Oppositional Defiant Disorder (ODD)

Signs and symptoms

The DSM-5-TR describes three groups of symptoms. A diagnosis requires at least four, shown with at least one person who is not a sibling, lasting 6 months or more:

Angry or irritable mood

• often loses temper
• often touchy or easily annoyed
• often angry and resentful

Argumentative or defiant behavior

• often argues with adults or authority figures
• often actively defies or refuses to follow rules or requests
• often deliberately annoys others
• often blames others for their own mistakes or misbehavior

Vindictiveness

• has been spiteful or vindictive at least twice in the past 6 months

Severity is graded by setting: mild if symptoms occur in one setting (often only at home), moderate in two, and severe in three or more.

ODD vs normal defiance

All children argue and say "no" sometimes, especially toddlers and teenagers. ODD differs because the behavior:

• happens far more often than in peers of the same age and development
• lasts at least 6 months
• causes significant distress or problems in family life, school or friendships
• is not mainly explained by another condition such as depression, bipolar disorder or a psychotic disorder

ODD vs conduct disorder vs ADHD

Many children with ODD also have ADHD. A minority of children with ODD later develop conduct disorder, particularly without treatment.

Causes and risk factors

No single cause has been found. ODD develops from a mix of:

• temperament: children who are more reactive, intense or have difficulty calming down
• biology and genetics: family history of ADHD, mood disorders or substance use
• environment: harsh, inconsistent or very permissive parenting, family conflict, parental stress or mental illness, abuse or neglect, frequent changes of caregivers
• social factors: poverty, community violence, rejection by peers

These are risk factors, not blame. Many loving, well-meaning families have a child with ODD.

Conditions that often occur with ODD

• ADHD
• anxiety and depression, where irritability is a key feature
• learning and language disorders
• autism spectrum disorder
• substance use in teenagers

Diagnosis

A child psychiatrist, psychologist or pediatrician makes the diagnosis after:

• interviews with the child, parents and often teachers
• rating scales and questionnaires completed by parents and teachers
• observation of behavior
• screening for ADHD, anxiety, depression, learning problems, trauma and other conditions
• ruling out medical causes, sleep problems and hearing or vision issues

Treatment

Parent management training

The most effective treatment, especially for younger children. Programs such as Parent-Child Interaction Therapy (PCIT), Incredible Years and Triple P teach parents to:

• give clear, simple instructions
• praise and reward positive behavior specifically and immediately
• use calm, consistent, predictable consequences, such as time-outs or loss of privileges
• avoid power struggles and harsh punishment
• spend regular positive one-on-one time with the child

Therapy for the child

• cognitive behavioral therapy: problem-solving, managing anger and frustration, and understanding others' perspectives
• social skills training
• family therapy to improve communication

School support

Teachers can use consistent behavior plans and rewards. An IEP or 504 plan may help if learning problems or ADHD are present.

Medicine

There is no medicine specifically for ODD. Treating co-existing ADHD with stimulants often reduces oppositional behavior. Medicines may be used for depression or anxiety. Other medicines are reserved for severe aggression under specialist care.

Outlook

Many children with ODD improve significantly with treatment, and symptoms often lessen with age. Without help, ODD can increase the risk of conduct disorder, depression, anxiety, substance use and school difficulties. Early treatment and supportive relationships make a big difference.

Tips for parents

• pick your battles, and focus on the most important rules
• stay calm, and take a break if you feel angry
• set routines and clear expectations
• notice and praise good behavior often
• look after your own wellbeing and seek support

Frequently asked questions

What are the signs of oppositional defiant disorder?

Signs include frequent temper outbursts, being easily annoyed, anger and resentment, arguing with adults, refusing to follow rules, deliberately annoying others, blaming others, and spitefulness. These must persist for at least 6 months and cause problems at home, school or with friends.

What causes ODD?

There is no single cause. ODD results from a mix of temperament, genetic factors and environment, including family stress, inconsistent discipline, conflict and trauma. It is often linked with ADHD, anxiety and depression.

Is ODD the same as ADHD?

No, but they often occur together. ADHD involves inattention, hyperactivity and impulsivity. ODD involves a pattern of anger, defiance and arguing. Treating ADHD often reduces oppositional behavior.

Can a child grow out of ODD?

Many children improve with age, especially with parent training and therapy. Some continue to have problems into adolescence and adulthood, and a minority develop conduct disorder. Early treatment improves the outlook.