Oppositional Defiant Disorder and Conduct Disorder
All children and adolescents exhibit outbursts and difficulty following adult expectations intermittently. However, some young people – perhaps around 3% - experience oppositional behavior beyond what is expected for their developmental level resulting in significant impairment. In these instances, oppositional defiant disorder (ODD) may be present. Without intervention, ODD can lead to an increased risk of legal challenges, peer difficulties, educational failures, substance use, and conduct disorder (CD). CD, consisting of inappropriate behavior for one’s age, serious difficulty following rules, and the persistent violation of the rights and well-being of others, has an estimated prevalence of around 5% in children and adolescents. If the behaviors associated with CD persist into adulthood, this can result in ongoing problems within one’s workplace, home, and social life. Understanding how ODD and CD manifest and how they relate to other mental health problems can help individuals receive effective interventions.
MYTH: ODD and CD are the same disorder
Fact: ODD and CD are related. However, ODD consists of defiant or rebellious behaviors, whereas CD is considered more severe and involves serious deviations from social norms, including intentionally harmful behaviors that violate the rights of others.
MYTH: Punishment is the best way to deal with disobedient children.
Fact: Managing the misbehavior of young people is complicated. Research suggests that strategies that reinforce the kind of behavior that parents want to see is more effective than punishment-based strategies, especially punishment alone. This is especially true when misbehavior rises to the level of a diagnosis of ODD or CD. Additionally, because ODD and CD are often comorbid with other mental health conditions, which may be exacerbated by intense punishment, understanding the full picture can help lead to more effective strategies.
Corey is an 8-year-old boy who presents to the pediatrician’s office for behavioral concerns. Grandma, his primary caregiver, reports that Corey is “always arguing” with her. He will intentionally do things that he is told not to, even as Grandma watches him do it. Yesterday, Corey broke his brother’s favorite toy because he was angry at his brother for getting a turn on the Xbox. He often takes out his frustrations on others and blames them when he makes mistakes. Grandma worries because “he is always angry” and that the family has to “walk on eggshells” around him, as to not make him angrier. He has angry outbursts or large arguments at least once daily. Grandma reports that Corey has always been a little argumentative, but his behavior has worsened over the past year. She reports trying time outs and taking away preferred activities when Corey is breaking the rules, but he does not seem to be affected by consequences for his behavior. Corey has started to get in trouble at school for arguing with his teacher and classmates when he does not like their answers to his questions. When the pediatrician attempts a physical exam, Corey refuses. He argues with Grandma who tells him it is necessary, but eventually he complies when the pediatrician mentions getting a prize at the end of the visit for his cooperation.
Lisa is a 15-year-old with a history of foster care placement and school truancy who presents for a visit with her new foster mother. Lisa reports that she was in a fight at school today, resulting in multiple bruises to her torso and face. She admits to starting four physical altercations this month and assault charges have been filed against her. Lisa has prior legal charges for shoplifting and theft. Foster mom is very concerned about Lisa. She reports that Lisa has been running away for days at a time and refusing to attend school. When school reached out to the foster mom, they reported that Lisa is three grade levels behind her peers. Lisa does not follow any of the rules in the home and says cruel or mean things to her younger foster sister. Foster mom reports that she has not seen “any remorse” from Lisa, even when she is caught breaking the law. When interviewed alone, Lisa denies feeling sad, worried, or anxious. She denies thoughts of suicide, homicide, and self-harm. She admits to weekly marijuana use but denies alcohol and other illicit drug use. She has been having unprotected sex with males, which she reports is consensual. She says she doesn’t care when she gets in trouble and that she doesn’t “see the point” in going to school. Her physical exam is reassuring, with only minor contusions present.
