Running head: LITERATURE REVIEW OF OPPOSITIONAL DEFIANT DISORDER 1

Literature Review of Oppositional Defiant Disorder

Robert Green
Wake Forest University








LITERATURE REVIEW OF OPPOSITIONAL DEFIANT DISORDER 2

Abstract
Oppositional Defiant Disorder is one of the more common diagnoses for children and
adolescents. Oppositional behavior as often described through aggression becomes pervasive in
a childs interaction with peers and adults. Questions regarding the distinction of oppositional
defiant disorder from normal adolescent behavior have led to the study of oppositional defiant
disorder (ODD) as a burgeoning area of international interest. A review of 25 epidemiological
studies conducted in 16 different countries found very consistent prevalence rates for ODD
across geographic regions, supporting the cross-cultural validity of the disorder (Canino et al., as
cited in Frick & Nigg, 2012). Further supporting the clinical recognition of ODD is its affects
on social adjustment in comparison to other debilitating mental health disorders. This
manuscript will provide an analysis of key parent and child characteristics in transactional
context related to ODD, overview the prevalence of comorbidity in relation to ODD, and
examine psychopharmacological and psychosocial treatment of oppositional defiant disorder.
Concluding this review will be a discussion of possible directions for future research and gaps in
the literature.






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Introduction
Children or adolescents who do not obey their parents may be labeled as being
noncompliant or defiant. During normative development, oppositional behaviors peek in early
childhood and decrease over time. In contrast, symptoms continue to persist and increase in
severity over time in children diagnosed with ODD (Hanish et al., as cited in Mckinney & Renk,
2008). According to American Psychiatric Association (2000), the prevalence of ODD in the
general population is between 2 and 16 percent with the range depending on the sample and
methodology used in various studies. ODD falls into the category of disruptive behavior
disorders in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric
Association [APA], 2000), also included are attention deficit/hyperactivity disorder (ADHD),
conduct disorder (CD), and disruptive behavior disorder not otherwise specified. Most children
diagnosed with ODD have a history of significant oppositional behavior as early as preschool,
however ODD is most commonly diagnosed in elementary school by the age of 8 years old
(APA; Connor, 2002, as cited in Steiner & Remsing, 2007). The majority of those who are
diagnosed with ODD in early childhood will likely develop a stable pattern of oppositional
behavior, affective disorder, or comorbid diagnoses. In general, earlier and more severe ODD is
associated with a poorer longer-term prognosis (Hamilton & Armando, 2008). Equally
detrimental, are the affects of ODD on social impairment and family dysfunction. A study by
Greene et al. (2002) using the Social Adjustment Inventory for Children and Adolescents
compared the scores of social difficulties in youth with ODD diagnosis to youth with other
presenting diagnoses including: ADHD, CD, bipolar disorder, major depression, multiple anxiety
disorders, tourettes disorder, and pervasive developmental disorders. This study found that
ODD accounted for significantly lower Global Assessment of Functioning Scale scores, poorer
LITERATURE REVIEW OF OPPOSITIONAL DEFIANT DISORDER 4

