Oppositional Deﬁant Disorder
S. SUTTON HAMILTON, MD, and JOHN ARMANDO, LCSW, Underwood-Memorial Hospital, Woodbury, New Jersey
ppositional deﬁant disorder
is among the most commonly
diagnosed mental health condi-
tions in childhood. It is deﬁned
by a recurrent pattern of developmentally
inappropriate levels of negativistic, deﬁant,
disobedient, and hostile behavior toward
authority ﬁgures.1 This behavior must be
present for more than six months and must
not be caused by psychosis or a mood disor-
der, and the behavior must negatively impact
the child’s social, academic, or occupational
functioning (Table 1).1
Several large community-based studies
have found that approximately 3 percent of
children meet criteria for oppositional deﬁ-
ant disorder as described by the Diagnostic
and Statistical Manual of Mental Disorders,
4th ed. (DSM-IV).2-4 However, studies show
considerable variance associated with differ-
ences in the criteria used, age at assessment,
and number of informants used, resulting in
prevalence estimates of 1 to 16 percent.5
Children with oppositional deﬁant disor-
der have substantially impaired relationships
with parents, teachers, and peers. These
children are not only impaired in compari-
son with their peers, scoring more than two
standard deviations below the mean on rat-
ing scales for social adjustment, but they
also show greater social impairment than
do children with bipolar disorder, major
depression, and multiple anxiety disorders.6
When compared with oppositional deﬁant
disorder, only conduct disorder and perva-
sive developmental disorder had nonstatisti-
cal differences in social adjustment.6
Oppositional deﬁant disorder is more
common in boys than girls, but the data are
inconsistent.7 Some researchers propose that
different criteria be used with girls, who tend
to exhibit aggression more covertly.5 Girls
may use verbal, rather than physical, aggres-
sion, often excluding others or spreading
rumors about another child. Oppositional
deﬁant disorder is more common among
children in low-income households and is
typically diagnosed in late preschool to early
elementary school with symptoms often
appearing two or three years earlier. Cross-
sectional epidemiologic studies show a grad-
ually increasing prevalence of oppositional
deﬁant disorder as children age.4
Researchers agree there is no single cause
or even greatest single risk factor for oppo-
sitional deﬁant disorder. Rather, it is best
understood in the context of a biopsycho-
social model in which a child’s biologic vul-
nerabilities and protective factors interact
complexly with the protective and harmful
Oppositional deﬁant disorder is deﬁned by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., as a
recurrent pattern of developmentally inappropriate, negativistic, deﬁant, and disobedient behavior toward authority
ﬁgures. This behavior often appears in the preschool years, but initially it can be difﬁcult to distinguish from devel-
opmentally appropriate, albeit troublesome, behavior. Children who develop a stable pattern of oppositional behavior
during their preschool years are likely to go on to have oppositional deﬁant disorder during their elementary school
years. Children with oppositional deﬁant disorder have substantially strained relationships with their parents, teach-
ers, and peers, and have high rates of coexisting conditions such as attention-deﬁcit/hyperactivity disorder and mood
disorders. Children with oppositional deﬁant disorder are at greater risk of developing conduct disorder and antiso-
cial personality disorder during adulthood. Psychological intervention with both parents and child can substantially
improve short- and long-term outcomes. Research supports the effectiveness of parent training and collaborative
problem solving. Collaborative problem solving is a psychological intervention that aims to develop a child’s skills in
tolerating frustration, being ﬂexible, and avoiding emotional overreaction. When oppositional deﬁant disorder coex-
ists with attention-deﬁcit/hyperactivity disorder, stimulant therapy can reduce the symptoms of both disorders. (Am
Fam Physician. 2008;78(7):861-866, 867-868. Copyright © 2008 American Academy of Family Physicians.)
Patient i nforma tion :
A handout on oppositional
deﬁant disorder, written
by the authors of this
article, is provided on
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862 American Family Physician www.aafp.org/af p Volume 78, Number 7
October 1, 2008
aspects of his or her environment to determine the likeli-
hood of developing this disorder.5
Recent theories conceptualize children with opposi-
tional deﬁant disorder as possessing deﬁcits in a discrete
skill set that lead to oppositional behavior.6 An appar-
ently noncompliant child who “explodes” in response
to a parental demand may lack the cognitive or emo-
tional skills required to comply with the adult’s request.