Screening and Assessment of ODD
For primary care providers considering ODD, use of a screening instrument not specific for ODD can be very helpful. For instance, the parent version of the Vanderbilt Assessment Scale has 47 questions about symptoms, and items 19-26 are questions that each reflect one of the 8 items listed in the DSM-5 criteria for ODD; the criteria require that 4 symptoms are present for the diagnosis. Similarly, in the SNAP-IV, items 21-28 reflect the 8 items in the DSM-5 criteria for ODD; item 29 is an item that was included in the DSM-III version of the diagnosis (“often is quarrelsome”) but not included in DSM-IV and DSM-5, and item 30 is an item meant to summarize ODD overall (“often is negative, defiant, disobedient, or hostile toward authority figures”). Taking the Vanderbilt Assessment Scale specifically, three different strategies may aid in the diagnosis of ODD. One strategy is to look for the presence of at least 4 of the 8 items which are scored as “present,” defined as either a 2 (“often”) or 3 (“very often”). A second strategy is to look for a total score of 10 or greater from these 8 items, which research has shown to have a high negative predictive power (the proportion of individuals who do not meet the threshold who do not have the diagnosis, meaning the tool correctly identified them as not having the diagnosis). A third strategy is to simply use items scored as “present” on the Vanderbilt Assessment Scale as prompts to discuss verbally with caregivers to gather more information. For instance, a rating of 3 (“very often”) on item 21 (“actively defies or refuses to go along with adults’ requests or rules”) could lead the provider to ask for more information, where the caregiver could provide specific examples, go into more detail about where and when this is most commonly seen, and describe the impairment these symptoms have on domains of functioning such as school, family, activities, and peer relationships.
ODD Diagnostic Features
The three defining characteristics of ODD include (1) angry or irritable mood, (2) argumentative or defiant behavior, and (3) vindictiveness. The symptoms of angry and irritable mood include resentfulness, anger, touchiness, loss of temper, and being easily annoyed. Argumentative and defiant behavior is characterized by actively defying or refusing to comply with authority figures and adults, and annoying others deliberately or blaming them for mistakes and misbehavior. A minimum of four of the eight symptoms must be present, and the behavior must occur at least once per week for individuals 5 years or older, or on most days for children younger than 5 years, for at least six months, to meet the diagnostic criteria for ODD. Symptoms must also cause distress in the individual or in others, or negatively impact various domains of life, such as social, occupational, or work/academic functioning. The DSM-5 suggests specifying severity as well. Severity can range from mild, consisting of ODD symptoms in one setting, to moderate, where symptoms are present in at least two settings, to severe, in which symptoms are present in three or more settings.
CD Diagnostic Features
CD is defined by the repetitive and persistent violation of age-appropriate social norms and/or the violation of the basic rights of others. At least 3 of the possible 15 symptoms must be present for a period of 12 months to meet diagnostic criteria for CD. These symptoms can be divided among four categories, including (1) aggression towards people or animals, (2) destruction of property, (3) deceitfulness or theft, and (4) serious violation of rules. Specified serious violations of rules include running away from home overnight or, before age 13, frequent school truancy or often staying out at night despite being prohibited from doing so by the caregiver. For CD, onset timing specifiers include the following: childhood-onset type, adolescent-onset type, or unspecified onset. Severity ranges from mild, which includes the bare minimum diagnostic criteria, to moderate, which consists of an intermediate number of symptoms, and severe, which includes an excess of symptoms required for diagnosis.
ODD and CD Differential Diagnosis and Comorbidity
The idea of differential diagnosis in healthcare is to help providers distinguish between presentations which are similar but represent distinct conditions. This is an important cornerstone of medicine but is one which should be utilized with care in the case of ODD and CD, because these are each diagnostic entities which have characteristic symptoms meant to aid in differentiation from developmentally normal behavior or an adjustment disorder. The symptoms of both ODD and CD cannot be attributed to a singular cause and detecting the presence of these symptoms (DSM-5 criteria) does not suggest that having another mental disorder is unlikely. In fact, the comorbidity of ODD or CD with other conditions, especially ADHD or an anxiety disorder, is very high.
Attention-Deficit/Hyperactivity Disorder (ADHD): Hyperactivity and inattention often lead caregivers or teachers to describe a child as disobedient, raising concerns for ODD. It may be difficult to fully tease apart the cause of behavior problems at the time of initial presentation. Often, the symptom which may be foremost on the mind of the caregiver is a child’s oppositionality, whether this is accompanied by clear symptoms of ADHD or not. Certainly, if symptom criteria for ODD or CD are present along with ADHD symptomology, a diagnosis of comorbidity may be suitable.