family cohesion, higher rate of family conflict, and significantly impaired social functioning
across all domains (i.e., school, parents, siblings, and peers). These results support not only the
validity of the ODD diagnosis as a meaningful clinical entity, but also the extremely detrimental
effects of this disorder on multiple domains of functioning in children and adolescents (Greene et
al., 2002).
Etiology. Current research does not point to a single dominant risk factor for ODD.
Convincing evidence of causal links for the development of ODD remain elusive (Burke et al., as
cited in Steiner & Remsing, 2007). The most prevalent opinion is that ODD arises out of a
complex mix of risk and protective factors originating in the biopsychological constellation of an
individual (Steiner & Remsing, 2007). Furthermore, certain family characteristics such as low
income, low education, teenage pregnancy, isolation, high levels of stress, high levels of marital
discord and depression, inconsistent critical, hostile, or disengaged parenting, physical abuse,
and lack of cognitive stimulation are also associated with a diagnosis of ODD (Hanish, Tolan, &
Guerra, as cited in Mckinney & Renk, 2008) ODD is clearly familial, but research has yet to
determine what role genetics play because studies on the genetics of the disorder have produced
inconsistent results (Steiner & Remsing, as cited in Hamilton & Armando, 2008).
Methods
Research for this literature review was conducted through the Wake Forest University Z.
Smith Reynolds Library website. The databases PsycInfo, ERIC, and PubMed were utilized to
find contemporary articles related to diagnosis and treatment of ODD. Several key terms
assisted in this search such as: oppositional defiant disorder treatment, oppositional defiant
disorder diagnosis, medication for oppositional defiant disorder, and comorbidity and
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oppositional defiant disorder. Chronological parameters included articles between the years
2000 to 2012. The most frequently used database was PsycInfo as it presented the most relevant
articles. To assist individuals conducting a future literature review, I would propose using term
parameters in their search of oppositional defiant disorder NOT attention deficit hyperactivity
disorder NOT conduct disorder. Much of the literature in on ODD is as a construct relation to
ADHD or CD, which may or may not be relevant to a future literature review. However, setting
these term parameters will help identify articles studying ODD as a standalone construct and/or
in relation to other mental health disorders outside of the disruptive behavior disorder category.
A thorough search of articles relating ODD to non-categorical disorders could further serve to
validate clinical recognition of ODD.
Results
Diagnosis. A diagnosis of ODD is relatively stable over time, but most children
(approximately 67%) will ultimately exit from the diagnosis after a 3-year follow up (Connor;
Hinshaw & Anderson; Loeber et al., as cited in Steiner & Remsing, 2007). Conversely, earlier
age of onset of ODD symptoms conveys a poorer prognosis in terms of progression to CD and
ultimately antisocial personality disorder (Steinger & Remsing, 2007). The Diagnostic and
Statistical Manual-IV-TR (APA, 2000) establishes the necessary criterion of ODD as consisting
of:
A. A recurrent patters 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
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(3) Often actively defies or refuses to comply with adults requests or rules
(4) Often deliberately annoys people
(5) Is often touchy or easily annoyed by others
(6) Is often angry and resentful
(7) Is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is
typically observed in individuals of comparable 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 (p. 162).
Transactional Analysis. Conceptualization of the developmental pathway for ODD is
best achieved within the context of a transactional analysis of interactions within the family.
According to Greene, Ablon, & Goring (2002):
The transactional model posits that a childs outcome is a function of the degree of fit
or compatibility between child and adult characteristics. From this perspective,
oppositional behavior is viewed as one of many possible manifestations of parent-child
incompatibility, in which the characteristics of one interaction partner (e.g., the child) are
poorly matched to the characteristics of the second interaction partner (e.g., the parent),
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thereby contributing to disadvantageous behavior in both partners, which, over time,
contributes to more durable patterns of incompatibility (pp. 68-69).
For a model of development to be considered transactional, it must explain how characteristics of
the individual child and parent exert reciprocal influences on each other and shape the course of
each others development (Green & Doyle, 1999). Patterson (as cited in Mckinney & Renk,
2008) further describes the parent-child transaction in what he termed as the coercive process:
In this process, children and adolescents learn to escape and avoid parental criticism by
escalating their noncompliance and other negative behaviors. This escalation leads to
increasingly more aversive parental interactions, with parents escalating their demands
and methods of coercion in response to the noncompliance of their child or adolescent.
These negative parental behaviors, in turn, reinforce the avoidant behaviors exhibited by
their child or adolescent. This mutual training in aversive responding amplifies both the
parents coercive, nonresponsive behavior and the avoidant, aggressive, noncompliance
of the child. Thus, parents inadvertently teach their children to be noncompliant and are
modeling and reinforcing aggression through their daily interactions with their children
(pp. 42-43).
Comorbidity. A significant portion of research related to ODD has shown it to be a highly
comorbid disorder. In a study by Greene et al (2002), 1,600 children and adolescent referred to
the child psychiatry service in Massachusetts General Hospital were compared. The data from
this study suggested that approximately 65% of children diagnosed with ADHD have comorbid
ODD, and that over 80% of children diagnosed with ODD have comorbid ADHD (Greene et al,
as cited by Greene, Ablon, & Goring, 2002). An overlap between ODD and mood and anxiety
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disorders was demonstrated in that nearly 70% of children diagnosed with severe major
depression and 85% of children diagnosed with bipolar disorder were also diagnosed with ODD
(Greene et al, as cited by Greene, Ablon, & Goring, 2002). Roughly 60% of youth diagnosed
with ODD had comorbid anxiety disorder, and 45% of youth diagnosed with anxiety disorder
had comorbid ODD (Greene et al, as cited by Greene, Ablon, & Goring, 2002).
A second study by Nock, Kazdin, Hiripi, & Kessler (2007), provided a national
comorbidity survey to 3,199 respondents. Mental disorders were assessed using the World
Health Organization (WHO) Composite International Diagnostic Interview (CIDI; Kessler &
Ustun, as cited in Nock, Kazdin, Hiripi, & Kessler, 2007). Data revealed that during their
lifetime 92.4% of those with ODD meet criteria for another mental disorder. More specifically,
45.8% were found to have comorbid mood disorders, 62.3% comorbid anxiety disorders, and
68.2% comorbid impulse-control disorders non-specified (Nock, Kazdin, Hiripi, & Kessler,
2007). In another large study of schoolchildren aged 7-10 years with ADHD, 40% also met the
diagnostic criteria for ODD (Molina et al., as cited in Poulton, 2011). Finally, in a cohort of
children with severe ADHD presenting in the pre-school years, the proportion with comorbid
ODD was even higher at 52% (Greenhill et al., as cited in Poulton, 2011).
Treatment. Home visitation to high-risk families as a intervention has produced positive
outcomes in areas related to ODD (Eckenrode et al., as cited in Steiner & Remsing, 2007) In a
longitudinal study of a statewide population of children served by Medicaid, ODD was
diagnosed in one fourth of children receiving treatment (Heflinger & Humphreys, 2008). In the
same study, use of inpatient hospitalization or residential treatment doubled, family therapy was
used nearly four times as often, and use of medication management increased sevenfold for
children with ODD (Heflinger & Humhreys, 2008). According to Turgay (2009), studies
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regarding the effective medication in treatment of ODD are often derived from the sub-analyses
of studies designed for the treatment of ADHD. There have been no studies examining drug
therapy in patients with ODD without co-morbid disorders. Therefore, some of the
improvements in ODD symptoms seen in these studies may not be directly related to the
medication effects on ODD; rather, it may be possible that improvements in ODD symptoms
may be related to achieving increased control of ADHD symptoms (MTA Cooperative Group, as
cited in Turgay, 2009).
First-line medication for children with comorbid ODD and ADHD are psychostimulants
or atomoxetine (Poulton, 2011). Second-line medications which might be prescribed depending
on the severity of symptoms such as tricyclic antidepressants, atypical antipsychotics and
clonidine, are far less well supported by evidence of safety and efficacy (Poulton, 2011). One
rating scale used to measure the effects of stimulants on ADHD is the Swanson, Nolan and
Pelham (SNAP) questionnaire. This scale is inclusive of ODD symptoms found in the DSM-IV-
TR. A long-term treatment study of child psychiatric disorders completed by the National
Institute for Mental Health found that the use of psychostimulants in patients with comorbid
ADHD reduced ODD symptomatology, as measured by the SNAP rating scale (MTA
Cooperative Group, Turgay, 2009). Additionally, success rates for the treatment of ODD with
comorbid ADHD improved approximately 20% when combined with psychosocial treatment
(Swanson et al.; Hinshaw, as cited in Turgay 2009).
A review of effective psychosocial treatments for ODD has revealed parent training
programs as having the strongest evidence as a treatment for ODD (Farley, Adams, Lutton, &
Scoville, 2005). Parent training programs are standardized, short-term interventions that teach
parents specialized strategies such as positive attending, ignoring, the effective use of rewards
LITERATURE REVIEW OF OPPOSITIONAL DEFIANT DISORDER 10

