Q. I am wondering if Oppositional Defiant Disorder (ODD) may manifest itself differently in adolescent females from more conservative cultures (Asian or Middle Eastern). For example instead of being openly defiant they are more passive aggressive in there defiance due to the emphasis of cultural upbringing?

A. I doubt we have the data to answer your question adequately. Oppositional Defiant Disorder (ODD) is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months, and is characterized by at least four of the following: losing one's temper; arguing with adults; deliberately doing things that will annoy other people; blaming others for his or her own mistakes or misbehavior; being easily annoyed by others; being angry and resentful, or being spiteful or vindictive. [These are the basic criteria put forth in DSM-IV].

A number of psychiatrists are skeptical of ODD as a bona fide diagnosis, and believe that many such cases really signify an underlying bipolar or other mood disorder. There seems to be very little research on the cross-cultural prevalence or manifestations of ODD per se.

However, one would expect some cultural variation in the diagnosis of ODD, based on differing concepts of disobedience, hostile, etc. This was partially borne out in a study by Mann et al (Am J Psychiatry 1992 Nov;149(11):1539-42). These authors looked at the degree to which mental health professionals in four countries differed in their ratings of hyperactive-disruptive behaviors in children.

The assessment tool used derived many of its items from the DSM-III-R criteria for ODD. Mental health professionals from China (N = 8), Indonesia (N = 12), Japan (N = 9), and the United States (N = 8) rated the presence and degree of hyperactive-disruptive behaviors in standardized videotape vignettes of four 8-year-old boys participating in individual and group activities.

The study found that Chinese and Indonesian clinicians gave significantly higher scores for hyperactive-disruptive behaviors than did their Japanese and American colleagues. The authors concluded that, "...perceptions of hyperactivity vary significantly across countries even if uniform rating criteria are applied. Without correction for these perceptual differences, cross-cultural prevalence rates of hyperactivity may not be comparable."

The authors specifically note that, "...in China, emotional control and conformity are valued and expected from preschool on...[whereas] individual expression and creativity are emphasized in the United States." Until we can get beyond differing cultural perceptions of oppositional and defiant behavior, we may not be able to answer your question regarding the cultural influences on this condition--if it is a single condition at all. Many of us have our doubts!

September 2003

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