TOD. Artigo 1 em Ingles

International Journal of
Environmental Research
and Public Health
Systematic Review
A Systematic Review of Multiple Family Factors Associated
with Oppositional Defiant Disorder
Xiuyun Lin 1, *, Ting He 1 , Melissa Heath 2 , Peilian Chi 3 and Stephen Hinshaw 4
1 School of Developmental Psychology, Faculty of Psychology, Beijing Normal University, Beijing 100875, China
2 McKay School of Education, Brigham Young University, Provo, UT 84602, USA
3 Department of Psychology, University of Macau, Macau 999078, China
4 Department of Psychology, University of California, Berkeley, CA 94720, USA
* Correspondence: [email protected]
Abstract: Oppositional Defiant Disorder (ODD) is characterized by a recurrent pattern of an-

gry/irritable emotional lability, argumentative/defiant behavior, and vindictiveness. Previous studies
indicated that ODD typically might originate within a maladaptive family environment, or was at
least maintained within such an environment. As such, the present review summarized pertinent
research from the last 20 years that focused on the pathways connecting family risk factors to the
development of child ODD symptoms. A systematic search of electronic databases was completed in
August 2020, resulting in the inclusion of 62 studies in the review. The review established a multi-
level framework to describe the mechanisms underlying the pathway from familial factors to ODD
psychopathological symptoms: (a) the system level that is affected by the family’s socioeconomic
status and family dysfunction; (b) the dyadic level that is affected by conflict within the marital
dyad and parent–child interactions; and (c) the individual level that is affected by parent and child
factors. Additionally, from the perspective of family systems theory, we pay special attention to
the interactions among and between the various levels of the pathway (moderation and mediation)
that might be associated with the occurrence and severity of ODD symptoms. Considering future
Citation: Lin, X.; He, T.; Heath, M.; prevention and intervention efforts, this three-level model emphasizes the necessity of focusing on
Chi, P.; Hinshaw, S. A Systematic familial risk factors at multiple levels and the mechanisms underlying the proposed pathways.
Review of Multiple Family Factors
Associated with Oppositional Defiant Keywords: Oppositional Defiant Disorder; multiple risk factors; multi-level family factors theory;
Disorder. Int. J. Environ. Res. Public mediation; moderation
Health 2022, 19, 10866. https://
doi.org/10.3390/ijerph191710866
Academic Editor: Paul B. Tchounwou

1. Introduction
Received: 27 July 2022
1.1. Oppositional Defiant Disorder
Accepted: 27 August 2022
Published: 31 August 2022
Oppositional Defiant Disorder (ODD) includes a variety of emotional and behav-
ioral problems characterized by a recurrent pattern of angry/irritable moods, argumen-
Publisher’s Note: MDPI stays neutral
tative/defiant behavior, and vindictiveness toward authority figures [1–3] Although esti-
with regard to jurisdictional claims in
mates of prevalence range from 1% to 11%, the average prevalence rate is believed to be
published maps and institutional affil-
approximately 3–4% [1].
iations.
Prevalence rates of ODD vary across populations. One study conducted in China
found that the morbidity of ODD was 8% among Chinese children aged 7–15 years [4].
Furthermore, the rate of ODD may vary depending on the age and gender of the child [1].
Copyright: © 2022 by the authors.
For example, prior to adolescence, the disorder appears to be somewhat more prevalent in
Licensee MDPI, Basel, Switzerland. males than in females (1.4:1; [1]).
This article is an open access article A growing body of research documents that ODD is associated with distress in the
distributed under the terms and individual or others in his or her immediate social context (e.g., among family members,
conditions of the Creative Commons peer groups, work colleagues) and is accompanied by extensive social impairment [1,5].
Attribution (CC BY) license (https:// Throughout their development, children with persistent ODD symptoms are likely to
creativecommons.org/licenses/by/ be involved in interpersonal conflicts [6,7], and also have a high risk for several adjust-
4.0/). ment problems, including antisocial behavior, impulsivity, substance abuse, anxiety, and
Int. J. Environ. Res. Public Health 2022, 19, 10866. https://doi.org/10.3390/ijerph191710866 https://www.mdpi.com/journal/ijerph
Maíra Sobieski - [email protected] - CPF: 022.578.040-23
Int. J. Environ. Res. Public Health 2022, 19, 10866 2 of 19
depression [5,8]. Given the significant deleterious role of ODD in children’s social re-
lationships [1,7], it is necessary to investigate factors that influence the emergence and
trajectory of ODD. By deepening our understanding of this disorder, we can help to lay the
groundwork to better inform prevention and intervention strategies. We propose that these
strategies must strengthen family-based education, specifically focusing on the critical areas
of marital conflict, parent–child relationships, and individualized child-focused supportive
guidance [9].
1.2. ODD and Maladaptive Family Environment