For example, a child may not have developed the skill of
affective modulation, and tends to emotionally overreact,
losing his or her capacity to reason. A child may possess
deﬁcits in his or her executive cognitive skills (e.g., work-
ing memory, ability to change tasks, organized problem
solving). These deﬁcits undermine the child’s ability to
comply with adult demands. Such skill deﬁcits are com-
ponents of the transactional conceptualization of opposi-
tional deﬁant disorder, which emphasizes the
interaction of the children and parents, and
the context of the behavior. An important
feature of this model is the relative predict-
ability of the context (e.g., bath time, dinner-
time) and the parent and child behaviors that
precipitate a child’s meltdown.
Neurobiologic theories have been explored
in the etiology of aggression. Neurotransmit-
ters such as serotonin, norepinephrine, and
dopamine have been investigated in their
role with aggression. No single neurotrans-
mitter or neurologic pathway has been iden-
tiﬁed as the root cause. Oppositional deﬁant
disorder is clearly familial, but research has
yet to determine what role genetics play
because studies on the genetics of the dis-
order have produced inconsistent results.5
Smoking during pregnancy and malnutri-
tion during pregnancy have been associated
with the development of oppositional deﬁ-
ant disorder, although causality has not been
The natural history of oppositional deﬁant
disorder is not completely understood. The
SORT: KEY RECOMMENDATIONS FOR PRACTICE
rating References Comments
Children with ADHD should be evaluated for
oppositional deﬁant disorder.
C 10 Many studies show oppositional deﬁant disorder
commonly co-occurring in children with ADHD
Outpatient therapy directed at children,
parents, or both improves outcomes in
children with oppositional deﬁant disorder.
B 13, 16, 19 Studies ﬁnd outpatient therapy effective in treating
oppositional deﬁant disorder
Media-based parent training is effective for
improving outcomes of behavioral problems
in children with oppositional deﬁant disorder.
B 17, 19 Cochrane review
Psychostimulants reduce the behaviors of
oppositional deﬁant disorder in children
with coexisting ADHD.
A 20-22 Data from the Multimodal Treatment Study of
Children with ADHD and other randomized
ADHD = atte ntion-deﬁcit/hyperactivity disorder.
A = consistent, good-qualit y patient-oriented evidence ; B = inconsistent or limited-qualit y patient-oriented evidence ; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
Table 1. DSM-IV Diagnostic Criteria for Oppositional
A pattern of negativistic, hostile, and deﬁant behavior lasting at least six
months, during which four (or more) of the following are present:
Often loses temper
Often argues with adults
Often actively deﬁes or refuses to comply with adults’ requests or rules
Often deliberately annoys people
Often blames others for his or her mistakes or misbehavior
Is often touchy or easily annoyed by others
Is often angry and resentful
Is often spiteful or vindictive
The disturbance in behavior causes clinically signiﬁcant impairment in
social, academic, or occupational func tioning
The behaviors do not occur exclusively during the course of a psychotic
or mood disorder
Criteria are not met for conduct disorder, and, if the individual is 18 years
or older, criteria are not met for antisocial personality disorder
NOTE: Consider a criterion met only if the behavior occurs more frequently than is typi-
cally obser ved in individuals of comparable age and developmental level.
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th e d., rev.
Reprinted with permission from Diagnostic and Statistical Manual of Mental Disor-
ders. 4th ed. rev. Washington, DC: American Psychiatric Association; 1994:9 4.
October 1, 2008
Volume 78, Number 7 www.aafp.org/afp American Family Physician 863
majority of persons who are diagnosed with the disor-
der in childhood will later develop a stable pattern of
oppositional deﬁant disorder behavior, an affective dis-
order, or oppositional deﬁant disorder with coexisting
attention-deﬁcit/hyperactivity disorder (ADHD) or
affective disorders. Some children persist with opposi-
tional deﬁant disorder without coexisting conditions.
