Oppositional Defiant Disorder

Etiology

The exact etiology of oppositional defiant disorder is complex and likely results from an interplay between genetic, environmental, and psychosocial factors. Several models of oppositional defiant disorder exist, with 2 of the most prominent outlined in the DSM-5-TR.

• Bifactor model: Irritable and defiant/headstrong [2]  
• Trifactor model: Irritable, defiant/headstrong, and vindictive/hurtful [3]

Genetics

The heritability estimate for oppositional defiant disorder is moderate, often centered around 50%. Twin studies suggest that shared environmental factors have minimal impact, whereas unshared environmental factors have moderate impact. Significant genetic overlap exists between oppositional defiant disorder and other externalizing conditions, such as attention-deficit/hyperactivity disorder and conduct disorder. The correlation between oppositional defiant disorder and conduct disorder is about 50%, which is higher than that with attention-deficit/hyperactivity disorder. Studies have been inconsistent regarding the genetic factors unique to oppositional defiant disorder.[4][5][6][7] The genetic correlates of the irritable subdimension overlap with those of depression and anxiety. The genetic correlates of the defiant subdimension correlate with those of conduct disorder and attention-deficit/hyperactivity disorder. The vindictive/hurtful dimension correlates with callous/unemotional traits. 

Research on the epigenetics of oppositional defiant disorder, specifically DNA methylation, suggests that methylation changes are present in oppositional defiant disorder. These changes are most remarkable in the headstrong/defiant subdimension.[8] 

Environmental Factors

Several environmental and psychosocial factors correlate with the risk of developing oppositional defiant disorder and other psychiatric conditions. These factors include:

• Smoking during pregnancy, at least 1 cigarette per day in any trimester
• Socioeconomic adversity, as indicated by maternal age at birth, parental education levels, socioeconomic status at birth, and family income
• Parental maladaptive behaviors, including alcohol abuse, illicit drug use, and criminality
• Family instability, from circumstances such as separation, divorce, remarriage, death, and fostering
• Exposure to abuse, whether sexual, physical, or interparental
• Peer influences, including substance use, such as tobacco, alcohol, or cannabis; truancy; and law-breaking
• Perinatal maternal depression [9][10] 

Importantly, there is a bidirectional relationship between oppositional or defiant behavior and strict parenting, where each can reinforce the other.

Epidemiology

According to the DSM-5-TR, the prevalence of oppositional defiant disorder is 3.3%. In the literature, the prevalence of oppositional defiant disorder in children and adolescents is between 28% and 65% in clinical samples and 2.6% and 15.6% in community samples.[11] Most community sample estimates range between 3% and 6%, and this rate does not vary greatly internationally. The variance in prevalence between nations was found to be related to methodological differences.[12] The data for adult populations are severely limited. The relative risk of developing oppositional defiant disorder in male individuals compared to female individuals is roughly 1.6.[13] However, studies on whether this gender difference persists into late childhood have produced conflicting results. Notably, the prevalence of oppositional defiant disorder tends to decrease with age.

Pathophysiology

Deficits in punishment processing and reward sensitivity have been identified in disruptive behavior disorders such as oppositional defiant disorder and conduct disorder, correlating with skin conductance and mediated by autonomic nervous system functioning. The deficit in punishment processing is linked to a lack of fear conditioning, which may be associated with problems in serotonin, norepinephrine, and cortisol functioning. Studies indicate that male patients with disruptive behavioral disorders have low basal cortisol. In contrast, research shows mixed findings for either increased or decreased basal cortisol in female individuals with oppositional defiant disorder.[14] These changes may be due to repeated exposures to stress, given the environmental risk factors for the condition.

Poor punishment sensitivity leads to response perseveration and problems with set switching, with weak evidence for deficits in other cool executive functions.[15] Patients with oppositional defiant disorder also have difficulty recognizing anger in other people's faces.[16] Poor early-life fear conditioning predicts later aggression and criminal behavior. 

Poor reward sensitivity predisposes individuals to engage in risky behaviors to achieve a typical level of stimulation. This finding has also been associated with amygdalar dysfunction. Gene candidates for this effect include dopamine receptor D4, catechol-O-methyltransferase, and monoamine oxidase A.[17]

Neuroanatomical studies have demonstrated decreased volume and activity in the bilateral amygdalae and insulae in disruptive behavior disorders, which are suspected to underlie the difficulties in hot executive functions, such as motivation and affect. In addition, decreased volume and activity in the left precuneus, which is involved in cool executive functions, including problem-solving and self-regulation, has been observed, and this area inhibits amygdalar activation.[18]

History and Physical

Healthcare professionals should perform a thorough psychiatric evaluation with multiple informants, including parents and teachers, in multiple settings. The assessment should include the individual's academic history and possible coexistence of neurodevelopmental disorders, such as learning disorders, attention-deficit/hyperactivity disorder, and intellectual disabilities. Patients should have their environment assessed for modifiable risk factors. The evaluation should determine the presence of mood, anxiety, and substance use symptoms, which are common and treatable comorbidities.

