The Clinical and Public Mental Health Importance of Oppositional Defiant Disorder (ODD)
Occasional stubbornness, arguing with, and even defiance of parents is commonplace in young children. But when such behavior occurs often, in multiple forms, is cross-situation in its manifestations, and is persistent for 6 months or longer, it goes well beyond the pale of typical childhood behavior and can be considered a serious mental health condition.
That is because it often leads to significant harm or impairment for the child. It is also a condition that is highly persistent over time into adolescence and even young adulthood. And it is a significant risk factor for comorbidity with other and better recognized mental health disorders, such as attention deficit hyperactivity disorder (ADHD), conduct disorder, bipolar disorder, depression, and disruptive mood dysregulation disorder.
ODD is an often under-recognized yet important childhood disorder. It is characterized in the DSM-5 as “a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures” (American Psychiatric Association, 2013). It is comprised of a set of eight symptoms in DSM-5, at least three of which reflect negative affect (loses temper, touchy or easily annoyed, angry and resentful) while four reflect social conflict with others (argues with adults, defies or refuses to comply, deliberately annoys others, blames others for his or her own mistakes). The final symptom likely relates to both an affective and social component to the disorder (acts spiteful or vindictive) and may be more related to conduct disorder.
ODD has a point prevalence of 1.4% of girls and 3.2% of boys in children ages 5-16 years with 36% of girls and 43% of boys with ODD having another disorder. Lifetime prevalence of ODD is 10.2% with over 92% of such cases having another comorbid disorder. The most common comorbidity is ADHD or impulse-control disorders.
The inverse is also true. ODD is the most common comorbid psychiatric disorder seen in conjunction with ADHD occurring on average in 65% and in as many as 84% of clinic-referred cases in childhood. It is possible that this may even be an under-estimate given that such studies may not distinguish among the ADHD subtypes. It is ADHD (Combined Presentation) with which ODD is likely to have a far greater affiliation than in the Inattentive Presentation. ODD is 11 times more likely to co-exist with ADHD than is its base rate in the general population even in epidemiological samples. It has also been found to be a common comorbidity in children with ADHD followed to adulthood (50% of those with persistent ADHD) and in clinic-referred adults with ADHD, occurring in up to 35-53% of these adult cases when using self-reported information. Yet that source of information may lead to under-estimates of disorder among ADHD patients.
Evidence now shows that ADHD is clearly one of several causes or contributing factors to the risk for developing ODD. This is most likely because of the emotional impulsiveness and poor emotional self-regulation that is a central component of ADHD. That emotional dyscontrol leads to a greater occurrence of anger, impatience, hostility, and reactive aggression that are also features of ODD, or at least its emotional component. Disrupted parenting is also a known contributor to risk for ODD and may have more to do with its symptoms of social conflict (defiance, arguing, etc.) than with its emotional component, which seems to arise from its association with ADHD and mood disorders such as bipolar disorder or disruptive mood dysregulation disorder. Once ODD develops, it is a known risk factor for conduct disorder, and anxiety and depression by early and later adolescence, respectively. All of this suggests that ODD is often an under-appreciated disorder in both clinical practice and public mental health for its association with and likely contribution to other prevalent mental and neurodevelopmental disorders.
Left untreated, persistent ODD is linked to a variety of impairments in major domains of life activities, such as school under-achievement, suspension, expulsion, or retention in grade. It is also predictive of not only conduct disorder, but also a wider pattern of antisocial behavior and substance experimentation and use disorders. And it, along with its emotional dysregulation, is highly predictive of peer relationship problems, increased family conflicts, risk for physical, emotional, and sexual abuse, bullying and victimization, and post-traumatic stress disorder. Should it persist into adolescence or adulthood, it is further linked to degree of stress and disharmony in intimate rlationships as well as risk for perpetrating intimate partner violence (and being the victim of such as well).
Professional Textbooks:
Barkley, R. A. (2013). Defiant children: A clinician’s manual for parent training (3rd ed.). New York: Guilford Press.
Barkley, R. A., Edwards, G., & Robin, A. R. (2013). Defiant Teens: A Clinician’s Manual for Assessment and Family Intervention. New York: Guilford Press.