Children who were diagnosed with oppositional deﬁant
disorder at a young age (e.g., preschool, early elementary
school) may later transition to a diagnosis of ADHD,
anxiety, or depression.9 In general, earlier and more
severe oppositional deﬁant disorder is associated with a
poorer long-term prognosis.9
Coexisting conditions are common in children with
oppositional deﬁant disorder, particularly ADHD and
mood disorders. The extent and nature of their coex-
istence is not precisely deﬁned. The most comprehen-
sive study of children with ADHD is the Multimodal
Treatment Study of Children with ADHD. In this study,
researchers found that 40 percent of children with ADHD
also meet diagnostic criteria for oppositional deﬁant
disorder.10 Children who have both disorders tend to be
more aggressive, have more persistent behavioral prob-
lems, experience more rejection from peers, and more
severely underachieve academically.5
In one community study of children with oppositional
deﬁant disorder, 14 percent had coexisting ADHD,
14 percent had anxiety, and 9 percent had a depressive
disorder.7 The authors of another study found that chil-
dren with oppositional deﬁant disorder were twice as
likely to have severe major depression or bipolar disor-
der compared with a reference group.6,11 Speciﬁc data are
lacking, but expert consensus is that learning disabili-
ties and language disorders also commonly coexist with
oppositional deﬁant disorder.5
Oppositional deﬁant disorder has commonly been
regarded as a subset and precursor of the more serious
conduct disorder, in part because most children with
conduct disorder have a history of oppositional deﬁ-
ant disorder. Approximately one third of children with
oppositional deﬁant disorder subsequently develop con-
duct disorder, 40 percent of whom will develop antiso-
cial personality disorder in adulthood.12 Children with
coexisting oppositional deﬁant disorder and ADHD are
particularly likely to develop conduct disorder.
Among other features, aggression toward other
people and animals, a disregard for the rights of oth-
ers, and the theft or destruction of others’ property
characterize conduct disorder.1 The DSM-IV precludes
diagnosing a child with both oppositional deﬁant dis-
order and conduct disorder. When a diagnosis of con-
duct disorder is made, the diagnosis of oppositional
deﬁant disorder must be dropped if strict adherence to
the DSM-IV is sought. Some researchers conceptualize
conduct disorder and oppositional deﬁant disorder less
as separate disorders, but rather as differing primarily in
the severity of their disruptive behavior. Other research-
ers consider the two as entirely separate disorders. There
is little disagreement that conduct disorder is more seri-
ous and is a poor outcome for children previously diag-
nosed with oppositional deﬁant disorder.
Lisa is a ﬁve-year-old girl whose parents asked their
family physician to see her because of their increas-
ing concern about her temper tantrums in the home.
The parents indicated that Lisa often becomes enraged
and argumentative with them, refusing to follow rules
or take direction. In particular, they report difﬁculty
getting her to transition from playing with her toys to
coming to the dinner table. After Lisa ignored her par-
ents’ repeated prompts, her father became frustrated
and told her that she had lost her dessert privilege. Lisa
became aggressive and destructive, breaking her toys
and smashing food and water from the dinner table
into the carpet. Her parents described similar scenarios
at bedtime, bath time, and when getting dressed in the
morning. They described her as irritable in these situa-
tions and they felt she was deliberately ignoring or try-
ing to annoy them.
Tools such as the National Initiative for Children’s
Healthcare Quality (NICHQ) Vanderbilt Assessment
Scale,13 designed for the primary care evaluation of chil-
dren with suspected or diagnosed ADHD, contain ques-
tions that aid in the identiﬁcation of oppositional deﬁant
disorder. Use of this or similar instruments, such as the
SNAP-IV Teacher and Parent Rating Scale for children
with ADHD,14 may allow enhanced detection of oppo-
sitional deﬁant disorder as well as other psychological
concerns. Screening tools such as the Pediatric Symptom
Checklist are not speciﬁc for oppositional deﬁant disor-
der, but can screen for cognitive, emotional, or behav-
ioral problems, thereby identifying children who require
additional investigation.15 Table 2 provides more infor-
mation on how to access these tools online.13-15
Table 3 provides a differential diagnosis for oppo-
sitional deﬁant disorder.1 A higher index of suspicion
should be maintained in children with known risk
Oppositional Deﬁant Disorder
864 American Family Physician www.aafp.org/af p Volume 78, Number 7
October 1, 2008
factors such as ADHD because approximately 40 percent
of children with ADHD have coexisting oppositional
deﬁant disorder.10 It is useful to recognize the role of
established environmental risk factors such as living in a
single-parent household and having low socioeconomic
status. Chronically obese children are also at increased
risk for oppositional deﬁant disorder.4 Relevant family
history includes that of oppositional deﬁant disorder,
conduct disorder, or antisocial personality disorder.1
Oppositional deﬁant disorder is most commonly diag-
nosed during the elementary school years, although most
children with the disorder have a history of signiﬁcant
oppositional behavior in preschool.
The initial step in diagnosis is to determine whether or
not the behavior is, in fact, abnormal. A certain amount
of oppositional behavior is normal in childhood. Oppo-
sitional deﬁant disorder is only distinguishable by the
duration and degree of the behavior. Physicians should
carefully explore the possibility that the child’s oppo-
sitional behavior is caused by physical or sexual abuse,
or neglect. Given the wide range of normal oppositional
behavior during the preschool years, caution should be
exercised in diagnosing this disorder in the preschool-age
child.5 Assessment of the child with a potential diagnosis
of oppositional deﬁant disorder depends on establish-
ing a therapeutic alliance with both the child and fam-
ily. The assessment should include information gathered
from multiple sources (e.g., preschool, teachers) as well
as history obtained from the child directly.
