Mental Health

Oppositional Defiant Disorder

Many parents have been shocked at least once by a formerly cooperative teen resisting the house rules, talking back, or otherwise acting defiantly, but this type of behavior may just be part of normal growing up. More is required for a diagnosis of Oppositional Defiant Disorder.

Why Oppositional Defiant Disorder Is Difficult to Understand

There are two main guides to health issues and disorders that are used to guide the diagnosis of Oppositional Defiant Disorder (ODD). Whereas in many cases, these two resources present a similar view of disorders, in the case of Oppositional Defiant Disorder, the categorization is at odds, and this, in addition to a complicated definition, makes it difficult to understand what Oppositional Defiant Disorder is.

The DSM-IV-TR View of Oppositional Defiant Disorder

The Diagnostic and Statistics Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) includes Oppositional Defiant Disorder as a subcategory of Attention-deficit and disruptive behavior disorders, along with Attention-Deficit Hyperactivity Disorder, Conduct Disorder, and Disruptive Behavior Disorder NOS (Not Otherwise Specified).

Diagnosing ODD using the DSM-IV-TR criteria, which can only be done by mental health professionals who are qualified to do so,is only after determination that the criteria for Conduct Disorder are not met and, if the person is 18 or older, that criteria for Antisocial Personality Disorder are not met.

In that case, the individual must demonstrate a pattern of behavior that has lasted at least 6 months and shown at least four of the following signs or symptoms:

• frequently losing temper

• frequently argues with adults

• frequently defying or refusing to cooperate with the requests or rules of adults

• frequently annoying others on purpose

• frequently scapegoating others for his or her own mistakes or misbehavior

• frequently showing a high degree of sensitivity and touchiness with others

• frequently acting angry and resentful

• frequently acting spiteful or vindictive.

In addition, the behavior disturbance must:

• be more frequently that is normal for other individuals of similar age and development;

• cause “clinically significant impairment” in at least one area of life, whether academic, social, or occupational;

• not occur solely as the result of a psychotic disorder or mood disorder.

According to the Surgeon General’s website, Oppositional Defiant Disorder is sometimes considered a “precursor of conduct disorder.”

ICD-10 View of Oppositional Defiant Disorder

The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) takes a different approach to Oppositional Defiant Disorder than the DSM-IV-TR. It includes it under the category “Behavioral and emotional disorders with onset usually occurring in childhood and adolescence” within the subcategory “Conduct disorders.” The other members of the category are:

• Conduct disorder confined to the family context

• Unsocialized conduct disorder

• Socialized conduct disorder

• Other conduct disorders

• Conduct disorder unspecified.

As you can see, it is the only member of the category that does not have conduct disorder in its name. The subcategory “Conduct disorders” is separate from the following category, called “Mixed disorders of conduct and emotions,” which addresses the limitation in the DSM-IV-TR diagnostic criteria that rules out behavior that is only present in connection with a mood disorder or psychotic disorder.

The ICD-10 diagnosis, which specifically says that it usually occurs in “younger children,” begins with a child meeting the criteria for Conducts disorders generally. This requires that the pattern of behavior–whether dissocial, aggressive, or defiant—be both repetitive and persistent, as well as well outside age-appropriate expectations, and last six months or longer. If the behavior can be explained by a different psychiatric diagnosis, that explanation should be preferred.

Given that those criteria are met, one goes on to the specific Oppositional Defiant Disorder criteria, which limits the characterization of the behaviors to acts that are “defiant, disobedient, disruptive,” but not delinquent, extremely aggressive, or extremely dissocial, nor merely extremely mischievous or naughty.

The Upshot of Differing Understandings

A research study published in 2005 found that some children who were diagnosed with Oppositional Defiant Disorder using the criteria of ICD-10 as described above received no DSM-IV diagnosis, and this is a problem. The study suggested ways of addressing the situation.

