Special Articles

Oppositional Defiant Disorder

Joseph M. Rey, Ph.D., F.R.A.N.Z.C.P.

Objective: Oppositional defiant disorder is a common clinical diagnosis that has attracted
little research interest, and doubts about its validity as a distinct category remain. However,
it underwent substantial changes from DSM-III to DSM-III-R, and more are proposed for
DSM-IV. The objective ofthis study was to review the literature on this condition to establish
its place in the psychiatric nosology. Method: The terms used in computerized searches of the
literature included “oppositional disorder, “ “oppositional defiant disorder, “ and “opposi-
tional behavior. “ Publications found by these searches were supplemented with references in
articles, searches in the epidemiological literature, and noncomputerized searches. Results:
Findings of studies in which multivariate analyses were used support a distinction between
oppositional defiant disorder and conduct disorder. In these studies, one-third ofall commu-
nity-based children with any psychiatric condition had a diagnosis of oppositional defiant
disorder and used mental health services often. Symptoms of oppositional defiant disorder
appear to be stable over time and to have a developmentalprofile and sex distribution different
f rom those of conduct disorder. The reliability of the diagnosis is low. Conclusions: There is
some support for oppositional defiant disorder as a category that reflects an oppositional-ag-
gressive psychological dimension, which is different from a delinquent dimension. There is
little evidence for making oppositional defiant disorder a part of the construct of conduct
disorder and for making “lying” a criterion for it. Considerable impairment should be required
for the diagnosis. A more detailed description ofsymptoms, including a threshold for consid-
ering them present, may increase reliability of the diagnosis.
(Am J Psychiatry 1993; 150:1769-1778)

T he place
classification
of oppositional
system
defiant disorder
has been controversial
in the
from
criteria
milder
for oppositional
form of conduct
defiant
disorder.
disorder
However,
implied
opposi-
a

the very moment of its introduction by DSM-III. Some tional defiant disorder is one of the diagnoses more
authors (1 ) questioned whether oppositional defiant commonly made in clinical settings (2, 4, 5) and corn-
disorder was sufficiently distinct from normal opposi- munity samples (6-10). This popularity with clinicians
tional behavior to warrant its inclusion as a distinct di- has not resulted in much research interest, and recent
agnostic category, while others (2, 3) argued that the comprehensive child psychiatry textbooks (11, 12)
have largely ignored the disorder. Further, the concept
of oppositional defiant disorder has undergone consid-
Received Feb. 4, 1992; revision received Feb. 5, 1 993; accepted
enable changes during its short existence, and more are
March 9, 1 993. From Rivendell Child Adolescent and Family Psychi-
atric Services, Royal Prince Alfred Hospital, Sydney, and the Depart- being proposed for DSM-IV (13). The objective of this
ment of Psychiatry, University of Sydney, Australia. Reprints of this article is to follow the trajectory of these changes and
article are not available. Address correspondence to Dr. Rey, Riven- review the empirical evidence currently available, with
dell, Thomas Walker Hospital, Hospital Road, Concord West, the expectation that this may help to establish the place
N.S.W. 2138, Australia.
The author thanks J. M. Plapp for comments on successive drafts
of oppositional defiant disorder in the psychiatric
of the manuscript. nosology and clarify issues in relation to lCD-b (14,
Copyright © I 993 American Psychiatric Association. 15) and DSM-IV.

