Chapter 36. Oppositional Defiant Disorder and Conduct Disorder

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. A pattern of negative, 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

   3. often actively defies or refuses to comply with adults’ requests or rules

   4. often deliberately annoys people

   5. often blames others for his or her mistakes or misbehavior

   6. is often touchy or easily annoyed by others

   7. is often angry or resentful

   8. 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.

2. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

3. The behaviors do not occur exclusively during the course of psychotic or mood disorder.

4. Criteria are not met for conduct disorder, and, if the individual is 18 years or older, criteria are not met for antisocial personality disorder.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 American Psychiatric Association.)

General Considerations

As with conduct disorder and attention-deficit/hyperactivity disorder (ADHD) (described in previous chapter), with which it is often entangled, it is uncertain whether oppositional defiant disorder is a truly distinctive nosological category. Specifically, it is unclear whether oppositional behavior is better considered to be on a continuum between normal developmental limit-testing on the one hand and pathologically disruptive behavior on the other. The distinction between categorical disorders and dimensional psychopathology is more than a theoretical quibble. Valid categories delimit disorders that are likely to have a significantly biological (e.g., neurochemical) basis. Dimensional sets of behavior masquerading as categories may, in fact, obscure true categories that nest within their fictitious boundaries.

Oppositional defiant disorder, as defined in DSM-IV-TR, is manifest as age-inappropriate, persistent, intemperate, argumentative, defiant, deliberately annoying, irritable, resentful, vindictive behavior associated with the tendency of the subject to blame others for his or her own transgressions or omissions. The aggression of the oppositional child or adolescent is predominantly verbal rather than physical. The aggression tends to be reactive (e.g., in response to an unwelcome imposition of rules) rather than proactive (e.g., bullying), and overt (e.g., shouting) rather than covert (e.g., spreading malicious rumors).

Epidemiology

The prevalence of oppositional defiant disorder is uncertain, but it has been estimated at 5.7–9.9%. The average age at onset is 6 years. Oppositional defiant disorder is regarded by many researchers as a milder, precocious form of conduct disorder. The male-to-female sex ratio in childhood conduct disorder is 4:1. There is a clinical impression that childhood oppositional defiant disorder is more common among preadolescent males than females, however, the relative prevalence in females appears to rise in adolescence.

Etiology

The genesis of oppositional defiant disorder has not been studied separately from ...