If this comparison does nothing else, it will hopefully equip parents whose child is being considered for an ODD diagnosis, has been ruled out from having such a diagnosis, or has already received such a diagnosis to be able to discuss the criteria whereby the child’s behavior was analyzed and ask knowledgeable questions.


Mental Health

Conduct Disorders

Why Conduct Disorder Is Difficult to Understand

The two primary guides to diagnosing disorders, both of which are used in the diagnosis of Conduct Disorder are the Diagnostic and Statistics Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10).

In some cases, the two guides have a similar analysis of disorders and how they relate to each other. In the case of conduct disorder, however, the two views are different, complicating understanding.

The DSM-IV-TR View of Conduct Disorder

The DSM-IV-TR lists Conduct Disorder as a subcategory of “Attention-deficit and disruptive behavior disorders,” along with Oppositional Defiant Disorder, Attention-Deficit Hyperactivity Disorder, and Disruptive Behavior Disorder NOS (Not Otherwise Specified). There are three specific subcategories of Conduct Disorder, distinguished by the time of onset: in childhood, during adolescence, or unspecified.

Diagnosing Conduct Disorder using the DSM-IV-TR criteria, which should only be done by qualified mental health professionals. If the person is 18 or older, a diagnosis of Conduct Disorder cannot be given unless the criteria for Antisocial Personality Disorder are not met.

The descriptions make it clear that this is a more serious disorder than Oppositional Defiant Disorder. For a diagnosis, the person must demonstrate a pattern of behavior that has included three or more symptoms of those listed below for at least the past 12 months and shown at least one in the past 6 months:

• Aggression towards people and animals

  • frequently bullies, threatens, or intimidates
  • frequently initiates physical altercations
  • has employed a weapon capable of causing serious physical harm
  • has shown physical cruelty to people
  • has shown physical cruelty to animals
  • has confronted and stolen something from a victim
  • has forced sexual activity on someone

• Property destruction

  • has set at least one fire meaning to cause notable damage
  • has purposely destroyed property in some other way

• Deceit or theft

  • has forcibly entered someone else’s house or car without permission
  • frequently lies, conning others
  • has stolen items without a confrontation

• Serious rule violations

  • has frequently broken the house rules and stayed out at night, since before age 13
  • at least twice has stayed away from home overnight without permission or once for an extended period
  • has frequently been truant from school, since before age 13. 

In addition, these behavior disturbances must:

• result in “clinically significant impairment” in either academic, social, or occupational functioning;

If Childhood-Onset type is diagnosed, at least one characteristic must have manifested prior to age 10, whereas is Adolescent-Onset is diagnosed, there must be an absence of manifestation of any of the behaviors prior to age 10. The severity can be designated as mild, moderate, or severe.

ICD-10 View of Conduct Disorder

ICD-10 takes a different approach to Conduct Disorder than the DSM-IV-TR. It includes Conduct Disorder under the category “Behavioral and emotional disorders with onset usually occurring in childhood and adolescence” and designates six subcategories, which are:

• Conduct disorder confined to the family context

• Unsocialized conduct disorder

• Socialized conduct disorder

• Oppositional Defiant Disorder (ODD)

• Other conduct disorders

• Conduct disorder unspecified.

So ODD is a subset of Conduct disorder in the ICD-10 analysis, but not in the DMS-IV-TR analysis, and the category of Conduct Disorder is subdivided in a completely different way, based not on age of onset, but on other specifics of how it manifests.

Diagnosis of any of the ICD-10 subgroups requires that a child first meet the criteria for Conduct disorders generally. This means that the pattern of disruptive behavior–which may be dissocial, aggressive, or defiant—must both be repetitive and persistent, notably beyond outside age-appropriate expectations, and last for six months or longer. If a different psychiatric diagnosis explains the symptoms, that diagnosis should be used.

The further criteria that separate the subcategories are:

• Conduct disorder confined to the family context occurs only or almost only in the home and with members of the family or household.