Am J Psychiatry 1 50:1 2, December 1993 1769

OPPOSITIONAL DEFIANT DISORDER

A computerized search of the psychiatric and psycho- dictive, and 5) swears, and by the removal of stubborn-
logical literatune identified few articles specifically deal- ness; the remaining four criteria were reworded (e.g.,
ing with oppositional defiant disorder. The search temper tantrums became “often loses temper”). Finally,
terms consisted of “oppositional disorder, “ opposi-
“ the number of criteria required for the diagnosis was
tional defiant disorder,” and “oppositional behavior.” increased to five. These modifications were designed to
Articles found in this way were supplemented with ref- counter the criticism that oppositional defiant disorder
erences found in the texts of those articles, chapters in could not be distinguished from the behavior of many
books, reports on the epidemiology of psychiatric dis- normal children, and the changes were well received
orders, and noncomputerized review of all papers pub- (18). In both DSM-III and DSM-III-R, a diagnosis of
lished in the major child psychiatry jounnals since 1980. oppositional defiant disorder can be made only in the
For simplicity’s sake, the term “oppositional defiant absence of conduct disorder.
disonden” is used here to signify both oppositional dis- Two options have been proposed for DSM-IV (13).
order (DSM-III) and oppositional defiant disorder The first alternative entails maintaining the distinction
(DSM-III-R, lCD-b) unless specified otherwise; simi- between oppositional defiant disorder and conduct dis-
lanly, “attention deficit hyperactivity disorder” and order, while the second conceptualizes both disorders
“conduct disorder” are used to signify attention deficit as part of a dimension with three levels of severity. Op-
and conduct disorder according to DSM-III and DSM- positional defiant disorder would correspond to level 1
III-R. “Children” is used to mean both children and (less severe), while conduct disorder would correspond
adolescents when appropriate. to the other two levels. Diagnostic criteria would be the
same in both cases, but the addition of three more cni-
tenia (lying, bullying, and initiating physical fights at
EVOLW1ON OF OPPOSITIONAL DEFIANT DISORDER home) is suggested.
lCD-b (14) also includes a category of oppositional
A degree of oppositional and negativistic behavior is defiant disorder, defined by the presence of markedly
common among children. Learning to resist and even defiant, disobedient, provocative behavior in the ab-
oppose the will of others is part of normal development, sence of severe dissocial on aggressive acts that violate
particularly duning the phases of separation-individu- the law or the nights of others. lCD-b conceptualizes
ation in the second and third years of life and during oppositional defiant disorder as part of the dimension
adolescence, when such behavior may be explained as of conduct disorder. For the diagnosis of oppositional
a manifestation of the need to separate from parents defiant disorder, lCD-b requires that the child meet
and establish an independent identity. Levy (16), who two of three criteria (frequent and marked lying, exces-
drew attention to this type of conduct, saw negativ- sive fighting, and defiance of adult requests and com-
ism-the refusal to conform to the ordinary require- mands) and not meet any of the other 12 criteria for
ments of authority, or willful contrariness-as the core conduct disorder (15). lCD-b specifies that opposi-
of his concept of oppositional behavior. The Group for tional defiant disorder is typically seen in children
the Advancement of Psychiatry ( 1 7) elaborated on these younger than 1 0 years and that use of this diagnosis for
ideas and replaced the term “passive-aggressive person- olden children should be made with caution.
ality disorder” with that of “oppositional personality This brief historical review shows that oppositional de-
disorder” to describe children who express aggressive- fiant disorder has undergone a conceptual transforma-
ness through oppositional behavior. tion, from a disorder characterized mainly by opposition
DSM-III introduced oppositional disorder in the cate- to the requests or expectations of authority figures to a
gory Disorders Usually First Evident in Infancy, Child- pattern of angry, aggressive, negativistic comportment.
hood or Adolescence to describe children who show a
persistently disobedient, negativistic, and provocative
opposition to authority figures, manifested by at least NORMAL BEHAVIOR AND SYMPTOMS OF
two of the following symptoms: I ) violations of minor OPPOSITIONAL AND CONDUCT DISORDER
rules, 2) temper tantrums, 3) argumentativeness, 4)
provocative behavior, and 5) stubbonnness. This diag- Developmental Patterns
nosis was placed under the heading Other Disorders of
Infancy, Childhood and Adolescence, together with di- There is a substantial body of research showing that
agnoses such as schizoid disorder, elective mutism, and symptoms of oppositional defiant disorder typically ap-
identity disorder. ICD-9 did not contain a comparable pear during the preschool years, when they are consid-
diagnosis. Seven years later, DSM-III-R changed the ened normal. Temper tantrums reach their peak when
name to oppositional defiant disorder and placed it, to- children are 2-3 years of age ( 1 9, 20). During the pre-
gether with conduct disorder and attention deficit hy- school years negativistic and oppositional behavior is
penactivity disorder, under the heading Disruptive Be- common, resulting in angry outbursts and ensuing con-
havion Disorders. The number of diagnostic criteria flicts with parental authority about matters that vary
was increased to nine by the addition of 1 ) blames oth- with age, such as toilet training or possessions at age 2
ens for his or her own mistakes, 2) is touchy or easily and tidiness at age 5. Destructiveness, bullying, and
annoyed, 3) is angry and resentful, 4) is spiteful or yin- fighting decrease after the preschool years (21 ). Early

