Oppositional defiant disorder

Essential (Required) Features:

• A pattern of markedly noncompliant, defiant, and disobedient behaviour that is atypical for individuals of comparable age, developmental level, gender, and sociocultural context. The pattern of behaviour may include:
• Persistent difficulty getting along with others (e.g., arguing with authority figures, actively defying or refusing to comply with requests, directives, or rules, deliberately annoying others, blaming peers or co-workers for mistakes or misbehaviour).
• Provocative, spiteful, or vindictive behaviour (e.g., antagonizing others; using social media to attack or mock others).
• Extreme irritability or anger (e.g., being touchy or easily annoyed, losing temper, angry outbursts, being angry and resentful).
• The behaviour pattern has persisted for an extended period of time (e.g., 6 months or more).
• The oppositional behaviours are not better accounted for by relational problems between the individual and a particular authority figure toward whom the individual is behaving in a defiant manner. Examples may include parents, teachers, or supervisors who act antagonistically or place unreasonable demands on the individual.
• The behaviour pattern results in significant impairment in personal, family, social, educational or other important areas of functioning.

Specifiers for the presence or absence of chronic irritability-anger:

Two specifiers indicating the presence or absence of chronic irritability-anger can be assigned to the diagnosis of Oppositional Defiant Disorder.

6C90.0 Oppositional Defiant Disorder, with chronic irritability-anger

• All diagnostic requirements for Oppositional Defiant Disorder are met.
• Prevailing, persistent irritable mood or anger that is atypical for individuals of comparable age, developmental level, gender, and sociocultural context, including most of the following features:
• Often feeling angry or resentful; showing bitterness toward others, or feeling as if things are unfair.
• Often being touchy or easily annoyed; exhibiting oversensitivity or irritation to minimal or perceived provocations.
• Often losing temper; exhibiting angry verbal or behavioural outbursts, which may include tantrums, destructive behaviours, or other forms of severe mood dysregulation.
• The anger or resentment, touchiness or annoyance, and loss of temper is out of proportion in intensity or duration to any provocation, and may be present independent of any apparent provocation.
• Chronic irritability and anger are characteristic of the individual’s functioning nearly every day and are not limited to discrete periods, are observable across multiple settings or domains of functioning (e.g., home, school, social relationships), and are not restricted to the individual’s relationship with their parents or guardians.
• The pattern of chronic irritability and anger is not better accounted for by another mental disorder (e.g., irritable mood in the context of Manic or Depressive Episodes).
• Individuals with this subtype usually also display other characteristic features of Oppositional Defiant Disorder, including defiant, headstrong, or vindictive behaviours.

6C90.1 Oppositional Defiant Disorder, without chronic irritability-anger

• All diagnostic requirements for Oppositional Defiant Disorder are met.
• Absence of prevailing, persistently angry or irritable mood. In these individuals, anger and irritability occur less frequently, and tend to be transitory, less severe, and less often out of proportion to the provocation as compared to individuals with chronic irritability-anger.

6C90.Z Oppositional Defiant Disorder, unspecified

Specifiers for limited or typical prosocial emotions:

The specifier ‘with limited prosocial emotions’ may be applied to individuals who meet the diagnostic requirements for Oppositional Defiant Disorder and also exhibit a pattern of limited prosocial emotions sometimes referred to as ‘callous and unemotional traits.’ Individuals with these characteristics represent a minority of those with Oppositional Defiant Disorder diagnosis. The ‘with limited prosocial emotions’ specifier represents a relatively more severe and less common presentation of Oppositional Defiant Disorder, compared to those with this diagnosis and typical prosocial emotions.

In evaluating prosocial emotions, it is important to obtain information from others who have known the individual for an extended period of time, in addition to the individual’s self-report of their own behaviours and experience.

