464 Disruptive, Impulse-Control, and Conduct Disorders
Associated Features Supporting Diagnosis
In children and adolescents, oppositional defian t disorder is more prevalent in families in
which child care is disrupted by a succession of different caregivers or in families in which
harsh, inconsistent, or negl ectful child-rearing practice s are common. Two of the most
common co-occurring conditions with oppositi onal defiant disorder are attention-deficit/
hyperactivity disorder (ADHD)  and conduct disorder (see the section “Comorbidity” for
this disorder). Oppositional defiant disorder has been associated with increased risk for
suicide attempts, even after comorb id disorders are controlled for. 
Prevalence
The prevalence of oppositional defiant disord er ranges from 1% to 11%, with an average
prevalence estimate of around 3.3%. The rate of oppositional defiant disorder may vary
depending on the age and gender of the child . The disorder appears to be somewhat more
prevalent in males than in females (1.4:1) pr ior to adolescence. This male predominance is
not consistently found in samples of adolescents or adults. 
Development and Course
The first symptoms of oppositional defiant di sorder usually appear during the preschool
years and rarely later than early adolescence.  Oppositional defiant disorder often precedes
the development of conduct disorder, especial ly for those with the childhood-onset type
of conduct disorder. However, many children and adolescents with oppositional defiant
disorder do not subsequently develop cond uct disorder. Oppositional defiant disorder
also conveys risk for the development of anxi ety disorders and major depressive disorder,
even in the absence of conduct disorder. The defiant, argumentative,  and vindictive symp-
toms carry most of the risk for conduct disorder, whereas the angry-irritable mood symp-