1770 Am J Psychiatry 1 50:1 2, December 1993

 JOSEPH M. REY

adolescence is often associated with an increase in re- cause referral to a professional is likely to be prompted
bellious behavior (22). Teachers’ reports indicate that by parents’ or teachers’ perception that a child is im-
most oppositional symptoms, such as arguing, scream- pained, but it is important in epidemiological studies.
ing, disobedience, and defiance, peak between the ages For example, Bind et al. (30) showed that almost 20%
of 8 and 1 1 years and then decline in frequency (23). of children from a community sample met the DSM-III
According to parents, swearing and argumentativeness criteria for oppositional defiant disorder when impair-
become more prevalent during adolescence, particu- ment was not considered; the number of cases dropped
lanly among girls (24). By contrast, most symptoms of to 10% when impairment was included.
conduct disorder (truancy, stealing, drug and alcohol A follow-up study of a community sample showed
use, etc.), with the exception of lying, do not occur dun- that parents of children with oppositional defiant dis-
ing the preschool years but become increasingly fre- order were more likely to use child mental health serv-
quent during late childhood and adolescence (21-25). ices than parents of children diagnosed as having con-
Boys are significantly more aggressive than girls, but duct disorder, major depression, attention deficit
sex differences change with age: they are large in 4- to hyperactivity disorder, or ovenanxious disorder (31).
S-year-olds, moderate in 9- to 12-year-olds, and small Children with oppositional defiant disorder were also
in college students (26). Thus, developmental patterns found to use emergency services repeatedly (32).
of behavior in oppositional defiant disorder and con- It appears, therefore, that distinguishing children
duct disorder appear to follow a different course, but a with oppositional defiant disorder from normal sub-
developmental progression from symptoms of opposi- jects is not such a problem if disability is required. Nei-
tional defiant disorder to conduct disorder cannot be then DSM-III non lCD-b calls explicitly for the pres-
ruled out at this stage (27). ence of disability for a diagnosis of oppositional defiant
Lying has a developmental pattern similar to that of disorder to be made. DSM-III-R includes three severity
oppositional defiant disorder and correlates highly with criteria-mild, moderate, and severe-while the DSM-
symptoms of both oppositional defiant disorder and IV Options Book (13) makes significant impairment a
conduct disorder (2 8). However, Stouthamer-Loeber requirement in one of the options.
and Loeber (29) reported that lying tended to decrease
in children from grade 4 to grade 10. Correlations of Oppositional Versus Conduct Disorder Behavior
lying with stealing, truancy, drug use, police contact,
and self-reported delinquent lifestyle increased with Several clinicians and researchers have expressed the
age, while the correlation with fighting, the only symp- belief that oppositional defiant disorder is a mild form
tom of oppositional defiant disorder considered, re- of conduct disorder (1, 3). To clarify this matter, it
mained constant or even decreased as the children grew would be informative to know whether symptoms of
older. This suggests that lying is a common behavior oppositional defiant disorder and conduct disorder be-
during childhood that becomes increasingly associated long to the same or different behavioral dimensions.
with conduct problems as the child becomes older. This issue has been reviewed in the past few years (25,
33) and will not be discussed here. The authors of these
Differences From Normal Conduct reviews concluded that there is considerable agreement
across factor analytical studies in the finding that
One of the criticisms of DSM-III oppositional defiant symptoms of disruptive behavior consistently aggre-
disorder was that the conduct implicit in the DSM-III gate in two groupings: one consists of all oppositional
description could be applied to “normal” comportment defiant disorder behavior plus some symptoms of mild
(1). Defining the boundaries between normal and devi- physical aggression, such as fighting and bullying,
ant behavior is a constant problem in psychiatry. It is while the other consists of covert, nonaggressive con-
even more difficult with respect to children because duct disorder behavior, such as stealing, truancy, and
psychopathology must be seen against the background running away.
of normal development: behavior that is normative at The value of factor analytical techniques in the iden-
one stage may be deviant at other times. Symptoms of tification of clinical entities is arguable. Nevertheless,
oppositional defiant disorder are normative during the they seem to support the face validity of the diagnosis
preschool years; only their magnitude, inflexibility, on of oppositional defiant disorder (34, 35) and suggest
persistence at later developmental periods would justify that oppositional behavior is closely related to, or part
their being considered deviant. Therefore, distinguish- of, a dimension of aggression (36).
ing between normal and abnormal oppositional behav-
ion is likely to be difficult, and perhaps meaningless,
during periods in which the symptoms are normative. DIAGNOSIS
In addition, the presence of considerable distress and/on
disability is a necessary condition for the definition of Reliability
mental disorder according to DSM-III. Therefore, a di-
agnosis of oppositional defiant disorder should be Stability oven time of the symptoms that define a di-
made only in the presence of distress on disability. This agnosis is important in establishing that the symptoms
may not be a serious problem in clinical settings, be- are relatively enduring, rather than transient phenom-

Am J Psychiatry 150:12, December 1993 1771

OPPOSITIONAL DEFIANT DISORDER

TABLE 1. Reliability St udies of the Diagn osis of Oppositiona I Defiant Disorder

Reliability of
Age Diagnosis
Study Subjects N (years) Raters Method/Criteria (kappa)

Strober et al. (40) Inpatients 95 12-17 Two clinicians SADS,a joint interviewlDSM-III 1.00
Werry et al. (2) Outpatients 195 2-17 Two clinicians Clinical conferencelDSM-III 0.39
Shaffer et al. (37) Outpatients, 41 1 1-17 Twenty lay inter- Revised Diagnostic Interview 0.51 (parents),
inpatients viewers, 24 Schedule for Children versus 0.33 (children)
clinicians Clinician Assessment Formt’/
DSM-III-R
Rey et al. (5) Outpatients 393 12-17 Two clinicians Complete chart reviewlDSM-III 0.49
Ambrosini et al. (41 ) Outpatients 25 6-1 8 Two clinicians Videotapes of SADS for School- 0.89
Age Children/DSM-III-R
Spitzer et al. (39) Outpatients, 550 Mean= Seventy-two Clinical diagnosis versus ratings 0.47
inpatients 9.2 clinicians on DSM-III-R symptoms made
by the same clinicianlDSM-III-R
a5hedule for Affective Disorders and Schizophrenia.
bStructured interview by clinician covering the same symptoms as the Revised Diagnostic Interview Schedule for Children.