Anxiety: Anxiety disorders are an important cause of behavioral escalation in children and may be more difficult than ADHD to recognize as a primary condition present or as one comorbid with ODD. In addition to the symptoms mentioned in specific anxiety diagnoses such as generalized anxiety disorder, social phobia, separation anxiety disorder, and obsessive-compulsive disorder, a general characteristic of rigidity – needing things to be just so otherwise significant distress manifests as tantrums - or exhibiting poor flexibility and great resistance to situations which cause anxious distress – is commonly seen in individuals with anxiety disorders or clinically significant anxious distress. Of note, this may also be seen in the case of individuals with autism spectrum disorders, who may be more sensitive to experiencing anxious distress in the setting of change, whether or not a disorder that meets criteria for an additional anxiety disorder diagnosis is present.
Trauma: Exposure to interpersonal violence, such as witnessing intimate partner violence in the home or violence in the neighborhood, or being the direct recipient of abuse, can lead to disruptive and other problematic behaviors. This is also true of neglect and other circumstances impacting the development of healthy secure attachment in early life.
Depressive and Bipolar Disorders: Depressive and bipolar disorders can present with negative affect and irritability. However, these disorders can be differentiated from ODD and CD, as ODD and CD symptoms will occur when mood difficulties are not present as well. For instance, ODD and CD behaviors will exist without the presence of major depression, mania, or hypomania, unless one is presenting with comorbid diagnoses.
Intermittent Explosive Disorder: Intermittent explosive disorder (IED) can be differentiated from ODD in that it consists of severe aggression directed towards others, not associated with an ODD diagnosis. While individuals with CD may also exhibit aggression, for IED these behaviors are typically impulsive, not premeditated, and less obviously goal-directed than those typically seen in CD.
Adjustment Disorder with Disturbance of Conduct: If behavior is in response to a specific stressor, especially if it is possible to see that the behavior is transient, then adjustment disorder with disturbance of conduct is a more appropriate diagnosis than ODD or CD. If significant features of anxiety or depression are also present, then adjustment disorder with mixed disturbance of emotions and conduct is appropriate.
Disruptive Mood Dysregulation Disorder: Disruptive mood dysregulation disorder consists of more severe, frequent, and chronic temper outbursts than ODD. Escalations appear more related to a baseline irritable mood and are usually less obviously goal-directed than in CD.
Intellectual Disability (Intellectual Development Disorder): Individuals with intellectual disability are only diagnosed with ODD if the oppositional behavior is significantly greater than what is expected for one’s developmental level, which considers both age and severity of intellectual disability.
Language Disorder: ODD should be differentiated from disruptive behavior that results from impaired language comprehension.
Differentiating ODD from CD: While ODD and CD have overlapping features, CD is considered more severe and includes symptoms of aggression towards people or animals, destruction of property, and theft and deceit, which are not present in ODD. ODD may progress to CD; in individuals whose CD has an onset before adolescence, ODD is often a precursor.
Clinical Pearl: ODD as a Symptom Cluster
It may be most helpful to think of ODD as a symptom cluster which is not fully reflected in the criteria for other diagnoses, but which can be heavily impacted by the presence of another diagnosis. Comorbidity with ADHD and anxiety are high, and designing a treatment plan for these conditions is crucial. In many cases, if these complicating conditions are successfully treated, the symptoms of ODD may partially or even fully resolve. In other cases, the symptoms of the comorbid condition may improve significantly but the symptoms of ODD do not, which should lead to consideration of other factors which may be precipitating and perpetuating symptoms of ODD, and additional strategies to target the symptoms.
Clinical Pearl: Increased Risk
Individuals presenting for care with concerns for oppositionality and disordered conduct have a higher incidence of both substance use disorders and suicide risk. Additional information about handling these clinical concerns can be found in the modules on those topics on this site.
