A. A persistent pattern of angry and irritable mood along with defiant and vindictive behavior as evidenced by four (or more) of the following symptoms being displayed with one or more persons other than siblings.

Angry/Irritable Mood

1.   Loses temper

2.   Is touchy or easily annoyed by others.

3.   Is angry and resentful

Defiant/Headstrong Behavior

4.   Argues with adults

5.   Actively defies or refuses to comply with adults’ request or rules

6.   Deliberately annoys people

7.   Blames others for his or her mistakes or misbehavior

Vindictiveness

8.   Has been spiteful or vindictive at least twice within the past six months

B. (NOTE:  UNDER CONSIDERATION) The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic to determine if they should be considered a symptom of the disorder. For children under 5 years of age, the behavior must occur on most days for a period of at least six months unless otherwise noted (see symptom #8). For individuals 5 years or older, the behavior must occur at least once per week for at least six months, unless otherwise noted (see symptom #8). While these frequency criteria provide a minimal level of frequency to define symptoms, other factors should also be considered such as whether the frequency and intensity of the behaviors are non-normative given the person’s developmental level, gender, and culture.

C. The disturbance in behavior causes clinically significant impairment in social, educational, or vocational activities.

D. The behaviors may be confined to only one setting or in more severe cases present in multiple settings.

I.     Initial Literature Review

To guide decisions on the degree and types of changes that may be needed for the diagnostic criteria for Oppositional Defiant Disorder in the DSM-V, a comprehensive literature review was conducted by Dr. Deborah Drabick of Temple University, a advisor to the ADHD and Disruptive Behavior Disorders Workgroup, to evaluate the utility of the DSM-IV definition of the disorder. The review included published manuscripts from 1995-2008 that used DSM-IV definitions of ODD. However, given the importance of considering prospective and epidemiological studies, articles that used DSM-III-R criteria were included, if these studies were prospective investigations (most were epidemiological studies). The results of this review were presented to the workgroup on November 3^rd, 2008. The main questions addressed by the review and the main findings are summarized here.

a.    Does the diagnosis of ODD have independent predictive validity when comorbid disorders are controlled?

34 studies reviewed suggested that the DSM-IV definition of ODD predicted numerous important clinical outcomes controlling for ADHD, Conduct Disorder, anxiety disorders, depressive disorders, and substance abuse disorders

b.    Does the diagnosis of ODD add to the predictive validity of other comorbid disorders?

38 studies reviewed suggested that the DSM-IV criteria for ODD added to the prediction of numerous important clinical outcomes in youths with ADHD, Conduct Disorder, anxiety disorders, depressive disorders, and substance abuse disorders. 

c.    Would requiring a pervasiveness criterion improve the predictive validity of ODD?

The available research did not directly address this question. That is, most studies compared different informants (e.g., parent and teacher) and did not directly assess whether the ODD symptoms were situational (e.g., at home or home or school only) or pervasive. 7 studies reviewed suggested that even when ODD symptoms are reported by parents only, they are associated with significant impairment. However, when they are reported by multiple informants, the impairment is greater.

d.    Do the emotional (e.g., spiteful, angry) vs. behavioral (e.g., argues, defies) symptoms of ODD show different predictive associations with important outcomes?

5 studies were reviewed suggesting that the emotional and behavioral symptoms were highly intercorrelated and both symptom domains predicted disruptive behavior disorders outcomes (e.g., ADHD, Conduct Disorder). However, the emotional symptoms independently predicted mood and anxiety disorders.

II.    Recommendation 1. Do not make major changes to the symptoms or structure of the ODD criteria.

Based on the results of this review, it appeared that the DSM-IV criteria had been fairly successful for designating a group of children who were impaired and who were at risk for future problems in adjustment, even controlling for common co-morbid conditions. Further, its presence added to the predictive utility of other diagnoses.

III.   Recommendation 2. Remove exclusionary criteria for Conduct Disorder.

The DSM-IV criteria for ODD allowed for the diagnosis only if the criteria for Conduct Disorder are not met. In the review of the literature, ODD predicted the following outcomes, controlling for Conduct Disorder (either alone or with other comorbidities):

a.    Concurrent studies: injuries/maltreatment (n=1); anxiety/depression (n= 2); substance use (n=4); ADHD (n=1); delinquency or greater symptom severity of Conduct Disorder (n=2); family impairment (n=2); peer difficulties (n=1); treatment utilization (n=1)

b.    Longitudinal studies: anxiety/depression (n= 1); delinquency or Conduct Disorder at subsequent time points (n=3); truancy (n=1); impairment (n=1).