ena that are unpredictably evoked. Shaffer et al. (37) cated in the study by Ambrosini et al., which used the
reported that the test-retest reliability of questions ne- Schedule for Affective Disorders and Schizophrenia for
lating to diagnostic criteria for oppositional defiant dis- School-Age Children with clinic patients. Teachers’ re-
order was good when the basis was parents’ reports ports have shown that there is a considerable symptom
(kappa=0.65) and poorer when it was children’s reports overlap between oppositional defiant disorder and at-
(kappa=0.39). The corresponding reliabilities for inter- tention deficit hyperactivity disorder (43).
views with clinicians were kappa=0.47 and kappa= The item “bullies on is mean to other children” had a
0.22. Some criteria (annoys, blames, is angry, is spite- reasonably high odds ratio separating patients with op-
ful) were particularly unreliable, probably because they positional defiant disorder from those without, but it
have a high prevalence and this leads to uncertainty was excluded from the criteria in DSM-III-R on the ba-
about the threshold for deciding that a symptom is pres- sis that it was also correlated with a diagnosis of con-
ent. Parent-child agreement was poor for each of the duct disorder and fitted better with the conduct disor-
criteria and for the diagnosis as a whole (kappa=0.26). den construct (39). “Often lies,” on the other hand,
Parents appear to be better informants for this diagno- showed the best combination of sensitivity and specific-
sis than children, the latter adding little information to ity for a diagnosis of conduct disorder in the DSM-III-R
that provided by the former (38). field trials. Thus, it is surprising that lying is considered
A summary of studies reporting reliability of the diag- as a possible diagnostic criterion for oppositional defi-
nosis of oppositional defiant disorder in a variety of ant disorder, but not conduct disorder, by the DSM-IV
contexts and with diverse methods (2, 5, 37, 39-41) is task force (13).
presented in table 1 . The mean (weighted) reliabilities A comparative study that used the Diagnostic Inter-
obtained in studies using DSM-III and DSM-III-R criteria view Schedule for Children to assign DSM-III and
were kappa=0.S3 and kappa=0.48, respectively. There is DSM-III-R diagnoses to 177 outpatient boys found that
no evidence that DSM-III-R represents an improvement applying the criteria of the latter resulted in 25% fewer
oven DSM-III in this regard. Agreement between clini- diagnoses of oppositional defiant disorder than apply-
cians’ diagnoses and diagnoses obtained with a structured ing those of the former (44). This supports the belief
psychiatric interview (Diagnostic Interview Schedule for that DSM-III-R-defined oppositional defiant disorder is
Children) was very low (kappa=0.09) (42). more restrictive than its predecessor (18).

Diagnostic Criteria
EPIDEMIOLOGY
The choice and number of symptoms required for di-
agnosis can influence reliability. The internal consis- Five studies (6-10) that reported rates of oppositional
tency of the DSM-III-R criteria is high: in two studies defiant disorder in community samples based on the use
Cnonbach’s alpha=0.85 (39) and 0.86 (unpublished of specified criteria-mostly those of DSM-III-and
1990 paper of P.J. Ambrosini et al.). The DSM-III-R standardized interviews were identified. Two of the
field trials (39) reported that a threshold of five criteria studies (6, 10) were carried out with the same group of
fulfilled had the best combination of sensitivity (80%) subjects when they were 1 1 and when they were 15
and specificity (79%), discriminating between patients years of age. The results of the five studies are shown in
with and without oppositional defiant disorder. This table 2. The prevalence of oppositional defiant disorder
was the reason for the decision to use fulfillment of five ranged between 1.7% and 9.9%, with a weighted aver-
criteria as the diagnostic threshold for oppositional de- age of 5.7%. Approximately one-third of all of the chil-
fiant disorder in DSM-III-R. These results were repli- dnen with any disorder had a diagnosis of oppositional

1772 Am J Psychiatry 1 50:1 2, December 1993

 JOSEPH M. REY

TABLE 2. Rates and Sex Ratios of Oppositional Defiant Disorder and Conduct Disorder in Epidemiological Surveys
Oppos itional Defiant
Disorder Conduct Disorder
Percent of Percent of Subjects
Subjects Percent Percent Ratio With Oppositional
Age With Any of Ratio of of of Boys Defiant Disorder!
Study Criteria N (years) Disorder Subjects Boys to Girls Subjects to Girls Any Disordera

Anderson et al. (6) DSM-III 792 11 17.6 5.7 2.2:1 3.4 3.2:1 32
Kashani et al. (7) DSM-III 150 14-16 18.7 6.0 1:2 8.7 1.2:1 32
Cohen et al. (8) DSM-III-R 775 9-12 - 5.0 2.3:1 4.0
13-18 - 7.5 1:1.1 6.0 3:1 -