Previous studies have identified numerous factors across diverse domains that appear
to facilitate the development of ODD symptoms. These include demographic, biological,
environmental, and individual factors and the interplay among these factors [5,8,10]. Due to
strong biological correlates, numerous studies on ODD covered a wide variety of individual-
level child factors that are associated with ODD symptoms. For instance, empirical studies
have begun to explore its epigenetics and gene-environment interaction [11]. Neuroimaging
findings converge to implicate various parts of the prefrontal cortex and amygdala [12].
Furthermore, alteration in cortisol levels has also been demonstrated consistently [13].
Additionally, psychosocial characteristics such as temperament, social cognition, and
emotion regulation are strongly associated with child ODD symptoms as well [14,15].
Nevertheless, ODD has considerable environmental etiology [16]. Family factors, such
as familial psychopathology, poor disciplinary practices, maltreatment, and neglect, are
known to be significantly associated with children’s disruptive behaviors [1,14,16]. In fact,
ODD is more prevalent in families where child care is disrupted by a succession of different
caregivers or in families where harsh, inconsistent, or neglectful child-rearing practices
are common [1,14,16]. Moreover, parenting practices, in particular, are the most amenable
and easily approached target in the management of ODD, emphasizing the importance
and necessity of investigating the links between family factors and child ODD symptoms.
Therefore, the origin and development of ODD would not be completely understood if
only individual child characteristics are considered. However, no systematic theory to our
knowledge has been proposed to account for the occurrence and development of ODD
within the family system, except for the multilevel family factors model [9].
1.3. Multilevel Family Factors

According to multilevel assessment, initially promoted by Vose (2010) and based
on the family systems theory, the family is a dynamic and interactive system reflecting
interdependent forces at multiple levels, including system, dyadic, and individual lev-
els [17]. Further, Lin et al. (2018) proposed a multilevel family factors model to explain
such effects (across the system, dyadic, and individual levels) on the development and
maintenance/exacerbation of child ODD symptoms [9]. However, the family risk factors at
each level require clarification and amplification.
With regard to the system level, the family is considered as a complete unit and
system that is composed of surface characteristics (e.g., social economic status) and deep
characteristics (e.g., family function). We review literature that describes both lower
socioeconomic status and impaired family function as system-level family factors that
are prominent contributors to child ODD symptoms. Of which, family function refers
to the interaction of physical, emotional, and psychological activities among all family
members [18]. As one of the system-level family factors, the realization of family function
provides certain environmental conditions for the healthy development of family members
in physiological and social aspects [18].
The dyadic level refers to the operation of each subsystem in the family, including
the wife–husband subsystem and parent–child subsystem. Previous studies focusing on
ODD risk factors were more inclined to explore dysfunctional parent–child interactions
independent of other family-related interactions [19]. However, more recently, impaired
couple interactions are shown to be a key contributor to the emergence and maintenance

of child ODD symptoms [20]. As such, the current review identified literature that corre-
sponded with the dual influence of couple interactions and parent–child interactions as
family factors at the dyadic level.
For individual factors, we considered each family member as a separate subsystem.
We included parental and child’s individual characteristics, cognitive factors, and emotional
factors as factors at the individual level. According to this conceptual framework presented
in this review, impairment and dysfunction of the family factors at three levels are critical
for the occurrence and aggravation of child ODD symptoms.
Based on the multilevel family factors model [9], we review previous research, partic-
ularly exploring familial risk factors of ODD across the past two decades. Furthermore,
we examine interactive mechanisms underlying these pathways, to better understand
the development of ODD and to assist in developing effective family-based educational
strategies for this disorder. We end the paper with a proposal of a three-level multilevel
family factors framework to highlight the importance and necessity of understanding child
ODD symptoms within the family context.
2. Method
Notably, the symptoms of ODD may be observed to some extent in individuals
not formally diagnosed with this disorder. Longitudinal studies reveal that many ODD
symptoms escalate from minor behaviors during the preschool period to more extreme
behavioral patterns during adolescence [1]. Such longitudinal trends highlight the critical
implication for early intervention that focuses on risk factors of both ODD symptoms and
ODD-related behavior patterns [1]. All procedures and findings are reported in accordance
with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines [21].
2.1. Literature Search