Limited or typical prosocial emotions in individuals with Oppositional Defiant Disorder can be specified as follows:

6C90.y0 with limited prosocial emotions

• In the context of a diagnosis of Oppositional Defiant Disorder, the presence of a characteristic social-emotional pattern in which several of the following features are repeatedly manifested:
• Limited or absent empathy or sensitivity to others’ feelings or concern for their distress; the individual is more concerned with how behaviours affect himself/herself rather than how they affect others, even if they cause harm.
• Limited or absent remorse, shame, or guilt over one’s own behaviour (unless prompted by being apprehended); lack of concern about the consequences of his/her actions on others and relative indifference toward the probability of punishment.
• Limited or absent concern over poor/problematic performance in school, work, or other important activities; may put forth little effort and blame others for his/her poor performance.
• Limited or shallow expression of emotions, particularly positive or loving feelings toward others; emotional expression may appear shallow, superficial, insincere, or instrumental.
• This pattern is pervasive across situations and relationships (i.e., the specifier should not be applied based on a single characteristic, a single relationship, or a single instance of behaviour).
• The pattern is persistent over time (e.g., at least 1 year).
• Among individuals with Oppositional Defiant Disorder, those with limited prosocial emotions tend to display a particularly extreme and stable pattern of oppositional behaviours.

6C90.y1 with typical prosocial emotions

• In the context of a diagnosis of Oppositional Defiant Disorder, this specifier represents a more common pattern of Oppositional Defiant Disorder that is not characterized by the features of limited prosocial emotions.
• Although some features similar to limited prosocial emotions (e.g., low concern, limited remorse) may be evident at times, they are generally infrequent, transitory, and less pronounced and do not represent a persistent pervasive pattern of social-emotional deficits.
• Most individuals with Oppositional Defiant Disorder exhibit typical prosocial emotions.

6C90.yZ unspecified

Additional Clinical Features:

• Although often identified through parental report of noncompliant behaviour, the negative and antagonistic aspects of Oppositional Defiant Disorder also exert a broader negative influence on interactions with others outside the family. Oppositional Defiant Disorder is associated with peer rejection and interpersonal discord through the school years and into adulthood.
• Frequently, the oppositional defiant features have a provocative quality such that individuals initiate confrontations and may be seen as excessively rude and uncooperative.
• Younger children (e.g., 3 to 5 years of age), are typically more closely supervised and receive frequent instructions and limits imposed on them by authority figures (e.g., parents or other guardians, caregivers, teachers). As children grow older, direct demands by authority figures typically become less frequent. Moreover, others interacting with children or adolescents with Oppositional Defiant Disorder may come to avoid placing demands on them due to their negative response. Therefore, a diagnosis is not precluded because oppositional or defiant behaviours occur relatively infrequently, as long as they characterize most interactions with authority figures.
• Adults with Oppositional Defiant Disorder continue to experience conflictual relationships with parents and family members and have generally poorer social support networks. This affects the number and quality of their friendships and romantic relationships. They typically struggle to function in the workplace due to difficulties in their interactions with supervisors and co-workers.
• Features of irritability and anger (e.g., being touchy or easily annoyed, losing temper, being angry and resentful) are sometimes the predominant characteristics of the clinical presentation. However, irritability and anger alone are neither necessary nor sufficient for the diagnosis. These symptoms must be accompanied by a pattern of markedly noncompliant, defiant, and disobedient behaviour that is atypical for individuals of comparable age and developmental level. The presence of chronic irritability and anger is indicated by using the corresponding specifier.
• Oppositional Defiant Disorder with chronic irritability-anger is not necessarily more severe or rare than Oppositional Defiant Disorder without chronic irritability-anger. Rather, Oppositional Defiant Disorder with chronic irritability-anger identifies a pattern of mood dysregulation that can range in severity from frequent and impairing tantrums to extreme presentations of the mood dysregulation.
• Individuals with Oppositional Defiant Disorder may present with limited prosocial emotions. When assessing for Oppositional Defiant Disorder, the clinician should also assess for limited prosocial emotions, and, if present, assign the appropriate specifier. Individuals with Oppositional Defiant Disorder with limited prosocial emotions are more likely to exhibit a more persistent and severe pattern of antisocial behaviour that may subsequently meet the diagnostic requirements for Conduct-Dissocial Disorder.
• Oppositional Defiant Disorder in childhood frequently co-occurs with Attention Deficit Hyperactivity Disorder, Conduct-Dissocial Disorder, and internalizing disorders such as Depressive Disorders or Anxiety or Fear-Related Disorders.

