The many faces of oppositional defiant disorder.

The clinical heterogeneity within oppositional defiant disorder (ODD) is gaining some face validity with new research identifying two symptom factors within the eight DSM ODD symptoms. An “irritable/negative affect” symptom cluster is associated with internalizing disorders and a “headstrong/oppositional” cluster is differentially predictive of disruptive disorders (Stringaris & Goodman, 2009; Burke, Hipwell, & Loeber, 2010). This research is exciting as it suggests there may be more than one group of ODD children who would benefit from differential identification and provision of treatments. Gadow and Drabick (2012) identified groups who had predominantly irritable as opposed to disruptive ODD symptoms in their large clinical sample. The youth so identified did have some significant differences in comorbidity in the hypothesized direction (i.e. more internalizing disorders). However, the irritable group had more comorbidity overall, suggesting irritable youth with ODD are more globally impaired. Whether this group is a clinical subtype requiring a different treatment approach is unknown. In respect of this important work, I would like to suggest a clinical typology for ODD that may be of clinical use as it incorporates contextual and developmental information that we typically collect in practice.