Bird et al. (9) DSM-III 386 4-16 17.9 9.9 More corn- 1.5 - 55
mon in boysc
McGee et al. (10) DSM-III 943 15 22 1.7 1:3 7.3 1:1 7.7
aChildren with a diagnosis of oppositional defiant disorder as a percentage of those with any diagnosis.
bEight percent of the boys and none of the girls received a diagnosis of conduct disorder.
CAssociation of oppositional defiant disorder with sex did not reach statistical significance.

defiant disorder, showing that this disorder is one of the COMORBIDITY

most common psychiatric conditions in this age group.
Identification of risk factors is important for pneven- Several community surveys have provided data on
tive purposes but also to support the validity of a diag- comorbidity, but, regrettably, in all but one of them (7)
nosis if a characteristic pattern emerges. Since clinical oppositional defiant disorder was lumped together with
samples may be biased, only information obtained from conduct disorder. In the study by Kashani et al. (7), of
community surveys is considered here. The small num- nine adolescents with oppositional defiant disorder,
ben of studies, containing only a few cases of opposi- only two had pure oppositional defiant disorder, one
tional defiant disorder, suggests that interpretation also had depression, one also had anxiety, and five had
should be cautious. three diagnoses. A community study of 931 boys aged
Sex. Overall, oppositional defiant disorder was diag- 5-14 years (45), given diagnoses on the basis of teach-
nosed more often in boys than in girls (table 2), but this ens’ reports, showed that 93% of those with opposi-
pattern seems to depend on the age of the child. Studies tional defiant disorder had concurrent attention deficit
reporting diagnoses of children 12 years of age on hyperactivity disorder.
younger (6, 8) showed that the prevalence of opposi- My colleagues and I (46) reported that 20% of ado-
tional defiant disorder was more than double for boys, lescents with oppositional defiant disorder who were
while studies of adolescents (7, 8, 10) showed a higher referred for treatment had concurrent attention deficit
prevalence of oppositional defiant disorder in girls. hyperactivity disorder. A study that used the Revised
These changes parallel those reported for aggressive be- Version of the Diagnostic Interview Schedule for Chil-
havior (26). By comparison, conduct disorder was diag- dren (37) found that on the basis of parents’ reports,
nosed more often in boys in all age groups in most stud- 25% ofchildren with oppositional defiant disorder met
ies (table 2). the criteria for attention deficit hyperactivity disorder,
Age. It is difficult to establish whether overall rates of while 50% of those with attention deficit hyperactivity
oppositional defiant disorder increase or decrease with disorder had concurrent oppositional defiant disorder.
age, because findings from epidemiological studies are Children with oppositional defiant disorder also had
contradictory: one study (8) showed an increase, while concurrent diagnoses of separation anxiety (5%), gen-
another (10) showed a decline (table 2). McGee et al. eralized anxiety disorder (5%), and major depressive
(10) examined the same subjects when they were age 15 disorder ( 1 1 % ). The DSM-III-R field trials reported
that Anderson et al. (6) had studied when they were age that more than half(57%) ofpatients with oppositional
1 1 and reported a marked reduction in the prevalence defiant disorder had concurrent attention deficit hyper-
of oppositional defiant disorder, although there were activity disorder (39). An overlap of at least 35% with
methodological differences between the two studies. attention deficit hyperactivity disorder was reported in
On the basis of teachers’ reports, Pelham et al. (45) re- a recent review (47). Thus, there is high comorbidity
ported a gradual increase in oppositional defiant disor- between oppositional defiant disorder and attention
den with increasing age in a community sample. By con- deficit hyperactivity disorder. Two studies (37, 39) re-
trast, there is little doubt that conduct disorder becomes ported that 77% and 84% of patients with conduct dis-
more prevalent during adolescence (table 2). order met criteria for oppositional defiant disorder.
Socioeconomic status. The only epidemiological sur- However, it is still unresolved whether comorbidity be-
vey that provided information about socioeconomic tween oppositional defiant disorder and conduct disor-
status was the one carried out by Bird et al. (9) in Puerto den is higher than between oppositional defiant disor-
Rico, with the finding that oppositional defiant dison- den and other disorders, particularly attention deficit
der was more prevalent in groups with lower socioeco- hyperactivity disorder. Until this issue is clarified, the
nomic status. question of a hierarchical relationship between opposi-