The common principles underlying effective treatment of ODD and CD are as follows: (1) engage the family, (2) select the treatment and who should deliver it, (3) develop strengths, (4) treat comorbid conditions, (5) promote social and scholastic learning, (6) follow recommended guidelines for the chosen intervention(s), and (7) treat the child in their natural habitat.
Clinical Pearl: The PCP's Role
The PCP can play an important role in treatment of ODD and CD. They are often the first point of contact and can help caregivers understand basic principles and strategies for managing behavior problems, particularly in young children. But intervention by the PCP alone is usually only effective in mild or sub-threshold cases of ODD. Furthermore, it is important to consider that caregivers can hear behavior management advice that is offered in a single episode of care without a demonstrated nuanced understanding of a particular family’s situation or an established framework of gradual interventions as condescending and shaming; perhaps more importantly, they may not expect the advice to work even if it were perfectly implemented. For this reason, when symptoms are significantly impacting functioning, unless the PCP believes that an intervention they plan to take (such as pharmacotherapy for ADHD) will impact the behavior problems, a PCP should strongly consider adding a more intensive and longitudinal intervention in the form of psychotherapy or parent management training that will support the patient and family in addressing the symptoms.
Various treatment modalities may be utilized for ODD or CD, including family and individual interventions. Treatment interventions should be assessed throughout the course of recovery and be adapted as needed. It should be noted that non-medication interventions are suggested for these conditions unless medication is being used to treat another disorder, in which case a combination of non-medication and medication interventions may be used. Experienced psychotherapists may appropriately combine techniques drawn from different sources to effect positive change. Development of rapport with the patient and caregivers, utilizing principles of behavior management to promote adaptive behaviors, improving emotion regulation through coping skills training , and promoting open communication within the family are all common examples of the work done in psychotherapy that can lead to symptom improvement.
ODD Specific Interventions
Parent Management Training:
- The Incredible Years: The Incredible Years program consists of 13 to 16 2-hour weekly sessions composed of video segments demonstrating helpful and unhelpful ways to manage children's behavior. The parents then discuss the information they’ve learned from the videos in relation to their child’s behavior.
- The Triple P – Positive Parenting Program: A program designed to enhance parenting skills and improve parent-child relations particularly among preadolescents. This program consists of multiple levels including universal interventions, interventions for specific problem behaviors, and interventions for minor problem behaviors. In some instances, intensive programs will also address management strategies for mood difficulties.
School Based Approaches: Intervention strategies within the school setting can include any of the following:
- Use of tools based on social learning theory to promote positive behaviors
- Aiding in the development of problem-solving skills
- Supporting the reduction of problem behaviors through strategies such as behavioral analysis and positive reinforcement
- Adjusting the environment to limit oppositional behaviors from escalating
Individual Therapy – Anger Management: CBT-based anger management training has been identified as particularly useful for treating anger among children with ODD. CBT-based anger management training consists of three components, including (1) cognitive preparation, (2) skill acquisition, and (3) application training. Individual therapy to improve general awareness of emotions and regulation of anxiety can be a good general goal for therapy.
The pediatrician talks with Corey’s grandma about a tentative diagnosis of ODD but explains that she wants to rule out ADHD first. Grandma is given a Vanderbilt Assessment Parent Informant Form and three Teacher Informant Forms are sent to school for teachers to report back. Grandma’s Vanderbilt report is not positive for ADHD symptoms. Corey and grandma are referred to a local therapist for parent management training and given a follow up appointment in 6 weeks.
CD Specific Interventions
Functional Family Therapy (FFT): FFT is delivered in the family home, and typically lasts for 8-12 sessions. FFT consists of four stages, including (1) engagement, (2) motivation, (3) behavior change, and (4) generalization. Research suggests FFT is one of the most effective treatments for CD.
Multisystemic Therapy (MST): MST is another effective treatment approach for CD, and consists of the following nine principles: (1) assessment to understand one’s behavioral problems in context of their environment, (2) clinician emphasis of positives and strengths, (3) interventions are curated to promote responsible behavior and reduce irresponsible behavior, (4) interventions are specific, with defined goals, and focused in the present, (5) interventions target sequences of behaviors, (6) interventions are developmentally appropriate, (7) interventions require frequent (i.e., daily and weekly) effort by family members, (8) interventions are continually evaluated and adapted as needed, and (9) interventions are designed for generalization to promote positive behavior change across multiple contexts.
