# Evidence-based assessment/Oppositional defiant disorder (assessment portfolio)/extended version

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## What is a "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above.
Does this page feel like too much information? Click here for the condensed version.

## Preparation phase
### Diagnostic criteria for oppositional defiant disorder

   ICD-11 Diagnostic Criteria
   General Description: Oppositional defiant disorder is a persistent pattern (e.g., 6 months or more) of markedly defiant, disobedient, provocative or spiteful behaviour that occurs more frequently than is typically observed in individuals of comparable age and developmental level and that is not restricted to interaction with siblings. Oppositional defiant disorder may be manifest in prevailing, persistent angry or irritable mood, often accompanied by severe temper outbursts or in headstrong, argumentative and defiant behaviour. The behavior pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning
   Oppositional Defiant Disorder With Chronic Irritability-Anger: All definitional requirements for oppositional defiant disorder are met. This form of oppositional defiant disorder is characterized by prevailing, persistent angry or irritable mood that may be present independent of any apparent provocation. The negative mood is often accompanied by regularly occurring severe temper outbursts that are grossly out of proportion in intensity or duration to the provocation. Chronic irritability and anger are characteristic of the individual’s functioning nearly every day, are observable across multiple settings or domains of functioning (e.g., home, school, social relationships), and are not restricted to the individual’s relationship with his/her parents or guardians. The pattern of chronic irritability and anger is not limited to occasional episodes (e.g., developmentally typical irritability) or discrete periods (e.g., irritable mood in the context of manic or depressive episodes).
   * Note: The ICD-11 lists 3 additional subcategories of oppositional defiant disorder with chronic irritability-anger (i.e., with limited prosocial emotions, with typical prosocial emotions, and unspecified). They can be found here.
   Oppositional Defiant Disorder Without Chronic Irritability-Anger: Meets all definitional requirements for oppositional defiant disorder. This form of oppositional defiant disorder is not characterized by prevailing, persistent, angry or irritable mood, but does feature headstrong, argumentative, and defiant behavior.
   * Note: The ICD-11 lists 3 additional subcategories of oppositional defiant disorder without chronic irritability-anger (i.e., with limited prosocial emotions, with typical prosocial emotions, and unspecified). They can be found here.
   Changes in DSM-5
   The diagnostic criteria for ADHD changed slightly from DSM-IV to DSM-5. See the changes here.

### Base rates of ODD in different clinical settings

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of ODD that they are likely to see in their clinical practice.
* To see prevalence rates across multiple disorders, click here.
| Demography | Setting | Base Rate | Diagnostic Method |
| Various locations across USA | Meta-analysis of 38 studies | 3.3% | Varied |
| All of the U.S. | Nationally representative large-scale study (N = 3,119) | 10.2% (overall) 11.2% (males) 9.2% (females) | World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)$^r$ |
| Suburban and urban Colorado | Project to Learn about Youth-Mental health, school-based study for children from kindergarten to high-school (n = 236) | 6.8% | Diagnostic Interview Schedule for Children (DISC) |
| Urban and suburban Florida | Project to Learn about Youth-Mental health, school-based study for children from kindergarten to high-school (n = 289) | 6.9% | Diagnostic Interview Schedule for Children (DISC) |
| Rural and suburban Ohio | Project to Learn about Youth-Mental health, school-based study for children from elementary to high-school (n = 152) | 17.3% | Diagnostic Interview Schedule for Children (DISC) |
| Suburban and rural South Carolina | Project to Learn about Youth-Mental health, school-based study for children from elementary to high-school (n = 270) | 5.7% | Diagnostic Interview Schedule for Children (DISC) |
| Semi-rural North Carolina | Preschool-aged children from pediatric practices (N = 306; age 2 - 5 years old) | 6.6% | Preschool Age Psychiatric Assessment (PAPA)$^p$ |
| Western North Carolina | The Great Smoky Mountains Study - longitudinal, population-based study of community sample | 2.33% (overall) 3.16% (males) 2.75% (females) | Child and Adolescent Psychiatric Assessment (CAPA)$^{p,y}$ |
| Chicago | Preschool-aged children from inner city schools and pediatric practices (N = 796; age 2 - 5 years old) | 8.3% | Diagnostic Interview Schedule for Children–Parent Scale–Young Child Version (DISC-YC) $^p$ |
| Germany (Saarbrücken County) | All school-aged children were examined during a routine school-entry medical examination (N = 1676, mean age = 5.7) | 7.3% (males) 5.1%(females) | DISYPS-II |
| South Korea (Seoul) | Children were randomly surveyed across 6 school districts in Seoul (N = 1645, age 6 - 12 years old) | 5.8% (males) 4.1%(females) | Diagnostic Interview Schedule for Children–Parent Scale IV (DISC-IV) |
$^p$ Parent interviewed as part of diagnostic assessment; $^y$ youth interviewed as part of diagnostic assessment, $^r$ adult interviewed for retrospective report as part of diagnostic assessment
Note: Mash and Barkley note that prevalence rates of ODD must be qualified, because the definition of ODD has changed at a fast rate, the rates adolescents meeting criteria in any cross-sectional evaluation may be misleading because of the developmental progressions with and between ODD and Conduct Disorder, and categorical definitions of aggressive patterns may reflect arbitrary numbers of constituent estimates. These factors may lead to misleading prevalence rates. In addition, few studies have investigated the prevalence of ODD in preschool-aged children, and early onset of these behaviors is associated with more severe and stable impairment.

