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When to Refer Oppositional Defiant Disorder

Updated: May 3


Opposition and aggression are part of normal childhood development, but if they are developmentally inappropriate and last long periods of time, they can have serious consequences and may require a referral.

Oppositional defiant disorder (ODD) is a condition occurring in 2%–16% of children. Pediatricians have heard the parental complaints about the oppositional child: The child won't listen, won't obey, and does exactly the opposite of what is asked.

“Sixty percent of the time, preschoolers will do what the parents ask,” said Barbara Howard, M.D., a behavioral pediatrician at Johns Hopkins University, Baltimore. “But the oppositional child will only do what the parent asks about 30% of the time.”

“Pediatricians need to figure out the meaning of the behavior by eliciting specific examples from the parents,” Dr. Howard said at a meeting sponsored by the American Academy of Pediatrics and California Chapter 2 of the AAP.

Remember that ODD begins at home; just because the child is doing okay at school doesn't mean the child does not have ODD, she said.

The condition is defined as: developmentally inappropriate hostile or defiant behavior that lasts for more than 6 months.


It is characterized by:

  • the child's losing his or her temper

  • arguing with adults

  • actively defying compliance with requests.

  • The child deliberately annoys people and blames others for his or her mistakes. He or she often is angry, resentful, and vindictive.

The actions of the oppositional child may be:

  • a part of normal development

  • the result of inappropriate expectations by the parents

  • sleep deprivation

  • a stressful environment

  • attention-deficit hyperactivity disorder

  • traumatic life events

  • mood disorders

  • overly harsh discipline

  • overly lax discipline

What to do:

  • Take a detailed history, realizing that aggression and opposition can be a part of normal development, especially in children 18–36 months of age, she said.

  • Elicit specific examples of what was going on prior to the behavior, the actual behavior, and what resulted for the child and parents. Ask about the frequency, intensity and to what extent the behavior interferes with school and home life.

  • Then look for health, emotional or learning problems, school attainments, mood disorders, attention-deficit disorders or learning disorders, Dr. Howard said.