A systematic search of relevant electronic databases was completed in August 2020.
We conducted a literature search in ProQuest, Google Scholar, and Web of Science us-
ing the search term ODD/oppositional defiant disorder/oppositional defiant disorder
symptoms for all published journal articles from 2000 through 2020. Additionally, these
articles’ content-related citations were also examined. This procedure yielded a total of
4246 articles (see Figure 1 for the flow diagram of study selection). Of these, we found
that 1302 examined, to some extent, the associations of interest. Two independent coders
independently screened these articles against seven inclusion criteria, as noted next.
Figure 1. Flow diagram of study selection.

2.2. Eligibility Criteria

Inclusion criteria were established a priori: (i) peer-reviewed articles; (ii) publication in
English or Chinese; (iii) articles must be empirical studies; (iv) children or adolescents must
meet diagnostic criteria for ODD or exhibit ODD symptoms (with any version of the DSM
usable to assess the presence of ODD); (v) participant age under 18 years; (vi) consideration
of ODD or ODD symptoms as a child outcome; (vii) inclusion of familial risk factors such
as socioeconomic status and family function, marital conflict, parenting practices, parental
psychopathology or emotion regulation, and child temperament or social cognition.
A total of 62 articles met all inclusion criteria and, thus, were eligible. Descriptive
information about the studies is presented in Table 1.
Table 1. Descriptive information of studies included in the review (n = 62).
Characteristic n % Study Sample

Year of publication
2000–2010 20 32.3%
2011–2020 42 67.7%
Methodology
Cross-sectional 19 30.7%
Longitudinal 43 69.3%
Sample size
<100 8 12.9%
101–300 26 41.9%
301–600 12 19.4%
>600 16 25.8%
Mean age of child
participants
<5 years 16 25.8%
6–12 years 38 61.3%
13–18 years 8 12.9%
Note: The “Year of publication” indicates the year the article was published, the “Methodology” means whether
the article was a cross-sectional study or a longitudinal study, the “Sample size” represents the sample size the
study used, and the “Mean age of child participants” means the average age of the children in the article.
3. Result
3.1. Family System Level
3.1.1. Socioeconomic Status
Our review indicates the existence of increasing literature clarifying the negative effect
of low socioeconomic status (SES) on child ODD symptoms [22–25]. For example, of a
New Zealand longitudinal birth cohort, Boden, Fergusson, and Horwood (2010) sampled
926 youth who were diagnosed as CD (conduct disorder) or ODD. Family socioeconomic
disadvantage was significantly associated with CD and ODD [26]. Similarly, in their longitu-
dinal study—among a diverse community sample of 796 children—Lavigne and colleagues
(2016) found that family socioeconomic status was significantly and negatively related to
child ODD symptoms one and two years later (children at age 5 and 6, respectively) [19].
Life challenges associated with low SES include inadequate education, a chaotic
family environment, and nonresponsive and/or harsh parenting. Altogether, the negative
home environment prominently contributes to children’s externalizing and internalizing
problems [27]. From this perspective, the mechanism by which SES affects ODD might be:
a lower level of SES is linked to family conflict and hostility, which in turn contributes to
more ODD symptoms in children [28]. Additionally, the family investment model proposed
by Conger and Donnellan (2007) specifies that, when compared with children from low-SES
families, children from higher SES families had more access to financial, social, and human
(i.e., education) capital [29]. Accordingly, those parents might invest more in child-rearing
activities to foster child academic and social success, a robust protective factor against child
externalizing problems, including ODD symptoms [3].

3.1.2. Family Function

A solid research base confirms the robust link between family function and child
ODD symptoms [28,30]. Olson (2000) pointed out that family cohesion and adaptability
are two core components of family function [31]. Family cohesion refers to the emotional
connection among family members [32], while family adaptability refers to the ability
of a family system to change its power structure, role relationships, and relationship
rules in response to situational and developmental stress [31,33]. Lower levels of family
cohesion and adaptability are prominently linked to an increased number of child ODD
symptoms [28]. Compared to typical families, the quality of cohesion in families with ODD
children was much lower [34]. In a more recent study, among a sample of 256 children with
ODD (aged 6–12), Lin, and colleagues (2018) consistently found that a lower level of family
cohesion and adaptability was correlated with more child ODD symptoms, while a higher
level of family cohesion and adaptability predicted fewer child ODD symptoms [9].
According to McMaster’s family functional model theory, the failure of the realiza-
tion of family basic functions in the process of operation might be conducive to various
maladjustment and clinical problems among family members [35]. There are two possible
explanations for this. First, poor family function might lead to family role confusion and un-
stable rules, which may contribute to the increase of physical diseases and mental disorders
in children. Alternatively, families with poor function tended to have poor communication
and coordination ability and were less likely to solve family crises, which would lead to the
failure of the individual to learn positive coping styles. These threats to family functioning
might cause or exacerbate the symptoms of ODD in children.
3.2. Family Dyadic Level