To satisfy DSM-IV criteria for oppositional deﬁant
disorder, a child must frequently demonstrate behavior
from at least four of nine criteria (Table 1).1 The behav-
ior must be considerably more frequent than is typically
observed in persons of comparable age and developmen-
tal level and must cause clinically signiﬁcant impairment
in social, academic, or occupational functioning.1
When the diagnosis is unclear, patients should be
referred to a psychologist or psychiatrist trained in the
assessment of children with behavioral disorders. For
children in elementary school, a physician’s written
request should facilitate a school-based evaluation by an
appropriate professional. Evaluation of preschool chil-
dren can most often be prompted by a telephone call to
a county’s Child Find or similar program. When avail-
able, a developmental-behavioral pediatrician can be
an ideal beginning point of an assessment. Structured
psychological interviews (such as the National Institute
of Mental Health’s Diagnostic Interview Schedule for
Children [DISC] version 2.3), typically administered by
a psychologist, can be used for formal diagnosis. When
these services are unavailable, physicians may wish to use
a brief series of questions that researchers have shown to
possess 90 percent sensitivity and 94 percent speciﬁcity
for identifying oppositional deﬁant disorder (Table 4).7
Neuroimaging (e.g., functional magnetic resonance
imaging, single-photon emission computed tomogra-
phy, electroencephalography) has a role in the research
of aggressive behavior, but it has no clinical role in the
evaluation of children with suspected oppositional deﬁ-
Research supports outpatient psychological interven-
tions for children with oppositional deﬁant disorder.
Studies have demonstrated that parent training is an
effective means of reducing disruptive behavior.16 Par-
ents often come to see their child’s behavior as deliber-
ate and under the child’s control, intentionally hurtful
toward the parent, or as an attribute of a disliked family
Table 3. Differential Diagnosis
of Oppositional Deﬁant Disorder
Conduct disorder (by DSM-IV criteria; cannot be diagnosed
Impaired language comprehension (e.g., hearing loss, mixed
receptive- expressive language disorder)
Mood disorders (including bipolar disorder)
Normal individualization (i.e., in adolescence)
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders,
4th ed., rev.
Information from reference 1.
Table 2. Tools to Identify ADHD, Oppositional
Deﬁant Disorder, and Other Behavioral
NICHQ Vanderbilt Assessment Scale13
Web site: http://www.nichq.org/NICHQ/ Topics /
ChronicConditions/ADHD /Tools /
Web site: http://www.adhdcanada.com/ pdfs/SNAP-
Pediatric Symptom Checklist15
Web site: http://www.massgeneral.org/allpsych /
ADHD = attention- deﬁcit/hyperac tivity disorder; NICHQ = National
Initiative for Children’s Healthcare Quality; SN AP-IV = Swanson,
Nolan, and Pelham Teacher and Pare nt Rating Scale, 4th ed.
Information from references 13 through 15.
October 1, 2008
Volume 78, Number 7 www.aafp.org/afp American Family Physician 865
member (e.g., an abusive partner).17 The difﬁcult behav-
ior and social disruption caused by children with oppo-
sitional deﬁant disorder can have adverse effects on the
mental health of their parents.18 Parent training teaches
parents to be more positive and less harsh in their dis-
cipline style. Media-based parent training (e.g., watch-
ing a video) has been shown to be effective with results
continuing one year after the intervention.19 In a ran-
domized study, investigators found that applying parent
training to both the child and parent is superior to train-
ing aimed solely at the parent, supporting the generally
agreed-upon principle that therapies are more effective
when both parent and child are involved.20
Multisystemic therapy is a term for a community-based
intervention that explicitly attempts to intervene in mul-
tiple real-life settings (e.g., home, school). Studies support
the evidence behind multisystemic therapy, but there are
limitations in the ability to generalize ﬁndings.13
Collaborative problem-solving interventions seek to
facilitate joint problem solving, rather than to teach and
motivate children to comply with parental demands.
