise may decrease symptoms. 
• Family self-care: Parents and family members of children with ODD may benefit from practicing stress-reduction techniques such as meditation, routine exercise, and engaging in enjoyable social activities.  

The most appropriate treatment strategies for your child can vary depending on their developmental level, the severity of their symptoms, and the presence of comorbid conditions (such as ADHD or anxiety).

There are many resources available that can help prevent and address oppositional defiant disorder, including the following: 

• Online therapy: According to a 2022 survey, around 15% to 20% of parents experience symptoms of anxiety disorders, and 10% to 16% experience depression. In parents of children with ODD, these rates are estimated to be higher. If you’re experiencing mental health challenges, you may consider talking with a professional. Online therapy platforms like BetterHelp can be a convenient alternative to commuting to an appointment, as you can attend therapy from home via phone, video, or live chat sessions. 
• Parental education: There are many intervention programs available across the nation, including Incredible Years, Parent-Child Interaction Therapy, and Triple P-Positive Parenting Program, which can help parents build healthy relationships with their children and manage behavioral challenges more effectively, and find a doctor or therapy provider to access care for their child.
• Head Start: The US Department of Health and Human Services provides resources to help you assess eligibility and apply for Head Start and Early Head Start programs near you.

The effectiveness of different treatment approaches for ODD varies based on many factors. A 2022 study published in the Journal of Clinical Child and Adolescent Psychology aimed to evaluate moderators that impact behavioral improvement from parent management training (PMT) and collaborative proactive solutions (CPS). The authors found that, though both PMT and CPS are evidence-based treatment approaches, their effectiveness varies based on the severity of behavioral issues, lagging skills, child-responsible attributes, and inconsistent parental discipline strategies. 

For example, child-responsible attributes (CRA) measure the degree to which parents believe their children’s behaviors reflect their character. A parent with high levels of child-responsible attributes may make statements like, “My child tries to make me mad,” or “My child wants to push my buttons.” CRA is associated with lower PMT success rates, indicating that CPS may be more effective in these cases. 

Another recent study, which was published in BMC Psychiatry in 2021, sought to evaluate the interaction between maternal education level, oppositional defiant disorder, and substance use in college students. To do so, the researchers recruited 981 college-aged volunteers and asked them to complete questionnaires. After analyzing their responses, researchers found that a combination of low maternal education level and peer substance use were strong predictors of ODD. In contrast, high maternal education was protective of ODD and substance use.

Below are several statistics on oppositional defiant disorder: 

• Approximately 3% to 4% of children 18 and younger are estimated to have ODD. However, this statistic is complicated by overlapping symptoms with conduct disorder, underreporting of symptoms, and difficulty discerning ODD from typical opposition in teenagers and adolescents.
• Around 60% of children with attention-deficit hyperactivity disorder (ADHD) also have ODD. Children with co-occurring ADHD and ODD may have an increased risk of developing anxiety disorders, depressive disorders, or antisocial personality disorder (ASPD) in the future. 
• Oppositional defiant disorder and conduct disorder (CD) are related disorders that co-occur in approximately 60% of cases. While ODD and CD are classified as two distinct disorders, some experts believe that ODD may be a precursor to CD, which is a more serious behavioral disorder.
• After three years of treatment, around 67% of children who are diagnosed with ODD no longer meet the criteria for diagnosis.