Healthcare professionals should assess attachment security, the quality of patient-child relationships, and parental beliefs about child-rearing, as these factors are integral to nonpharmacological interventions. In addition, screening for serious criminal behavior is important to evaluate the potential presence of conduct disorder. No specific laboratory tests or imaging studies are required for diagnosis or treatment.

Evaluation

Clinicians may use the following assessment tools to identify oppositional defiant disorder:

• Eyberg Child Behaviour Inventory
• Sutter-Eyberg Student Behavior Inventory-Revised
• Child Symptom Inventory 4
• Conners Child Behaviour Checklist 
• Achenbach System of Empirically Based Assessment
• Behaviour Assessment System for Children
• Strength and Difficulties Questionnaire [19]
• Child and Adolescent Psychiatric Assessment
• Development and Well-Being Assessment
• Diagnostic Interview Schedule for Children
• Disruptive Behaviour Diagnostic Observation Schedule [20]

These assessment tools serve different purposes based on their objectives, target age groups, and formats. Choosing the appropriate tool depends on the context of use, the available information, and whether a detailed evaluation for diagnosis or monitoring is needed. These assessment tools should complement the clinical history and physical examination.

Treatment / Management

Treatment for oppositional defiant disorder is multimodal and should involve the patient, family, school, and community. Healthcare professionals should identify and treat comorbidities and modifiable risk factors, such as bullying and parenting techniques. Patients should be assessed regularly for depression, anxiety, and substance use, as patients with oppositional defiant disorder are predisposed to developing these conditions. Treatment modalities include parent management training (PMT), school-based interventions, individual child therapy, and family therapy.

Parent Management Training

PMT is based on the principles of social learning theory and is the primary treatment for oppositional behaviors. PMT demonstrates a medium effect size on decreasing antisocial behaviors over short-term intervals, such as 3 months after cessation of PMT. The response tends to wane in 12 months after PMT cessation. A central principle in PMT is using positive reinforcement to decrease unwanted behaviors and promote prosocial behaviors.[21]. The other central principle is using natural, nonviolent consequences for behavior. Many programs also focus on improving communication between parents and children. Functional family therapy or brief strategic family therapy may also be supplemented to identify factors in the home that may contribute to or exacerbate aggressive behaviors. Studies suggest that online PMT is noninferior to standard PMT.[22] (A1)

School-Based Interventions

Supportive interventions to improve school performance, peer relationships, and problem-solving skills are particularly useful in treating oppositional defiant disorder.[23] These interventions include education and specific tools for the teacher to improve classroom behavior and prevent oppositional behavior and its escalation. Evidence-based programs include Incredible Years and the Good Behavior Game.[24](A1)

Individual Therapy

Anger management training based on cognitive behavioral therapy is useful in treating anger problems. In older children, problem-solving skills training and perspective-taking are cognitive behavioral therapy components that may alleviate aggressive behaviors.[25] The Coping Power program is an anger management program with multiple formats and consists of an additional component of parent involvement and periodic home visits.[26]

Pharmacologic Therapy

Psychosocial interventions are the first-line treatment for children with oppositional defiant disorder. However, pharmacologic agents are sometimes considered in cases where aggressive behavior cannot be managed with psychosocial interventions alone. The literature in this regard often does not separate patients with oppositional defiant disorder from conduct disorder and frequently examines patients with comorbid attention-deficit/hyperactivity disorder.

Studies support the use of lithium, haloperidol, risperidone, and aripiprazole.[27][28] Notably, the burden of adverse effects from these medications for disruptive behavior disorders has been very high and generally weighs against their use. Pharmacologic therapy for comorbid conditions such as attention-deficit/hyperactivity disorder and anxiety leads to improved outcomes in oppositional defiant disorder care. Clear treatment goals should be identified before initiating pharmacotherapy, and adverse effects should be discussed with the patient and family members and regularly assessed during follow-ups. Pharmacologic agents in the acute setting should be evaluated on a case-by-case basis after careful consideration by the clinician.(A1)

Differential Diagnosis

Conduct Disorder

Although both conduct disorder and oppositional defiant disorder deal with conflicts with authority figures, behaviors in oppositional defiant disorder are less severe compared to those in conduct disorder. The criteria for conduct disorder involve physical violence toward people, animals, and property destruction; theft; and running away. Not all children diagnosed with conduct disorder have prior oppositional defiant disorder, and not all children with oppositional defiant disorder develop conduct disorder. The overlap between the 2 conditions from genetic and functional neuroimaging studies is incomplete; thus, they are considered separate entities. 