3.2.1. Couple Interaction
There are considerable conceptual and empirical links between couple interaction
(marital quality and marital conflict) and child ODD symptoms [23,36]. According to the
emotional security hypothesis [37], marital conflict or a lower level of marital quality might
create a negative emotional atmosphere in the family, and long-term exposure to such a
negative emotional atmosphere may increase the risk of disruptive behaviors in children,
such as ODD symptoms [38]. Additionally, based on the “spillover” hypothesis, the feeling
or behavior born from one subsystem could emerge in another subsystem [39]. As such,
parents with impaired marital functioning may engage in poor parent–child relationships,
which in turn are related to poor child psychosocial outcomes [20].
In fact, previous studies have shown that lower levels of marital quality are associated
with more ODD symptoms in children [20,40,41]. Conversely, adaptive marital relation-
ships decrease the risk of child ODD symptoms [9,42]. Additionally, there is a consensus
that marital conflict is a pivotal contributor to child ODD symptoms [14,23,26]. For instance,
Burnette (2013) collected the data from wave 1 (n = 1992, mean age = 4.63 years) to wave 3
and the results suggested that intimate partner violence was associated with an increased
risk of child ODD symptoms [43]. Similarly, in the 4-year longitudinal study (199 3-year-old
children at wave 1), Harvey and her colleagues (2011) confirmed a significant predictive
effect of intensive marital conflict on the number of child ODD symptoms [23].
3.2.2. Parent–Child Interaction

As for factors associated with parent–child interaction, parenting practice appears to
play a critical role in the development of child ODD symptoms. As such, in this study, we
primarily focused on the effect of parenting practice on child ODD symptoms. Darling
and Steinberg (1993) defined parenting practice as “the behaviors that include both the
specific, goal-directed behaviors through which parents perform their parental duties and
non-goal-directed parental behaviors, such as gestures, changes in tone of voice, or the
spontaneous expression of emotion” (page 488) [44]. Maladaptive parenting practices
that contribute to the development of ODD symptoms included less parental monitoring
and less parental involvement and discipline [45–48]. Brown et al. (2017) investigated

the association between parental monitoring and ODD in children at age 3 (n = 419) and
again at age 6 [46]. The results manifested that poor parental monitoring at age 3 predicted
more child ODD symptoms at age 6, suggesting that a higher level of parental monitoring
is a potential protective factor for child ODD. An uninvolved parenting style was also
significantly correlated with more ODD symptoms in children [45]. For example, by
utilizing a community sample of 89 children ranging in age from 9 to 12 years, Pederson
and Fite (2014) demonstrated that poor parental involvement is linked to more ODD
symptoms [49].
Parental discipline practices have also been linked to child disruptive behavior dis-
order, including ODD. Specifically, inconsistent use of discipline, failure to use positive
reinforcement (e.g., support and acceptance), and excessive use of corporal punishment
have been linked to child ODD symptoms. Of which, inconsistent use of discipline refers to
not following through with proposed punishments [50,51]. Tung and Lee (2013) sampled
162 5- to 10-year-old children and concluded that inconsistent discipline predicted elevated
ODD among children experiencing low peer acceptance or high peer rejection, even control-
ling for children’s age, sex, number of ADHD symptoms, and parents’ race-ethnicity [51].
Additionally, less use of positive strategies, such as support and acceptance, in parenting
also contributed to more ODD symptoms in children [43]. For instance, in a longitudinal
study, Lavigne and colleagues (2016) found direct effects of parental hostility on child ODD
symptoms one year later. In contrast, a higher level of parental support lowered the risk of
subsequent ODD symptoms [19]. Moreover, research has shown that excessive use of cor-
poral punishment promotes and exacerbates child problem behaviors and ODD symptoms
as well [49,52]. Li, Lin, Hou, Fang, and Liu (259 6- to 13-year-olds; 2016) and Liu, Lin, Zhou,
Zhou, Li, and Lin (368 7- to 14-year-olds; 2017) found that parental maltreatment served
as a vital risk factor in relation to children’s emotional and behavioral problems [53,54].
Cruz-Alaniz, Martin, and Ballabriga (2018) also found that harsh parenting was positively
associated with child ODD symptoms, based on data from their sample of 100 families
with preschool children [55].
3.3. Family Individual Level