IV.   Recommendation 3. Organize symptoms in the criteria for ODD to distinguish emotional and behavioral symptoms.

The review suggested that the symptoms of ODD were highly intercorrelated and that all of them contributed to the prediction of disruptive behavior disorders outcomes. However, the emotional symptoms also contributed uniquely to the prediction of emotional disorders. Also, the workgroup viewed it important to highlight the fact that, although the emotional symptoms of the disorder are not reflected in the name of the disorder, the criteria consist of both emotional and behavioral indicators. Finally, one additional study that emerged after this review supported the importance of separating the behavioral and emotional symptoms but also supported separating the spiteful/vindictive symptom from the other behavioral symptoms

Stringaris, A. & Goodman, R. (2009). Longitudinal outcome of youth oppositionality: Irritable, headstrong, and hurtful behaviors have distinctive predictions. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 404-412.

V.    Recommendation 4. Develop a severity index based on the cross-situation pervasiveness of the symptoms.

The review suggested that youth reported as meeting ODD criteria by parents only were impaired and likely warrant a diagnosis; however, those reported as meeting criteria by both parents and teachers seemed to show even greater impairment. These results were suggestive that cross-situationality should not be a criteria for the disorder but may be a useful index of severity.

To test this possibility more directly, Dr. Eric Youngstrom of the University of North Carolina Chapel Hill, conducted secondary data analyses on 802 youths, ages 5 to 18, seeking outpatient mental health services.  A comprehensive summary of these analyses are provided in Appendix B. To summarize the main findings supporting the proposed severity index:

a.    The KSADS interview was used to separate youth with an ODD diagnosis into those impaired in three different contexts – with peers, at home, with the family, and at school.

b.    Of the cases meeting DSM-IV criteria for ODD (n=311), 96% reported impairment at home, 85% reported impairment at school, 67% reported impairment with peers. When looking at cross-setting impairment, 11% of ODD cases had impairment only at home, 27% had impairment in at least one other setting besides home, and 62% had impairment reported in all three settings. The number of cases with single-setting impairment that was not in the home was negligible.

c.    Those youth showing impairment due to ODD symptoms only at home did show significant levels of externalizing behaviors and other signs of disability but less so than those who showed impairment in one other setting. Further, those who were impaired in two settings showed lower levels of externalizing behaviors and lower scores on other indices of disability than those who were impaired by ODD symptoms in more than two settings.

d.    Regression analyses indicated that impairment across settings explained significant variance in the various measures of impairment and functioning, even after controlling for the number of ODD symptoms.

VI.   Under consideration: Provide objective and standard definitions of frequency for ODD symptom threshold.

The DSM-IV criteria for ODD define each symptom as occurring “often” (e.g., often loses temper). In the text, the frequency threshold is defined as follows:

“the behaviors must occur more frequently than is typically observed in individuals of comparable age and developmental level and must lead to significant impairment in social, academic, or occupational functioning” (p. 100).

The workgroup is currently reviewing secondary data analyses from various clinic and community samples of children and adolescents of various age groups to determine if a more objective frequency criteria can be used to define symptom thresholds.

a.    Advantages - such objective criteria could provide clinician with guidance from research as to what level of these behaviors, which occur to some degree in non-disordered individuals, is indicative of a more pathological condition.

a.    Disadvantages - such objective criteria change the wording of symptoms that have been evaluated extensively by research and have proven indicative of an impairing condition; further, it may be impossible to find objective thresholds that generalize across age, gender, and cultural groups and such decisions may be best left to clinicians.

0 - Absent:  Shows fewer than two symptoms

1 - Subthreshold:  Shows at least two but fewer than four symptoms or symptoms do not cause significant impairment in any setting

2 - Mild:  Shows at least four symptoms but symptoms are confined to only one setting (e.g., at home, at school, at work, with peers)

3 - Moderate: Shows at least four symptoms and some symptoms are present in at least two settings

4 - Severe:  Shows at least four symptoms and some symptoms are present in 3 or more settings

A. A pattern of negativistic, 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 and 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.

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

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.