Boundary with Normality (Threshold):

• Transient noncompliance, defiance, and disobedience including irritability or anger can occur within the normal range of behaviour as a part of typical development or in response to increased demands on the developing child, changes in the child’s environment (e.g., transition to a new school or city), or as a manifestation of normative anxiety in the context of specific tasks or situations (e.g., going to school and separating from parents for the first time). The presence of such behaviours should not be taken as evidence for a presumptive diagnosis of Oppositional-Defiant Disorder. Oppositional-Defiant Disorder should only be diagnosed when there is a persistent pattern of markedly noncompliant, defiant, and disobedient behaviour that is atypical considering the individual’s age, gender, and social-cultural context.

Course Features:

• The heterogeneity of presentations in Oppositional Defiant Disorder has meaningful clinical and prognostic implications. Oppositional Defiant Disorder can be a developmental precursor for the development of Conduct-Dissocial Disorder, especially when the presentation of Oppositional Defiant Disorder includes severely defiant or spiteful/vindictive behaviours. However, many children with Oppositional Defiant Disorder do not subsequently develop Conduct-Dissocial Disorder.
• A diagnosis of Oppositional Defiant Disorder with chronic irritability and anger is associated with the subsequent development of Depressive Disorders and Anxiety or Fear-Related Disorders.

Developmental Presentations:

• Typical age of onset of Oppositional Defiant Disorder is in middle childhood with initial symptoms typically appearing at preschool age. Symptoms rarely emerge for the first time later than early adolescence.
• Prevalence rates of Oppositional Defiant Disorder are estimated at 3.3% among children and adolescents (aged 6 – 18). Although rates are equivalent among preschool-aged boys and girls as well as adolescents and adults, higher rates are observed among school-aged boys (ratio of 1.4:1). Some evidence suggests that the overall prevalence of Oppositional Defiant Disorder decreases beginning in adolescence and young adulthood.
• Oppositional Defiant Disorder is more common among children and adolescents whose families have experienced substantial disruptions in care-giving relationships or in which parenting practices tend to be harsh, inconsistent, or neglectful.
• Although oppositional and argumentative behaviours are common in typically developing children, unlike in Oppositional Defiant Disorder, these behaviours tend to be transient and do not consistently negatively impact the child’s functioning and development.
• Oppositional Defiant Disorder has been associated with greater peer rejection, heightened interpersonal conflict, and increased risk for co-occurring and subsequent difficulties in adjustment throughout childhood and adulthood.

Culture-Related Features:

• There is substantial variation in the prevalence of Oppositional Defiant Disorder across cultures. These differences may be related to cultural norms regarding uncooperative or defiant behaviour in children. For example, cultures that value obedience highly may have a lower threshold for considering a child’s behaviour to be noncompliant, defiant, or disobedient. The behaviours relevant to assigning a diagnosis of Oppositional Defiant Disorder should be evaluated in relation to social, cultural and subgroup norms.
• Variation in the prevalence of Oppositional Defiant Disorder and Conduct-Dissocial Disorder across cultural groups may be related to differences in family structure and behaviour. Lower prevalence may be associated with stricter disciplinary practices at home, strong emphasis on educational or occupational attainment, and cultural values that disapprove of an antisocial lifestyle.