3.3.1. Parental Individual Level of Factors
In this section, we review information about individual levels of parent factors. These
factors include parental individual characteristics (parental psychopathology), cognitive
factors (parental negative attribution style), and emotion factors (emotion regulation).
Parental psychopathology. Parent psychopathology, through its impact on the emo-
tional climate of the family [37], is another factor linked to child ODD symptoms. To date,
parental depression, aggression, anxiety, and alcohol and drug dependence have all been
suggested to contribute to an increased number of ODD symptoms in children [56–58]. A
study that investigated how parental depression affected children was conducted by Liu,
Lin, Xu, Olson, Li, and Du (2017, [59]). Their research findings demonstrated that parental
depressive symptoms were associated with higher levels of depression and conduct prob-
lems among children with ODD (n = 234, aged 6–13-years). Importantly, Harvey et al.
(2011) found that initial changes in maternal depression corresponded to initial changes in
child ODD symptoms [23].
Furthermore, Antúnez, Nuria, Granero, and Ezpeleta (2016) sampled a total of 550 chil-
dren evaluated at ages 3, 4, and 5 and revealed that maternal high aggressive behavior is
positively associated with the child’s ODD level [60]. Additionally, children of parents with
depression and anxiety may be more likely to have behavioral problems and develop ODD.
In a similar study, based on a community sample of 622 children who were assessed longi-
tudinally at age 3 and age 5, Trepat, Granero, and Ezpeleta (2014) suggested that fathers’
anxiety-depression and aggressive behavior were strong predictors of child ODD [52].
In terms of parents’ alcohol and drug dependence, data from a community-based
investigation of adolescents (age 17 years, n = 1252) and their parents revealed that parental
alcohol and drug dependence were similarly associated with an increased risk for ODD [57].

Likewise, Rowe, Maughan, Pickles, Costello, and Angold (2010) also asserted that children
with CD showed significantly higher rates of parental drug and alcohol problems when
compared to their study’s no-diagnosis group [61]. The ODD group’s data fell between
the other two groups (CD group and no-diagnosis group) when compared to the other
two groups’ data. Rowe et al.’s analyses were based on four waves of data covering
1420 children in the community aged 9–16 years.
Parental attribution style. According to Weiner’s (1974) original attributional model,
three proposed dimensions are linked to the attribution process [62]. These dimensions
include the locus (whether the behavior was caused by the child, other people, or the
environment), control, and stability [63]. Johnston and Ohan (2005) suggested that parents
of children with ADHD and disruptive behavior disorders were more likely to attribute
children’s negative behaviors as internal and stable, whereas they attributed children’s
positive behaviors as external, less stable, and less controllable [64]. These attributions were
especially noted when child behavioral stimuli were ambiguous. Parents’ inaccurate attri-
bution of their child’s ODD symptoms frequently limited the parent’s ability to realistically
interpret the child’s real intent underlying the behaviors. In turn, the parent’s negative
attributions further impacted child development negatively [64].
Research on the relationship between parental attribution style and child ODD symp-
toms is less abundant. However, studies on the linkages between parental attributional
style and children’s emotional and behavioral problems may provide indirect evidence.
For example, Wang and Wang (2018) sampled 864 students (mean age = 13.55 years) in
China and found that negative paternal attribution was positively associated with child
emotional problems [65]. From the perspective of parental locus of control (PLOC), McCabe,
Goebring, Yeh, and Lau (2008) studied 58 children with behavior disorders and 57 typically
developing children with no behavioral disorders. Children in the sample ranged between
the ages of 3 and 7 [66]. They found that their sample of Latino parents were more apt to
adopt external control attribution and that their pre-school children were more likely to
exhibit behavioral problems. In studies such as McCabe et al. (2008) and Wang and Wang
(2018), parents of children with ODD symptoms are inclined to consider child behavior
problems as uncontrollable and difficult to manage. Consequently, these parents might not
take the initiative to discipline children.
Parental emotion factors. One of the main contributing factors to the development
of ODD symptoms in children is parental socialization of emotion, which is thought to
occur through modeling of emotional expression and regulation, direct coaching in how to
identify and cope with emotion, and/or parental reinforcement of emotional expression [67].
Dunsmore, Booker, and Ollendick (2013) illustrated that parental emotional expression
placing value on children’s appropriate expression of emotion, and engaging in direct
instruction about coping strategies, may ameliorate children’s emotion regulation and
emotional understanding, which would reduce ODD symptoms [68]. In the aspect of
the empirical research, Duncombe, Havighurst, Holland, and Frankling(2012) conducted
a study among 373 5- to 9-year-old children with typical ODD symptoms. They found
that negative parental emotional expression positively correlated to the number of ODD
symptoms in children [56]. Similarly, by using a longitudinal design with a sample of 146
children (5 years old at Time 1) and their parents, Weber-Milne (2015) confirmed the strong
link between parents’ emotional expression and children’s OD behavior [69].
As for the other aspect of parent emotion socialization, parental emotion regulation
plays an important role in the development and maintenance of child ODD symptoms as
well [53]. The deficits in parental emotion regulation might affect the process of child emo-
tion socialization, contributing to poor psychological outcomes [70]. For instance, among a
sample of 239 6- to 13- year-old children with ODD, Lin et al. (2019) found that parental
emotion dysregulation was positively associated with child depressive symptoms [15].
Additionally, Jiang, Lin, Zhou, Hou, Ding, and Zhou (2020) sampled 123 Chinese children
with ODD (ages 6–13) and their mothers. Their data indicated that maternal emotion
dysregulation was significantly and positively related to child ODD symptoms [71].