This model encourages parents and children to identify
issues and to use cognitive approaches to resolve the con-
ﬂict to the mutual satisfaction of both parties. Collab-
orative problem solving appears to be at least as effective
as parent training.21
Several studies have found that medicines used in the
treatment of ADHD, such as methylphenidate (Ritalin),
atomoxetine (Strattera), and amphetamine/dextroam-
phetamine (Adderall), are effective in the treatment
of ADHD with coexisting oppositional deﬁant disor-
der.22-24 According to these studies, stimulants reduced
the symptoms of both ADHD and oppositional deﬁant
disorder symptoms. There are also two small studies
that show the effectiveness of clonidine (Catapres) in
treating children with ADHD and oppositional deﬁant
disorder, either as monotherapy or as augmentation to
medical therapy.25,2 6 Studies have not demonstrated that
stimulants reduce the symptoms of oppositional deﬁant
disorder when ADHD is absent.
There is evidence that programs for preschool children
(e.g., Head Start) reduce delinquency and, by infer-
ence, oppositional deﬁant disorder.13 In elementary
school-age children, the greatest evidence on prevention
supports parent management strategies. Researched
programs include the Triple P-Positive Parenting Pro-
gram and Incredible Years parenting series. Both of
these use self-directed, multimedia, parenting and
family support strategies to prevent severe behavioral
problems in children by enhancing the knowledge,
skills, and conﬁdence of parents. These programs are
most appropriate for parents whose children appear to
be at risk of developing emotional and/or behavioral
problems. School-based programs that focus on anti-
bullying, antisocial behavior, or peer groups can also be
effective prevention approaches.27
Family physicians should suspect oppositional deﬁant
disorder when parents report an excessively argumenta-
tive, deﬁant, and hostile school-age child. Oppositional
deﬁant disorder is common in children with ADHD,
and use of the validated instruments mentioned in this
article for the assessment and diagnosis of ADHD can
help physicians to identify oppositional deﬁant disorder.
Suspicion for oppositional deﬁant disorder should be
raised when known risk factors (e.g., family history of
oppositional deﬁant disorder/conduct disorder, ADHD,
low socioeconomic status) are present. Formal diagno-
sis may require referral to a children’s psychologist or
Children with oppositional deﬁant disorder are best
served by referral to a professional who is skilled and
knowledgeable in evidence-based therapies for these
children, although ﬁnding such professionals can be
challenging. A physician’s ability to locate particular
resources for a child will depend on the family’s insur-
ance, ﬁnancial resources, and motivation, as well as the
availability of such resources in their community. There
is no single best way to connect a child to the best ser-
vices for him or her, and it is often prudent to explore
multiple avenues to ﬁnd the optimal available services.
A physician’s knowledge of oppositional deﬁant disorder,
Table 4. Evidence-Based Questions for
Assessing Likelihood of Meeting DSM-IV
Criteria for Oppositional Deﬁant Disorder
Has your child in the past three months been spiteful
or vindictive, or blamed others for his or her own
mistakes?(Any “yes” is a positive response.)
How often is your child touchy or easily annoyed, and how
often has your child lost his or her temper, argued with
adults, or deﬁed or refused adults’ requests?
(Two or more times weekly is a positive response.)
How often has your child been angry and resentful
or deliberately annoying to others?
(Four or more times weekly is a positive response.)
NOTE: A positive response for all three is 91 percent speciﬁc for meet-
ing DSM-IV criteria on full interview. Any negative response is 94 per-
cent sensitive for ruling out oppositional deﬁant disorder.
DSM-IV = Diagnostic and Statistical Manual of Mental Disorder s, 4th
Information from reference 7.
Oppositional Deﬁant Disorder
866 American Family Physician www.aafp.org/af p Volume 78, Number 7
October 1, 2008
its typical symptoms, and best available treatments can
allow the physician to serve as a patient advocate, to con-
nect families with services, and to provide families with
educational materials and online resources.
S. SUTTON HAMILTON, MD, is associate director of the Underwood-
Memorial Hospital Family Medicine Residency Program in Woodbury, N.J.
He received his medical degree from the University of Pittsburgh (Pa.)
School of Medicine, and completed a family medicine residency at Franklin
Square Hospital Center in Baltimore, Md., and a facult y development fel-
lowship at the University of Cincinnati ( Ohio).
JOHN ARMANDO, LCSW, is a behavioral scientist at the Underwood-
Memorial Hospital Family Medicine Residency Program. He earned his
master of social service degree at the Bryn Mawr (Pa.) College Graduate
School of Social Work and Social Research.
Address correspondence to S. Sutton Hamilton, MD, Underwood-
Memorial Hospital, Family Medicine Residency Program, 75 West Red
Bank Ave., Woodbury, NJ 08096 (e-mail: HamiltonS@umhospital.org).
Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
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