• Unsocialized conduct disorder is marked by serious abnormalities in relationships between the child and other children.

• Socialized conduct disorder is diagnosed when a person gets along well with peers, and is generally characterized by delinquent activities as a group, or gang, as well as truancy.

• Oppositional Defiant Disorder is usually diagnosed in younger children and the behaviors demonstrated are better characterized as disobedient, defiant, and disruptive rather than delinquent, dissocial, or aggressive.

Understanding a Diagnosis of Conduct Disorder

If you or someone you know has a child who has received a diagnosis of conduct this order, you can use the information in this article to ask questions and find out more. Which type of conduct disorder has been diagnosed and according to which definition? Which criteria were met to support the diagnosis?


Troubled Teen Issues

Behavior Problems

Not everything that can happen will happen. This is a good thing to keep in mind when considering the range of issues that can afflict adolescents. It is also important to remember that because of chemical and hormonal imbalances, the difficulties of creating an identity, the sensitivities of adolescents, and the tensions between being cool to peers and respectful to parents, all teens are likely to—at least occasionally—behave in a way that their parents deem unacceptable.

But here, we’re not discussing a child who occasionally swears, breaks curfew, takes more ice cream than you said he or she could, or argues heatedly for more time with the family car. This article focuses on and provides an overview of the more concerning behavior problems that can afflict a teen.

What Is a Behavior Problem?

Although some people may casually lump all issues when teens act in a problematic way as “behavior problems,” it is actually useful to distinguish behavior problems from other types of issues. For example, a mental health issue may lead to problematic behaviors, but a mood disorder, like bipolar disorder, is not a “behavior problem” per se.

In addition, what appears to be a behavior problem may be caused by a different type of underlying issue—for example, substance abuse that arises out of an attempt to deal with a major depression. If this is the case, treating the behavior in isolation from its root cause will not be successful: the substance abuse and depression need to be addressed in tandem.

The role of an apparent behavior problem in signaling other issues may be more evident in a teen than in an adult. For example, an adult who can’t afford to lose his or her job may have the maturity, experience, and self-preservation instincts to hide his or her feelings about some practice or situation that seems entirely unfair in the workplace. A teen faced with the same situation or practice at school or at work and not having the same level of maturity may manifest his or her contempt or righteous indignation by his or her behavior, whether words or actions or facial expressions.

In addition, some types of problem seem to defy clear categorization. When one person does physical harm to another person or property, is it even without some other type of mental health issue? It’s difficult to say. Even the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) groups “Mental and behavioral disorders” as a group. For these reasons, the list below does not attempt to be complete or to sort out all the issues of what is a behavior problem and what would be better classified in another way.

Some Behavior Problems that May Afflict Adolescents and Require Expert Help

• Teenagers are curious, and they may try substances that are illegal period or illegal for them to use at their age. If there is no other underlying cause, then substance abuse is a behavior problem.

• There are several behavior problems that the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) classifies under the heading Attention-deficit and disruptive behavior disorders. These include the following:

  • Attention-Deficit Hyperactivity Disorder (AD/HD), which has four subtypes
  • Conduct Disorder, which has three subtypes
  • Oppositional Defiant Disorder
  • Disruptive Behavior Disorder Not Otherwise Specified (NOS)

• The DSM-IV-TR also includes Antisocial behavior with two subtypes

• The ICD-10 classifies a group of “Behavioral syndromes,” that lists eating disorders—including anorexia nervosa, bulimia nervosa, overeating, and vomiting—are often linked to adolescence.

• The ICD-10 also lists “Behavioral and emotional disorders with onset usually occurring in childhood and adolescence.” The ones most closely tied to behavior include:

  • Hyperkinetic disorders, of which Attention-deficit hyperactivity disorder is a subgroup
  • Conduct disorders, which in the ICD-10 includes Oppositional defiant disorder