Am J Psychiatry 1 50:1 2, December 1993 1773

OPPOSITIONAL DEFIANT DISORDER

tional defiant disorder and conduct disorder cannot be when they become adults? Very little is known about
resolved (27). The pattern and range of comonbidity this. DSM-III-R states that oppositional defiant disor-
with other disorders, particularly anxiety and depres- den evolves into a mood disorder in many cases, but no
sion, is unclear at this stage. data were found to support such a theory.
There appears to be an association between opposi-
tional defiant disorder and communication disorders Oppositional Defiant Disorder and Passive-
(48). However, this could be explained by the co-occur- Aggressive Personality Disorder
rence of attention deficit hyperactivity disorder (49).
Comorbidity of oppositional defiant disorder with Both DSM-III and DSM-III-R mention that opposi-
nonpsychiatnic disorders is not well known but might tional defiant disorder in childhood predisposes to the
be relevant, because a concurrent diagnosis of opposi- development of passive-aggressive personality disorder
tional defiant disorder is likely to make treatment more in adulthood. This appears to be based on the notion
difficult. For example, Beratis (50) reported that a diag- that children with oppositional defiant disorder and
nosis of oppositional defiant disorder was common passive-aggressive adults share similar defense mecha-
among children with thalassemia who were not corn- nisms that result in procrastination, resistance to de-
pliant with iron chelation therapy regimens. mands for adequate performance, stubbornness, etc.
Having one psychiatric disorder increases the prob- (55). This relationship makes intuitive sense if the origi-
ability of having a second disorder (SI, 52). Thus, it nal concept of oppositional defiant disorder, reflecting
should be kept in mind that a specific association be- mainly opposition to adult requests, is considered,
tween oppositional defiant disorder and another disor- but it makes less sense if oppositional defiant disor-
den can be assumed only if comorbidity is significantly den predominantly reflects an angry, aggressive con-
higher than that expected when another diagnosis is stnuct. No empirical evidence is available to support
present. either assumption.

Family Studies
VALIDITY
No published family studies of children with opposi-
Prospective Studies tional defiant disorder were found. Faraone et al. (56)
assessed the relatives of groups of patients with atten-
Cantwell and Baker (53) did a 4-year follow-up study tion deficit hyperactivity disorder, attention deficit hy-
of a group of children who had been diagnosed as suf- peractivity disorder plus oppositional defiant disorder,
fening from DSM-III disorders at a mean age of 5.9 attention deficit hyperactivity disorder plus conduct
years. Together with autism and attention deficit hypen- disorder, and other psychiatric diagnoses, comparing
activity disorder, oppositional defiant disorder was one them with the relatives of normal control subjects. The
of the most stable diagnoses. Oppositional defiant dis- relatives of children with attention deficit hyperactivity
order showed the poorest recovery rate of all the behav- disorder plus oppositional defiant disorder had a sig-
ioral psychiatric disorders. Two (13%) of 15 children nificantly greaten risk of both attention deficit hyperac-
met the criteria for conduct disorder at follow-up. The tivity disorder and oppositional defiant disorder, sug-
authors concluded that the natural history of opposi- gesting that oppositional defiant disorder may be
tional defiant disorder was quite different from that of familial. The relatives of probands with attention defi-
conduct disorder and normal development. Symptoms cit hyperactivity disorder plus conduct disorder had a
of oppositional defiant disorder also seem to be particu- significantly higher risk of substance abuse than the
larly stable. Cohen et al. (31) showed that a diagnosis relatives of probands with attention deficit hyperactiv-
of oppositional defiant disorder predicted a significant ity disorder alone or with attention deficit hyperactivity
increase in the use of mental health services 2 years disorder plus oppositional defiant disorder. Although
later. A follow-up study of children with attention defi- this study did not provide data on children with oppo-
cit hyperactivity disorder into adolescence (54) re- sitional defiant disorder alone, it suggests that the mor-
ported that most differences between children with at- bid risks for relatives of patients with attention deficit
tention deficit hyperactivity disorder and normal hyperactivity disorder plus oppositional defiant disor-
control subjects were attributable to the group with co- den and relatives of patients with attention deficit hy-
morbid oppositional defiant disorder at follow-up. Fur- peractivity disorder plus conduct disorder are not iden-
thermore, the degree of aggression in childhood pre- tical, although these findings may be explained by
dicted symptoms of oppositional defiant disorder in differences in severity between oppositional defiant dis-
adolescence, and these were very stable. order and conduct disorder.
These findings show that symptoms of oppositional
defiant disorder are stable over time and that children Other Validity Studies
with oppositional defiant disorder do not necessarily
develop conduct disorder when they grow older (27, A pattern of correlates different from those of other
53). If oppositional defiant disorder has such a low re- disorders, particularly conduct disorder and attention
covery rate, what happens to children with the disorder deficit hyperactivity disorder, would also support the

