Oppositional Defiant Disorder: Symptoms, Causes, and Treatment
Oppositional defiant disorder (ODD) is one of many disruptive, impulse control and behavior disorders, a series of alterations in the behavior of children, adolescents, or adults, which cause them suffering and interference in their daily lives (and the people around them).
Within this group of disorders, we find oppositional defiant disorder, conduct disorder, intermittent explosive disorder, pyromania, and kleptomania. In this article, we’ll talk about one of them: oppositional defiant disorder.
We’ll find out what it consists of, what its symptoms and diagnostic criteria are, its causes, and the most accepted treatments for it so far.
Oppositional defiant disorder: what is it?
Oppositional defiant disorder (ODD) is part of the so-called “Disruptive, impulse control and behavior disorders” of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders).
According to data from the manual itself, currently, disruptive behavior disorders are one of the most frequent diagnoses in child and adolescent mental health. In relation to this, there are prevalences of this type of disorder of up to 18%.
ODD prevalence
Beyond the prevalence of disruptive behavior disorders in mental health services, we know that the actual prevalence of ODD, according to DSM-5, ranges from 1% to 11%. Its estimated average prevalence is 3.3% in the general population.
It’s a disorder that appears to be slightly more prevalent in boys than in girls, with a ratio of 1.4: 1. This is the case before adolescence, but male predominance hasn’t been consistently found in adolescent or adult samples.
As we can see, it’s a disorder that can appear at any age, although it appears especially in childhood and adolescence.
How does ODD develop?
In relation to how it develops, and emphasizing what we mentioned in the previous point, the first symptoms of oppositional defiant disorder usually appear during the preschool years. They rarely appear later than early adolescence.
It’s a disorder that often precedes conduct disorder (another type of disorder, also called disruptive behavior), especially in cases of childhood-onset conduct disorder. However, in many other cases, ODD doesn’t end up “leading to” conduct disorder, and symptoms tend to subside.
Risk of other problems in adulthood
The manifestations of ODD, throughout development, appear to be uniform. Children and adolescents who suffer from it are at greater risk of manifesting adaptation problems as adults, the most frequent being antisocial behavior, impulse control problems, anxiety and depression, and substance abuse.
Symptoms
ODD, according to DSM-5 criteria, consists of an angry/irritable mood pattern, coupled with argumentative/defiant behavior, or resentment. This pattern of behavior lasts for at least 6 months.
On the other hand, a minimum of 4 symptoms appear from a series of categories, these being three:
- Angry and/or irritable mood.
- Controversial and/or defiant behavior.
- Resentment.
As a note to take into account, for this disorder to be diagnosed in children under 5 years of age, the behavior should occur most days, for a period of at least 6 months (except the symptom of resentment that, as we will see, only needs to appear a minimum of 2 times in the last 6 months).
In contrast, in people 5 years and older, the behavior must occur at least once a week for at least 6 months. But what are these categories and what symptoms are included within each of them? Let’s have a look:
Angry/irritable mood
Among the possible symptoms of this category, we find that the child or adolescent often “loses the rag”, and is often susceptible or easily disturbed by others. They are often angry and resentful.
Argumentative / defiant behavior
The child or adolescent often argues with authority figures or with adults. They may also actively defy adults, or refuse to obey orders from authority figures (or rules).
Another possible symptom of this category is that the person deliberately annoys other people. Finally, these people often tend to accuse others of their own mistakes or bad behavior.
Resentment
The resentment category of the Oppositional Defiant Disorder criteria includes resentment or the desire for revenge, on the part of the subject, on at least 2 occasions during the last 6 months.
Comorbidity with other disorders
Oppositional defiant disorder carries an added risk in the subject of developing other disorders (which is called comorbidity), especially anxiety disorders and major depressive disorder. On the other hand, and more specifically, we know that:
- Symptoms of defiance, arguing, and revenge pose an added risk of developing conduct disorder.
- Irritability and anger (or both) are symptoms that pose a greater risk for the development of emotional disorders.
In addition, also according to DSM-5 data, the rates of ODD are much higher in children, adolescents, and adults with ADHD (attention deficit hyperactivity disorder). This may be due to common temperamental risk factors.
Causes
What’s the possible cause of oppositional defiant disorder? Are we talking about a single cause or many?
In general, in disruptive disorders (where ODD and conduct disorder are included), the consideration of a multicausal origin is accepted (thus, many factors intervene in their etiology, at a biological, personal, social, or family level).