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder is a childhood behavioral disorder commonly comorbid with oppositional defiant disorder. Inattentiveness and impulsivity contribute to noncompliance with rules and demands and must be distinguished from oppositional defiant disorder. Careful attention must be paid to identifying this condition as a potential modifiable factor. 

Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder is a childhood disorder characterized by frequent temper outbursts along with a persistently irritable mood in between outbursts. To meet the criteria, symptoms must persist for at least 12 months in multiple settings and have an onset before age 10. Although oppositional defiant disorder and disruptive mood dysregulation disorder share symptoms of chronically irritable mood and temper outbursts, the irritable mood in between outbursts persists in disruptive mood dysregulation disorder, and temper outbursts are more severe. According to the DSM-5, if an individual meets the criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder, only disruptive mood dysregulation disorder should be diagnosed.

Intermittent Explosive Disorder

Intermittent explosive disorder is a condition characterized by recurrent behavioral outbursts that may manifest as physical or verbal aggression toward others. These outbursts are more severe compared to those observed in oppositional defiant disorder and do not necessarily align with symptoms in the defiant or vindictive categories. 

Autism Spectrum Disorder

Autism spectrum disorder may present with noncompliance with requests or seeming defiance of authority figures due to social communication deficits, speech development delays, difficulties adjusting behaviors to a new context, restrictive patterns of behavior and interest, and inflexibility. Autism spectrum disorder and oppositional defiant disorder may be diagnosed together. However, determining whether the symptoms attributed to oppositional defiant disorder are better explained by autism spectrum disorder is essential.

Intellectual Developmental Disorder

Intellectual developmental disorder may present with emotional dysregulation, noncompliance with requests, and seeming defiance of authority figures. These symptoms are due to pervasive deficits in intellectual and adaptive function. Behavioral disturbances that are disproportionate to a preexisting diagnosis of intellectual developmental disorder may be diagnosed as oppositional defiant disorder if they meet the criteria.[29]

Anxiety Disorders

Irritability and avoidance behaviors are common in anxiety disorders such as social anxiety disorder and generalized anxiety disorder and may be misidentified as oppositional defiant disorder. Anxiety conditions do not result in defiant or vindictive behaviors. Anxiety disorders comprise another common comorbidity of oppositional defiant disorder. 

Mood Disorders

Emotional dysregulation, negative affect, and irritability are commonly observed in mood disorders and may be misidentified as oppositional defiant disorder. Mood disorders are a common comorbidity in oppositional defiant disorder, and the latter may not be diagnosed if the symptoms only occur during an episode.

Adjustment Disorder

Emotional or conduct disturbances may present similarly to symptoms in the irritable or defiant domains of oppositional defiant disorder. Disturbances associated with adjustment disorder are typically tied to a stressor.

Post-traumatic Stress Disorder

Emotional dysregulation, irritability, anger, risky behavior, and oppositional behavior are common in post-traumatic stress disorder. Symptoms of this condition are typically linked to a specific traumatic event.

Language Disorder

Difficulties in using and acquiring language may lead to noncompliance with requests and be misinterpreted as defiance, particularly in young children. 

Prognosis

Individuals with oppositional defiant disorder often experience significant social, academic, and occupational impairments, frequently resulting in conflicts with parents, teachers, and peers. These disruptive behaviors are associated with increased societal costs and poor psychosocial adjustment in adulthood. The prevalence of oppositional defiant disorder wanes with age, but a diagnosis of oppositional defiant disorder increases the risk of developing mood, anxiety, and substance use disorders later in life. The hypothesis that severe oppositional defiant disorder is a necessary intermediary in the development of conduct disorder has been contradicted by more recent evidence.

Low intellectual capabilities and lack of proper supervision suggest a poor prognosis. A good prognosis is associated with effective treatment of comorbidities, individual or family therapy, and positive parenting.

Complications

A diagnosis of oppositional defiant disorder increases the risk of future anxiety, mood, substance use, and behavioral disorders. Early intervention helps avert these complications.