|
According to the DSM-5-TR,2 ODD involves at least 6 months of symptomatology across three categories, including (a) angry/irritable mood; (b) argumentative/defiant behavior; and (c) vindictiveness, during interactions with “at least one individual who is not a sibling”. Symptoms must also cause impairment (including distress in the child and/or others) in at least one setting (e.g., home, school, with peers). Given that some degree of defiant behavior is common in children under 5, symptoms/behaviors must be present for most days in this age group, whereas behaviors must be present at least once per week for children 5 and older.2 ODD is more common in males than females prior to adolescence (with a more even distribution afterward), and first symptoms often appear during the preschool years.2 Importantly, ODD is often comorbid with other disorders; therefore, screening for comorbidities is critical, given the implications for treatment (e.g., use of medications for ADHD, additional supports for learning disabilities). The most common comorbid disorders with ODD include ADHD, substance use, learning disorders, and mood disorders (including depressive disorders, bipolar disorders, and disruptive mood dysregulation disorder).3
An additional requirement for diagnosis of ODD is that the symptoms/disruptive behaviors are not solely due to the presence of another disorder. Anxiety disorders are often overlooked in the assessment/treatment of disruptive behavior. For example, a child with anxiety who is confronted with a feared stimulus (e.g., peers in the context of social anxiety) may engage in disruptive behavior either due to behavioral dysregulation and/or as an attempt to escape the feared item/situation/avoid the acute fear. Similarly, a patient with a trauma-related disorder may engage in disruptive or dysregulated behavior in the context of exposure to a reminder of the traumatic event.
ODD often (but not always) precedes CD, which generally describes a more severe set of symptoms than ODD. The symptoms of CD occur across four domains: (a) aggression (i.e., physical, sexual, or threats/psychological) toward people and/or animals; (b) destruction of property; (c) deceitfulness or theft; and/or (d) serious rule violations (e.g., repeated truancy).2 CD can be further specified by onset, with childhood onset type being characterized by demonstration of at least one symptom by 10 years of age and adolescent onset characterized by no symptoms displayed prior to age 10.2 An additional specifier is the presence of so-called “callous-unemotional” traits (e.g., limited prosocial emotions, lack of remorse/guilt, lack of empathy, shallow/insincere display of emotions), which is associated with greater heritability, and generally with worse outcomes. Importantly, CD is also frequently comorbid with other disorders, including ADHD, substance use, learning disorders, and mood disorders. Of note, there is some evidence that individuals with CD have higher rates of suicidal thoughts and behaviors.4
While there is some degree of heritability in both ODD and CD, there are also important and strong environmental risks for both disorders including exposure to violence, socioeconomic adversity, family factors (e.g., harsh discipline, parental rejection or neglect), and lower educational attainment, underscoring the importance of screening for (and addressing) risk factors (e.g., parenting challenges). CD is more common in males, and most commonly presents during middle childhood or adolescence.5
| 