3.3.2. Child Individual Level of Factors

Over the past 20 years, research findings indicate that several individual child factors
are associated with the development of child ODD symptoms. These child factors include
child individual characteristics (children’s temperament), cognitive factors (social cogni-
tion), and emotion-related factors (emotion regulation). These factors are described in the
following sections.
Children’s temperament. Researchers have focused on the link between infant
temperament—such as high novelty seeking, low harm avoidance, high persistence,
negative affect, low levels of effort control, and disinhibition [72,73]—and future psy-
chopathology, including ODD [74,75].
Kim, Cho, Kim, Kim, Shin, and Yeo (2010), for example, confirmed the positive rela-
tionship between novelty seeking and child ODD symptoms. Their study was conducted
with parents of children (mean age of children, 10.4 ± 3.0 years), including 94 parents of
children with ODD and 94 parents of children with no identified behavioral problems [76].
Kim et al.’s study is in line with other research, such as the study conducted by Joyce
and Oakland (2005) [77]. Interestingly, Melegari and her colleagues (2015) elucidated that
children with ODD were characterized with higher scores on novelty seeking, persistence,
and harm avoidance. In particular, higher persistence accounted for more resistance to
the extinction of maladaptive behaviors, which align with the oppositional and defiant
symptoms in ODD. Their sample consisted of four groups (n = 120; 30 per group): ADHD,
anxious, ODD, and control children. The mean age of children was 4.65 ± 0.88 years. [78]
Additionally, a high level of negative affect (i.e., high levels of anger, sadness, and fear)
proved to be a robust risk factor for child behavior problems, especially when combined
with a lower level of effortful control (i.e., thoughtful, deliberate forms of regulation; [60,69]).
Nielsen (2014) found that negative affect was positively correlated with the initial level of
ODD symptoms, and predicted an increase in ODD symptoms from age 4 to 6 (n = 797) [79].
While high effortful control was associated with minimal ODD symptoms at age 4, effortful
control did not predict a change in such symptoms over time. However, in interactions
with negative affect, the protective effect of effortful control was strong for children high
on negative affect but lower for children low to moderate on negative affect. More recently,
Frick and Brocki (2019) sampled 77 children aged 8 to 12 years and found that child
effortful control contributed independently to inattention and hyperactivity/impulsivity,
while negative affect contributed to child ODD symptoms [80].
Furthermore, disinhibition (i.e., difficulties with behavioral, cognitive, and emotional
regulation), another similar dimension of maladaptive temperament, has also attracted
researchers’ attention [76]. Extant studies have indicated that disinhibition is a prominent
contributor to the development of children’s disruptive behavior disorders, including
behaviors associated with ODD [81]. Additionally, among a total of 7140 children in a
longitudinal study, Stringaris et al., (2010) found that high levels of emotionality and
activity at the age of 38 months strongly predicted the development of ODD at the age of
91 months [75]. In this sense, higher levels of activity might contribute over time to children
developing additional ODD symptoms, including impulsivity and hyperactivity. Notably,
over time, higher levels of emotionality might lead children to behave in an oppositional
manner, particularly during stressful or emotionally arousing situations [82].
Children’s social cognition. Previous studies have investigated the relationship be-
tween social cognition and children’s emotional and behavior problems, including ODD
symptoms [83–86]. For instance, research conducted by Dinolfo and Malti (2013) has veri-
fied that interpretive understanding, sympathy, and strength of moral emotion attribution
predicted ODD symptoms negatively [87]. Their study included an ethnically diverse
sample of 128 4- and 8-year-old children. Additionally, Osa, Granero, Domenech, Shamay-
Tsoory and Ezpeletain (2016) sampled 538 preschoolers, more specifically in a subsample
of 40 children diagnosed with ODD [88]. The results revealed that children diagnosed with
ODD had a slower response time when performing the affective mentalizing condition
than children without the disorder, indicating that children with ODD were impaired