and punishments, token economies, and time out to address oppositional behavior. Oppositional
behaviors usually stem from the family context, thus a solution aimed at empowering the parent
to address the needs of their child in the home is optimal. Other effective psychosocial
treatments for ODD include: Anger Copying Therapy, Problems Solving Skills Training,
Incredible Years Child Training, and Incredible years Teacher Training (Farley, Adams, Lutton,
& Scoville, 2005).
Discussion
After reviewing the literature, patterns of ODD being studied in its comorbid state
consistently emerged. There is an apparent need for ODD to be studied in a systematic way and
as a standalone construct. Furthermore, rating scales often used to assess ODD are not specific
to ODD and refer to oppositional symptoms within the context of another disorder. A brief
rating scale that maps directly onto the diagnostic criteria of the DSM-IV-TR and provides a
dimensional assessment of symptoms specific to ODD is the Oppositional Defiant Disorder
Rating Scale (ODDRS). This measure was shown to have high validity and inter-rater reliability
(Hommersen, Murray, Ohan, & Johnston, 2006). However, future research is needed to
demonstrate its specificity and ability to discriminate ODD from other clinical conditions such as
ADHD. Future research is also needed to test gender differences in the rating scale as boys and
girls tend to express aggression in different way.
Also noted from the literature is the need for a systematic procedure for treatment of
ODD without a comorbid diagnosis. Although parent training programs are frequently
recommended as an effective treatment, there is no consensus, as to the next step, should initial
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treatment not work. A proposed treatment algorithm as delineated by Turgay (2009) supports
pursuit of treatment as follows:
Step 1: A comprehensive evaluation is required to establish the presence of comorbid
disorders and/or to rule out these disorders: use a general psychopathology screening and
rating scale or structured interview.
Step 2: For a single diagnosis of ODD, in the absence of other psychiatric disorders,
psychosocial interventions should be attempted first.
Step 3: If psychosocial interventions do not provide improvement within the first 2-3
months, either psychostimulants or atomoxetine (which have proven effectiveness in the
treatment of ODD) may be tried (p.12).
Future research utilizing this treatment algorithm would help to systemize the initial treatment of
ODD. Finally, the use of more expensive treatment options for ODD such as group home or
residential placement would be preceded by a more systematic approach towards keeping
children in their home environment.






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