1774 Am J Psychiatry 150:12, December 1993

 JOSEPH M. REY

validity of the diagnosis of oppositional defiant disor- ficult-child type of temperament appears to be closely
der. Few studies, comprising a relatively small number related to oppositional behavior (4). For example, Maz-
of patients, that examined differences between them jade et al. (65) followed prospectively a group of chil-
were identified. Reeves et al. (57) compared 105 chil- dren who had extremely difficult temperaments at age
dren diagnosed as suffering from anxiety, attention 7, finding that this was associated later on with disrup-
deficit hyperactivity disorder, conduct disorder, and tive disorder diagnoses, particularly oppositional defi-
oppositional defiant disorder with one another and ant disorder. However, difficult temperament at age 7
with normal control subjects; they concluded that con- predicted psychiatric status in preadolescence and ado-
duct disorder and oppositional defiant disorder resem- lescence only when family functioning was taken into
bled each other and seldom occurred in the absence of account, suggesting a multifactorial pathogenesis.
attention deficit hyperactivity disorder. My associates There is a large body of research dealing with the
and I (46) reported that children with oppositional de- causes of aggression (66, 67) and antisocial behavior
fiant disorder had a higher level of functioning during (e.g, 21 ), but it is unclear how much this literature is
the previous year, were more socially competent at the applicable to oppositional defiant disorder, conduct
time of referral, had lower externalizing scores, and disorder, attention deficit hyperactivity disorder, or a
were less disturbed overall than their counterparts with combination of them, because these diagnoses were not
conduct disorder. Patients with oppositional defiant separated until recently, and comorbidity was almost
disorder were also described as having higher rates of always not taken into consideration (S 1 ). A better un-
problems in social relationships and as coming from denstanding of the relative influence of these factors in
more dysfunctional families than normal control sub- the development of oppositional defiant disorder will in
jects, but differences between them and children with large measure await taxonomic clarity.
conduct disorder were few (58), and perceptions of par-
enting were similar among patients with oppositional
defiant disorder and patients with conduct disorder TREATMENT
(59). Although it is much too early to draw any reliable
conclusions from these reports, it appears that children One cannot argue for oppositional defiant disorder as
with oppositional defiant disorder have correlates dif- a separate diagnostic category on the basis of a charac-
ferent from those of normal control subjects but similar tenistic response to treatment. Systematic studies corn-
to those of children with conduct disorder (60). paring children with oppositional defiant disorder who
received different treatment interventions were not
found, with the exception of a report by Wells and Egan
ETIOLOGY (68) showing that parent training based on social learn-
ing was superior to family systems therapy. In clinical
Symptoms of oppositional defiant disorder may be practice children with oppositional defiant disorder are
the final common pathway of many etiological factors, treated with a variety of psychological and behavioral
alone or in combination, including genetic, constitu- approaches, alone or in combination, targeting the
tional, social, and psychological mechanisms (4). Op- child and/or the family. These include child psychother-
positional behavior may also be observed in patients apy, behavior therapy, various modalities of family
with depression, anxiety, or other psychiatric condi- therapy, and parent management training (4, 62, 69-
tions, but it is unclear whether this represents true co- 72). No study was identified that used medication for
morbidity or whether oppositional defiant disorder in children with oppositional defiant disorder. However,
these cases is a symptom of the other disorder. There is pharmacotherapy may be effective in those with comor-
no systematic evidence so far that would permit identi- bid attention deficit hyperactivity disorder (73-75).
fication of a unique etiology or a constellation of causal It is widely accepted that response to treatment of
factors for oppositional defiant disorder in comparison patients with conduct disorder is very poor (76). If it
with other conditions such as conduct disorder. Per- could be shown that children with oppositional defiant
haps as a result, speculative models abound. For exam- disorder respond to specific treatments more consis-
ple, Levy (16) considered that markedly oppositional tently than those with conduct disorder, this would sup-
behavior occurs as a reaction of the child to overly strict port the validity of the diagnosis ofoppositional defiant
parenting. Meeks (61 ) interpreted oppositional behav- disorder.
ior as the youngster’s response to a restrictive and de-
manding parental environment. Psychodynamic theo-
ries conceptualize oppositional defiant disorder as a CONCLUSIONS
fixation in the anal stage of development (62), while
other writers emphasize the causative role of negative As yet, very few child psychiatric disorders have been
reinforcement of inappropriate child behavior through convincingly shown to be independent conditions (77).
inadequately resolved parent-child conflict, particu- This illustrates the difficulties in validating a symptom
larly about issues of control and autonomy (63), or the cluster, let alone defining its etiology or treatment. In-
development of coercive family processes as a result of deed, this is a problem afflicting not only child psychia-
poor parental discipline and monitoring (64). The dif- try but psychiatry as a whole. For example, as Roth (78)