in the theory of mind aspect and the psychological domain. Furthermore, Skoulos and
Tryon (2007) studied 27 children who met the ODD diagnostic criteria and 27 children
(aged between 14.3–19.3 years) who did not meet the ODD diagnostic criteria [89]. They
suggested that a lack of adaptive social skills exacerbated psychopathology in adolescent
females who were identified with educational disabilities and who displayed symptoms
of ODD.
Additionally, the social information processing (SIP) was particularly well docu-
mented in previous studies, which accounted for the proximal factors of child externalizing
problems [90]. Specifically, there are several steps in the SIP model (encoding, making
attributions, selecting a goal, generating responses, evaluating responses, and enacting
responses), and researchers investigated the different outcomes resulting from problems
associated with different SIP steps and the interactions among these steps [90]. Coy, Speltz,
Deklyen, and Jones (2001) compared the difference in social information encoding between
children with ODD and those without ODD [91]. The sample included 88 preschool boys
with ODD and 80 nondisruptive boys, with longitudinal assessments over a two-year
period. The results showed that boys with ODD encoding of social information were less
accurate than normally developing children.
Children’s emotion regulation. The development of adaptive emotion regulation (ER)
competencies is critical in children’s early development [92]. When persistently failing
to cope with negative emotions (i.e., venting and lack of effective regulatory strategies),
children become overwhelmed with distress and frustration and are at a heightened risk
for developing psychopathology and experiencing maladaptive outcomes [93,94]. Indeed,
considerable research has shown that maladaptive ER competencies are significantly related
to the development of child ODD symptoms [95–97]. More succinctly stated, children with
impaired ER competencies appear to be more vulnerable to developing ODD symptoms
and other psychopathology [98–101].
In another study conducted by Schoorl, van Rijn, de Wied, van Goozen, and Swaab
(2016), included 65 boys with ODD/CD and 38 typical developing boys (8–12 years),
Schoorl et al. (2016) asserted that the ODD/CD group rejected more ambiguous offers
than the non-clinical (NC) group, which was seen as an indication of poor emotion reg-
ulation [102]. Parents also reported that the ODD/CD group experienced more emotion
regulation problems in daily life than the NC group. Additionally, Paliziyan, Honarman,
and Arshadi (2018) sampled 320 students with a mean age of 16.34 (SD = 0.66) years and
found that emotion dysregulation was the most effective predicting variable of ODD [103].
More recently, Lin et al. (2018, 2019) also stated that lower levels of emotion regulation play
a transdiagnostic predictive role in children’s co-occurring internalizing psychopathology
and ODD symptoms [9,15].
3.4. Multi-Level Family Factors Interactions

Taken together, the multilevel family factors, including the system level, dyadic level,
and individual level, play critical roles in the development of child ODD symptoms. With
regard to the system level, both low levels of SES and family dysfunction were related to
the development of child ODD symptoms. As for the dyadic level, the negative effects of
marital conflict and negative parent–child interactions on child ODD symptoms is well
documented. Concerning the individual level, both parental and child factors (individual
characteristics, cognitive factors, and emotion factors) contribute to the development and
maintenance of child ODD symptoms.
Nevertheless, according to family systems theory [104], during interactions, any
changes in the function of one family member elicits a compensatory change in another
family member. Within the family system, both the interactive processes among different
familial factors are emphasized. In other words, rather than in a direct manner, the influence
of risk factors in one family level on the development of child ODD are likely to be mediated
and moderated by factors in other levels of the family system.