Sex- and/or Gender-Related Features:

• Prevalence of Oppositional Defiant Disorder is higher among school-aged boys than school-aged girls, but does not appear to differ by gender at other points across the lifespan.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Conduct-Dissocial Disorder: The behaviour problems associated with Oppositional Defiant Disorder are largely characterized by interpersonal conflict with authority figures and difficulty getting along with others. In contrast, Conduct-Dissocial Disorder is characterized by a repetitive and persistent pattern of more severe and dissocial behaviour in which the basic rights of others or major age-appropriate social or cultural norms, rules, or laws are violated (e.g., aggression toward people or animals, destruction of property, deceitfulness or theft, serious violations of rules). However, individuals with Conduct-Dissocial Disorder often demonstrate a range or history of behaviour problems that may include the interpersonal difficulties characteristic of Oppositional Defiant Disorder. Both diagnoses may be given if the full diagnostic requirements are met for each.
• Boundary with Attention Deficit Hyperactivity Disorder: Individuals with Attention Deficit Hyperactivity Disorder often have difficulty following directions, complying with rules, and getting along with others. When these disruptive behaviours are better accounted for by inattention or hyperactivity-impulsivity (e.g., failure to follow long and complicated directions, difficulty remaining seated or staying on-task when asked), Oppositional Defiant Disorder should not be diagnosed. In Oppositional Defiant Disorder, the pattern of noncompliance is characterized by disobedience, beyond problems with attention and behavioural inhibition. However, Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder commonly co-occur and both diagnoses may be given if the full diagnostic requirements are met for both disorders.
• Boundary with Autism Spectrum Disorder: Noncompliant and other disruptive behaviours characteristic of Oppositional Defiant Disorder should be distinguished from behaviour problems that are common among individuals with Autism Spectrum Disorder. The key difference is that, in Autism Spectrum Disorder, disruptive behaviours are often associated with specific environmental factors (e.g., sudden change in routine, aversive sensory stimulation), or the noncompliance is a consequence of the core symptoms of that disorder (e.g., social communication deficits, restricted, repetitive, inflexible patterns of behaviour, sensory sensitivities) rather than reflecting an intention to be provocative or spiteful. Individuals with Oppositional Defiant Disorder do not typically exhibit the social communication deficits and restricted, repetitive, and inflexible patterns of behaviour, interests, or activities that are characteristic of Autism Spectrum Disorder.
• Boundary with Mood Disorders: It is common, particularly in children and adolescents, for patterns of noncompliance and symptoms of irritability/anger to occur as a feature of a Mood Episode. Specifically, noncompliance may result from a number of depressive symptoms (e.g., diminished interest or pleasure in activities, difficulty concentrating, hopelessness, psychomotor retardation, reduced energy). During Manic, Mixed or Hypomanic Episodes, individuals are less likely to follow rules and comply with directions. Moreover, in children and adolescents, depressive, manic, or hypomanic mood can manifest as irritability. When the behaviour problems occur entirely in the context of Mood Episodes, a separate diagnosis of Oppositional Defiant Disorder should not be assigned.
• Boundary with Anxiety or Fear-Related Disorders: In children and adolescents, symptoms of Anxiety or Fear-Related Disorders can sometimes manifest as noncompliance, defiance, and disobedience including irritability or anger. For example, children may exhibit angry outbursts and refuse to comply with requests when presented with a task or a situation that makes them feel anxious (e.g., when a child with Social Anxiety Disorder is asked to make a presentation in class). These behaviours are typically a manifestation of a desire on the part of the child or adolescent to avoid the feared situation or stimulus. Furthermore, children and adolescents with Anxiety or Fear-Related Disorders do not typically exhibit provocative, spiteful, or vindictive behaviour. If the defiant behaviour occurs only in response to situations or stimuli that elicit anxiety, fear, or panic, Oppositional Defiant Disorder should not be diagnosed.
• Boundary with Intermittent Explosive Disorder: Regularly occurring severe temper outbursts that are grossly out of proportion in intensity or duration to the provocation are the core symptom of Intermittent Explosive Disorder but may also occur in the context of Oppositional Defiant Disorder with chronic irritability-anger. Individuals with Oppositional Defiant Disorder with chronic irritability-anger typically display other features of Oppositional Defiant Disorder, including defiant, headstrong, or vindictive behaviours, which are not characteristic of Intermittent Explosive Disorder. In addition, individuals with Intermittent Explosive Disorder are more likely to exhibit significant physical aggression.