Am J Psychiatry 150:12, December 1993 1775

OPPOSITIONAL DEFIANT DISORDER

pointed out, there is a strong divergence of opinion re- case could be made, however, for a simplification of
garding the classification of anxiety and depressive dis- the name to avoid redundancy (“oppositional” and
orders. Some would consider that there are not clear “defiant” convey very similar meanings) or a change
lines of demarcation between the two groups, which are to “oppositional aggressive disorder” to reflect the un-
seen as part of a “general neurotic syndrome.” Others derlying construct more accurately.
would judge that the evidence is consistent with the ex- It is apparent that the oppositional defiant disorder
istence of discrete categories with some overlap. The construct has undergone a transformation. Whether
gulf between those favoring a categorical system, who this change actually reflects a better understanding of
focus on discontinuities, and those who emphasize the its manifestations or is the result of inadequate opera-
continuities and support a dimensional approach is un- tionalization of the original clinical construct by DSM-
likely to be bridged in the near future, yet one model III is unclear. A similar drift has been described for
does not necessarily exclude the other (78, 79). It would antisocial personality disorder (81). In line with this,
be surprising if such a recent addition to the taxonomy what is currently understood by the term “opposi-
as oppositional defiant disorder were free of contro- tional defiant disorder” appears to be equivalent to the
versy, and the data presented here should be regarded concept of “nondelinquent disturbances of conduct”
in that context. described in some European textbooks ( 1 1 ) or the ag-
Arguments for considering oppositional defiant dis- gressive syndrome described in empirically derived
order as a separate category arise from the findings taxonomies (33, 36).
that such a diagnosis describes severely handicapping The reliability of the diagnosis needs improvement.
behavior displayed by a large number of children in To achieve this, clarification of the oppositional defiant
both clinic and community settings. There is evidence disorder construct and further operationalization of the
from factor analytical studies that symptoms of oppo- diagnostic criteria are likely to be more rewarding tasks
sitional defiant disorder tend to occur together, the in- than tinkering with the number of criteria. A more de-
ternal consistency of the criteria is high, and the behav- tailed description of symptoms, including clearly speci-
ion has been found to be stable oven time and to have fied thresholds for their presence, would be helpful. The
a developmental profile different from that of symp- presence of considerable impairment should be made
toms of conduct disorder. Factor analytical research explicit, to rule out confusion with extreme forms of
does not support the notion that oppositional defiant normative comportment. Making lying a diagnostic cni-
disorder and conduct disorder are part of the same di- tenon for oppositional defiant disorder instead of con-
mension of behavior. Oppositional defiant disorder duct disorder goes against the available evidence. Bul-
appears to belong to an oppositional-aggressive di- lying and aggression limited to the home, on the other
mension, whereas conduct disorder represents mainly hand, appear to be part of the construct.
a construct characterized by truancy, stealing, lying, The rationale underlying oppositional defiant disor-
and other delinquent behavior. On the other hand, an- den in lCD-b is ambiguous and not supported by em-
guments based on etiology, response to treatment, on pinical evidence. First, too many children are likely to
the pattern of correlates do not support considering the qualify for a diagnosis of oppositional defiant disorder
disorder as a separate category, but there is insufficient if fulfilling only two of three criteria, without impair-
evidence on these aspects of diagnostic validity to draw ment, is all that is required. Second, since oppositional
definite conclusions. Also, the reliability of the diagno- defiant disorder behavior is particularly common be-
sis is barely acceptable. fore adolescence, the suggestion that the diagnosis
Should oppositional defiant disorder and conduct should rarely be made for children after the age of 10
disorder be amalgamated? The stated philosophy of years implies that adolescents with the same symptoms
the DSM-IV work group is that the threshold for revi- should not receive a diagnosis, although the behavior is
sion of diagnoses is to be “much higher than was the developmentally more inappropriate. Third, lCD- 10
case for DSM-III and DSM-III-R” and is to be based assumes that oppositional defiant disorder and conduct
on empirical evidence (13). Indeed, it is hoped that disorder are part of the same continuum of behavior. It
“empirical evidence” is understood as findings repli- appears that lCD-b is repeating the errors of DSM-III
cated by a variety of researchers. On these grounds, (1) and DSM-III-R (82). Because ofthe lack of evidence,
there does not appear to be enough justification to it would have been more consistent for ICD-10 not to
merge oppositional defiant disorder and conduct dis- include a category of oppositional defiant disorder or,
order. There are no clear advantages in such a change, if introduction of such a category was deemed neces-
and it has the disadvantage that it may increase confu- sary, it would have made more sense to adopt what is
sion among clinicians and discourage research even already understood about oppositional defiant disorder
more. Further, such a change is likely to have implica- and avoid further confusion in the field.
tions for the diagnosis and prevalence of adult antiso- Follow-up studies of well-diagnosed groups of sub-
cial personality (80). There would be no “cost” in- jects are sorely needed. Other areas of research interest
volved if oppositional defiant disorder is retained as a are epidemiological family studies, comorbidity, and
different category, even if in fact it is not, because this differences between oppositional defiant disorder, at-
would not result in children being deprived of an effec- tention deficit hyperactivity disorder, and conduct dis-
tive treatment or having a worse outcome. Perhaps a order in risk factors, correlates, and response to treat-

1776 Am J Psychiatry 150:12, December 1993

 JOSEPH M. REY

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Form and Teacher Version of the Child Behavior Profile. Bun-
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lington, University of Vermont, Department of Psychiatry, I 986
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and 1991 Profile. Burlington, University of Vermont, Depart-
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