The primary care doctor asks about other services involved in Lisa’s care. She has a case worker, a therapist, and is involved with a juvenile justice program through the courts. The doctor talks to foster mom about having an evaluation to determine eligibility for the OhioRISE program, which could provide Lisa with intensive services, such as Intensive Home-Based Therapy (IHBT). The doctor recommends foster mom discuss the OhioRISE program with Lisa's care team to determine if she may be eligible for services. The doctor orders a urine pregnancy test, which was negative, and a sexually transmitted disease panel. Upon discussion with Lisa, birth control pills are started, and a follow up appointment is scheduled.
Once treatment has begun, the PCP can help keep patients and families on a positive path. This can include:
- Continue interventions and the treatment plan as agreed upon by the clinical team
- Provide ongoing support to families and caretakers, which may include seeking professional services
- Collaboration with other service systems, such as juvenile justice or social services, depending on youth and family circumstances
- Provide anticipatory guidance including interventions to build resilience: http://www.ohiomindsmatter.org/resilience
- If medication is involved, proper monitoring of medication compliance and side effects
- Continue to screen for and monitor substance use disorders and increased risk of suicide
Corey returns to the pediatrician’s office for scheduled follow up. His Vanderbilt Teacher Rating Scale forms are attached to his chart and they are also not consistent with ADHD. Corey has been attending twice weekly sessions with the therapist and Grandma has been following the recommendations discussed. She reports that they now have a daily routine with positive praise and rewards built in. Corey has only had one angry, argumentative episode over the past week. Grandma and his therapist have given recommendations to school, and he is no longer getting in trouble.
Lisa presents for follow up 3 months later, as she missed her previously scheduled visit. She is with the same foster mom, who reports some improvements in behaviors. Lisa has been involved in a special program through OhioRISE that includes specialized services such as multi-systemic therapy for youth with complex needs, such as behavioral health and juvenile justice involvement. She has started back at school and an IEP evaluation has begun. She has not had any more legal charges or physical altercations since last visit. Lisa reports that she is required to attend her program because she does not want to go to jail. She admits that it has been helpful to learn how to better control her anger. She also likes her foster mom and is starting to become closer with her. Lastly, Lisa reports taking her birth control daily and using condoms.
Clinical Resources and Services
American Academy of Child and Adolescent Psychiatry Opposition Defiant Disorder Resource Center: https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Oppositional_Defiant_Disorder_Resource_Center/Home.aspx
Child Mind Institute: https://childmind.org/article/what-is-odd-oppositional-defiant-disorder/
Lives in Balance: https://livesinthebalance.org/
Nationwide Children’s Hospital “Oppositional Defiant Disorder” Webpage: https://www.nationwidechildrens.org/conditions/oppositional-defiant-disorder
American Academy of Child and Adolescent Psychiatry Conduct Disorder Resource Center: https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Conduct_Disorder_Resource_Center/Home.aspx
Child Mind Institute: https://childmind.org/guide/quick-guide-to-conduct-disorder/
Lives in Balance: https://livesinthebalance.org/
Nationwide Children’s Hospital “Conduct Disorders” Webpage: https://www.nationwidechildrens.org/conditions/conduct-disorders
American Academy of Child and Adolescent Psychiatry. (n.d.). Conduct disorder resource center: Frequently asked questions. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Conduct_Disorder_Resource_Center/FAQ.aspx
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th edition). https://doi.org/10.1176/appi.books.9780890425596
Foy, J (Ed.). (2018). Mental health care of children and adolescents: A guide for primary care clinicians. American Academy of Pediatrics (AAP)
Rey, J.M., & Martin, A. (Eds.). (2020). JM Rey’s IACAPAP e-textbook of child and adolescent mental health. International Association for Child and Adolescent Psychiatry and Allied Professions
Riley, M., Ahmed, S., & Locke, A. (2016). Common questions about oppositional defiant disorder. American Family Physician, 93(7), 586-591