Oppositional Defiant Disorder, 313.81

Diagnostic Features
The essential feature of Oppositional Defiant Disorder  is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months (Criterion A)
And is characterized by the frequent occurrence of at least four of the following behaviors:

- losing temper (Criterion A1),
- arguing with adults (Criterion A2),
- actively defying or refusing to comply with the requests or rules of adults (Criterion A3),
- deliberately doing things that will annoy other people (Criterion A4),
- blaming others for his or her own mistakes or misbehavior (Criterion A5),
- being touchy or easily annoyed by others (Criterion A6),
- being angry and resentful (Criterion A7),
- or being spiteful or vindictive (Criterion A8).

To qualify for Oppositional Defiant Disorder, the behaviors must occur more frequently than is typically observed in individuals of comparable age and developmental level and must lead to significant impairment in social, academic, or occupational functioning (Criterion B).
- The diagnosis is not made if the disturbance in behavior occurs exclusively during the course of a Psychotic or Mood Disorder (Criterion C)
or if criteria are met for Conduct Disorder or Antisocial Personality Disorder (in an individual over age 18 years).
   
Negativistic and defiant behaviors are expressed by persistent stubbornness, resistance to directions, and unwillingness to compromise, give in, or negotiate with adults or peers. Defiance may also include deliberate or persistent testing of limits, usually by ignoring orders, arguing, and failing to accept blame for misdeeds. Hostility can be directed at adults or peers and is shown by deliberately annoying others or by verbal aggression (usually without the more serious physical aggression seen in Conduct Disorder).

Manifestations of the disorder are almost invariably present in the home setting, but may not be evident at school or in the community. Symptoms of the disorder are typically more evident in interactions with adults or peers whom the individual knows well, and thus may not be apparent during clinical examination. Usually individuals with this disorder do not regard themselves as oppositional or defiant, but justify their behavior as a response to unreasonable demands or circumstances.

Associated Features and Disorders
    Associated features and disorders vary as a function of the individual's age and the severity of the Oppositional Defiant Disorder. In males, the disorder has been shown to be more prevalent among those who, in the preschool years, have problematic temperaments (e.g., high reactivity, difficulty being soothed) or high motor activity. During the school years, there may be low self-esteem, mood lability, low frustration tolerance, swearing, and the precocious use of alcohol, tobacco, or illicit drugs. There are often conflicts with parents, teachers, and peers. There may be a vicious cycle in which the parent and child bring out the worst in each other.

Oppositional Defiant Disorder is more prevalent in families in which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or neglectful child­rearing practices are common. Attention-Deficit/Hyperactivity Disorder is common in children with Oppositional Defiant Disorder. Learning Disorders and Communication Disorders also tend to be associated with Oppositional Defiant Disorder.

Specific Age and Gender Features
    Because transient oppositional behavior is very common in preschool children and in adolescents, caution should be exercised in making the diagnosis of Oppositional Defiant Disorder especially during these developmental periods. The number of oppositional symptoms tends to increase with age. The disorder is more prevalent in males than in females before puberty, but the rates are probably equal after puberty. Symptoms are generally similar in each gender, except that males may have more confrontational behavior and more persistent symptoms.

Prevalence
Rates of Oppositional Defiant Disorder from 2% to 16% have been reported, depending on the nature of the population sample and methods of ascertainment.

Course
    Oppositional Defiant Disorder usually becomes evident before age 7 years and usually not later than early adolescence. The oppositional symptoms often emerge in the home setting but over time may appear in other settings as well. Onset is typically gradual, usually occurring over the course of months or years. In a significant proportion of cases, Oppositional Defiant Disorder is a developmental antecedent to Conduct Disorder.

Familial Pattern
    Oppositional Defiant Disorder appears to be more common in families in which at least one parent has a history of a Mood Disorder, Oppositional Defiant Disorder, Conduct Disorder, Attention-Deficit/Hyperactivity Disorder, Antisocial Personality Disorder, or a Substance-Related Disorder. In addition, some studies suggest that mothers with a Depressive Disorder are more likely to have children with oppositional behavior, but it is unclear to what extent maternal depression results from or causes oppositional behavior in children. Oppositional Defiant Disorder is more common in families in which there is serious marital discord.

Differential Diagnosis
    The disruptive behaviors of individuals with Oppositional Defiant Disorder are of a less severe nature than those of individuals with Conduct Disorder and typically do net include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. Because ail of the features of Oppositional Defiant Disorder are usually present in Conduct Disorder, Oppositional Defiant Disorder is not diagnosed if the criteria are met for Conduct Disorder. Oppositional behavior is a common associated feature of Mood Disorders and Psychotic Disorders presenting in children and adolescents and should not be diagnosed separately if the symptoms occur exclusively during the course of a Mood or Psychotic Disorder.

Oppositional behaviors must also be distinguished from the disruptive behavior resulting from inattention and impulsivity in Attention-Deficit/Hyperactivity Disorder. When the two disorders co-occur, both diagnoses should be made. In individuals with Mental Retardation, a diagnosis of Oppositional Defiant Disorder is given only if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable age, gender, and severity of Mental Retardation. Oppositional Defiant Disorder must also be distinguished from a failure to follow directions that is the result of impaired language comprehension (e.g., hearing loss, Mixed Receptive-Expressive Language Disorder). Oppositional behavior is a typical feature of certain developmental stages (e.g., early childhood and adolescence).

A diagnosis of Oppositional Defiant Disorder should be considered only if the behaviors occur more frequently and have more serious consequences than is typically observed in other individuals of comparable developmental stage and lead to significant impairment in social, academic, or occupational functioning. New onset of oppositional behaviors in adolescence may be due to the process of normal individuation.

Diagnostic criteria for Oppositional Defiant Disorder, 313.81
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults’requests or rules
(4) often deliberately annoys people
(5) often blames other for his or her mistakes or behavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindicative
Note : Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of compatible age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder
D. Criteria are not met for conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Disruptive Behavior disorder Not Otherwise Specified, 312.9
This category is for disorders characterized by conduct or oppositional defiant behaviors that do not meet the criteria for Conduct Disorder or Oppositional Defiant Disorder. For example, include clinical presentations that do not meet full criteria either for Oppositional Defiant Disorder or Conduct Disorder, but in which there is clinically significant impairment.

American Psychiatric Association
1994  ©