This fact (the multicausality of these disorders) has motivated a line of research focused on identifying risk factors and protective factors that would increase or decrease the possibility of the appearance of these disorders. But what are the risk factors for ODD?
Biological factors
Among the biological factors that could be possible causes (or risk factors) of oppositional defiant disorder, we find:
- Pre and perinatal: low birth weight, cerebral anoxia of the newborn and/or suffering in childbirth, and malnutrition during pregnancy.
- Cerebral: alterations in the frontal lobe and deficit in the function of the amygdala.
- Biochemicals: increased testosterone levels in the subject and decreased serotonin.
- Diet: A decrease in the intake of vitamins or minerals (iron) and food additives.
Personal factors
Regarding personal factors that can be understood as one more possible cause of ODD, we found different factors:
- Personality: a difficult temperament, narcissism, impulsiveness, sensation seeking and affective instability.
- Cognitive: difficulties in solving problems, cognitive impulsivity, deficits in the inhibitory response, and low level of verbal aptitude.
- Social skills: A clear deficit in this area and poor empathy.
- Low self-esteem.
- Moral development: difficulties in processing the value system and absence of feelings of guilt.
- School performance: Academic difficulties and/or delays in learning.
Social factors
Social factors refer to factors that are related to the individual’s social class, their socioeconomic level, and their school adjustment:
- Social class: unemployment, marginal environments and low socioeconomic status, geographic habitat, or disadvantaged neighborhood.
- Relationship with equals: difficulties in social relationships or rejection by equals.
- School adjustment: negative school environment, curricular non-adaptation, and school dissatisfaction.
- Leisure: many hours watching violent television and video games.
Family factors
Finally, regarding family factors as a possible cause (remember, we always talk about a multicausal disorder) of ODD, we find:
- Parental psychopathology: parental alcoholism, drug addiction, and antisocial behavior, and depression in the mother.
- Unstructured families: The loss of one of the parents, insecure attachment, and serious conflicts with a partner (gender violence).
- Educational styles: A lack of supervision, premature autonomy in the adolescent, and excessive use of punishment and punitive methods.
Treatment
The reality is that, out of all the intervention proposals that have been developed to work with children or adolescents with some type of disruptive behavior disorder and their families, none of them have conclusively demonstrated their effectiveness.
However, we can say that there are two treatments of choice for oppositional defiant disorder (as well as conduct disorder):
- Behavior modification techniques (positive reinforcement, negative reinforcement, shaping, chaining…).
- Intervention with parents (its objective is to reduce the inappropriate behavior of their children through a series of guidelines).
In addition, the therapeutic approaches that have offered the best results to date are contingency control programs, parent training, and pharmacological treatment (with the use of stimulants, atypical antipsychotics, lithium…).
This type of intervention has been especially effective when the design of the intervention itself was multidisciplinary, that is, when the subject’s family and teachers were included in the treatment.
Oppositional defiant disorder: a complex and multicausal disorder
As we can see, ODD is a multicausal disorder, where the appearance of multiple variables is necessary for it to occur. Biological, personal, family and social factors are involved, so we cannot speak of a single cause that explains the disorder.
It is a complex disorder that affects the subjects themselves (in their relationships with peers and adults, with themselves, in their academic performance, etc.), but also the people around them. Early and multidisciplinary treatment, when possible, will always be the best option for this type of case.
Thus, intervention with parents and teachers will be essential, as well as with the subjects themselves, where everything that could explain the appearance and maintenance of the disorder will be investigated.
Emotional management and impulse control
Treatment of ODD will be focused, above all, on working with difficulties in one’s own emotional management and impulse control. It will seek to offer the subject strategies and tools (for example, alternative behaviors to aggression) that allow the person to self-regulate in a healthier way for themselves and for their environment.
- American Psychiatric Association –APA- (2014). DSM-5. Manual diagnóstico y estadístico de los trastornos mentales. Madrid: Panamericana.
- Caballo (2002). Manual para el tratamiento cognitivo-conductual de los trastornos psicológicos. Vol. 1 y 2. Madrid. Siglo XXI.
- Comeche, M.I. y Vallejo, M.A. (2016). Manual de terapia de conducta en la infancia. Dykinson. Madrid.
- Ramírez, M.A. (2005). Padres y desarrollo de los hijos: prácticas de crianza. Estudios pedagógicos (Valdivia).
- Servera, M. (2002). Intervención en los trastornos del comportamiento infantil. Una perspectiva conductual de sistemas. Pirámide. Madrid.