## Prediction phase

The following section contains a list of screening and diagnostic instruments for ODD. The section includes administration information, psychometric data, and PDFs or links to the screenings.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.
Screening measures for ODD :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Where to access |
| Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL) | Parent report | 6-18 | 10 - 15 minutes | A | E | E | G | Purchase |
| ASEBA: Teacher Report Form (TRF) | Teacher report | 6-18 | 10 - 15 minutes | A | E | E | G | Purchase |
| ASEBA: Youth Self-Report (YSR) | Youth self-report | 11-18 | 10 - 15 minutes | A | E | E | G | Purchase |
| Behavior Assessment for Children, Third Edition (BASC-3): Parent Rating Scale | Parent report | 2-21 | 10 - 20 minutes | A | E | G | E | Purchase |
| BASC-3: Teacher Rating Scale | Teacher report | 2-21 | 10 - 20 minutes | A | E | G | E | Purchase |
| BASC-3: Self-Report of Personality | Youth self-report | 6 - college age | 30 minutes | A | E | G | E | Purchase |
| Eyberg Child Behavior Inventory (ECBI) | Parent report | 2-16 | 5 minutes | A | G | E | E | Purchase |
| Sutter-Eyberg Student Behavior Inventory - Revised (SESBI-R) | Teacher report | 2-16 | 5 minutes | A | G | E | E | Purchase |
| Child and Adolescent Behavior Inventory (CABI) | Parent Report | 3 - 18 | 5 - 10 minutes | | A | | | PDF |
| Strengths and Difficulties Questionnaire (SDQ) | Parent report | 3 - 16 | 3 - 5 minutes | E | G | | | SDQ HomepagePDFs -Strengths and Difficulties Questionnaire for parents or educators of 2-4 year olds Assessment Center Link -Strengths and Difficulties Questionnaire for parents or teachers of 4-10 year olds Assessment Center Link -Strengths and Difficulties Questionnaire for parents or teachers of 11-17 year olds Assessment Center Link -Strengths and Difficulties Questionnaire (Child Self-Report) [age 11-17] Assessment Center Link -Strengths and Difficulties Questionnaire for self-report by those aged 18+ Assessment Center Link -Strengths and Difficulties Questionnaire for informant report on those aged 18+ Assessment Center Link |
| Disruptive Behavior Disorder Rating Scale | Parent report, teacher report | 5 - 17 | 5 - 10 minutes | | | | | PDF |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening instruments for ODD

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
| Screening Measure (Primary Reference) | Area Under Curve (AUC) | LR+ (Score) | LR- (Score) | Clinical Generalizability | Where to Access |
| CBCL DSM-Oriented Scales | .71 (N=475) | 2.80 (60+ to 70+) | .52 (60- to 70-)* | Youth aged 5 - 18 seeking out patient treatment across a variety of settings | Purchase |
| SDQ | .81 -.88 (N = 18,416) | 7.00 | .55 | Youth aged 5 - 18 seeking out patient treatment across a variety of settings | SDQ HomepagePDFs |
| SDQ - DSM -IV Conduct and ODD | | 7.55 (3+) | .35 (3-) | Surveyed youth aged 5 - 15 in the UK | SDQ HomepagePDFs |
| ECBI- Intensity Scale | | 6.92 (131+) | .11 (131-) | Youth aged 7-16 had responses compared to diagnosis | Purchase |
| BASC-2 PRS - Aggression | .76 (N =156) | 3.62 (65+) | .60 (65-) | Youth from first through fourth grade who were at risk for CD | Purchase |
Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation.
Search terms: [Oppositional Defiant Disorder] AND [sensitivity OR specificity] in GoogleScholar and PsychINFO;

### Interpreting ODD screening measure scores

* For information on interpreting screening measure scores, click here.

## Prescription phase
### Gold standard diagnostic interviews

* For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

### Recommended diagnostic instruments for ODD

Diagnostic instruments for ODD :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Where to Access |
| Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (KSADS-PL) | Structured interview | 6-28 | 45-75 minutes | E | G | | | | Website to access |
| Diagnostic Interview Schedule for Children (DISC-5) | Structured Interview (Self report and parent) | 6-17 | | | | | | | Coming soon |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

The following section contains a list of process and outcome measures for oppositional defiant disorder. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

### Outcome and severity measures

* This table includes clinically significant benchmarks for generalized anxiety disorder specific outcome measures
* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
| Measure | Subscale | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Benchmarks Based on Published Norms ||||||||
| | | A | B | C | 95% | 90% | SE$_{difference}$ |
| CBCL T-scores (2001 Norms) | Externalizing | 49 | 70 | 58 | 7 | 6 | 3.4 |
| ECBI Scaled Scores (1983 Norms) | Intensity | 80.1 | 169.5 | 112.9 | 9.5 | 8 | 4.8 |
| ECBI Scaled Scores (1983 Norms) | Problem | 3.9 | 17.7 | 11.5 | 2.1 | 1.8 | 1.1 |
Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

### Process measures

See Section 1.1 for overview of evidence-based measures to use depending on etiology and symptomatology of Oppositional Defiant Disorder.

## Treatment
### Behavioral parent training

Behavioral Parent Training is considered the most effective treatment for childhood disruptive behavior disorders (e.g., Oppositional Defiant Disorder), especially for younger children (i.e., 3-8 year-olds). See http://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/rule-breaking-defiance-and-acting-out/ a website sponsored by The Society for Child and Adolescent Psychology (APA, Division 53) and the Association for Behavioral and Cognitive Therapies (ABCT), for current summary of evidence-based treatments.

### Overview of recommendations for assessment and treatment

See the National Institute for Health and Care Excellence (NICE) Practice Guidelines for Childhood Conduct Disorders, for an overview of recommendations for both assessment and treatment of Oppositional Defiant Disorder.

## External Links

* Society of Clinical Child and Adolescent Psychology
* http://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/rule-breaking-defiance-and-acting-out/