Given the importance of the family systems theory, in the following sections, we
review the interplay of how family factors at the system, dyadic, and individual level affect
child ODD symptoms. We elucidate these interconnected multi-level relationships as we
propose our understanding of how factors at system, dyadic, and individual levels exert
effects on the development and maintenance of child ODD symptoms.
3.4.1. Mediation/Moderation Effect between Family SES and Child ODD Symptoms
Researchers have illuminated that lower SES, as a distal factor to the child, exerts its
effect indirectly, through more proximal factors, such as dyadic marital relationship, parent–
child relationship, and parenting, as well as individual parent and child factors [19,28]. For
example, Granero, Louwaars, and Ezpeleta (2015) sampled 622 3-year-old children and
demonstrated that the association between low SES and high ODD was partially mediated
by difficulties in child effort control, corporal punishment, and inconsistent discipline [105].
Additionally, Lavigne et al. (2012) studied 796 4-year-old children and found a direct
and negative relationship between SES and child ODD symptoms [28]. Further, this
relationship was mediated by dyadic-level factors (e.g., marital conflict, parental hostility,
parental support, and parental scaffolding), and individual-level factors (e.g., child effortful
control and sensory regulation). Consistently, Lavigne et al. (2016) examined a cascade
model of ages 4 and 5 multi-domain factors on child ODD symptoms at age 6 in a diverse
community sample of 796 children [19]. Significant indirect effects on age 6 ODD symptoms
were found for age 4 SES via age 5 conflict and parental scaffolding skills.
3.4.2. Mediation/Moderation Effect between Family Function and Child ODD Symptoms
Aside from SES, family dysfunction, a system-level family factor, also appears to
predict child ODD symptoms through the mediation of dyadic- and individual-level factors,
such as parenting practices and parental psychopathology [28]. In fact, impaired family
function might lead to more negative parenting practices (e.g., inconsistent discipline
and hostile parenting) and fewer positive parenting practices (e.g., warm and supportive
parenting), which further facilitates child ODD symptoms [28].
Individual parent and child factors are also significant mediators between family dys-
function and child ODD symptoms. For example, studies have suggested that family stress
and conflict, associated with parental depressive symptoms and child temperament, may
facilitate child ODD symptoms [28]. Additionally, Lin et al. (2018) purported that family
cohesion/adaptability affected child ODD symptoms indirectly through the sequence of
parent–child relationship and child emotion regulation [9]. This study’s results illustrated
that the distal factor of family cohesion/adaptability could exert its effects on child ODD
symptoms via more proximal factors, such as parent–child relationship and the child’s
emotion regulation.
Moreover, individual child factors also moderated the pathway from family dysfunc-
tion to the development of ODD symptoms. For instance, Chen et al. (2020) demonstrated
that children’s emotional lability/negativity significantly moderated the link between fam-
ily violence and children’s ODD symptoms, by using a sample of 409 children (Mage = 9.36,
SD = 1.55). Consistent with this viewpoint, a higher level of family violence was associated
with higher levels of ODD symptoms among children with lability/negativity [98].
3.4.3. Mediation/Moderation Effect between Couple Interaction and Child ODD Symptoms
Several studies have explored the individual mediators and moderators between
marital conflict and child ODD symptoms [15]. In particular, Lavigne et al. (2012) conducted
a multi-domain model of risk factors for ODD symptoms in a community sample of
796 4-year-old children [28]. The results showed that marital conflict had both direct effects
on ODD symptoms, and indirect effects via parental depression and child effortful control
and sensory regulation.
Furthermore, Ding et al. (2019) found that the link between marital quality and child
ODD symptoms was particularly moderated by child gender [20]. Specifically, parental

marital quality predicted subsequent ODD symptoms for boys. However, the direct effect
of paternal marital quality on girls’ ODD symptoms was not significant. Their sample
included 253 6- to 13-year-old children with ODD and their parents and teachers from
mainland China.
3.4.4. Mediation/Moderation Effect between Parent–Child Interaction and Child

ODD Symptoms
Previous studies also explored the interactive effect between parent–child interaction
and other familial risk factors on the etiology of child ODD symptoms [28,69,71]. Numerous
individual parent and child factors were identified to mediate or moderate the link between
parent–child interaction and child ODD symptoms [19,68]. For example, Duncombe et al.
(2012) elucidated that children’s emotion regulation ability may mediate the spillover from
parenting practices to child ODD symptoms [56]. In line with this, Lin et al. (2018) found
that parent–child relationships contributed to the development of child ODD symptoms
through the mediation of child emotion regulation [9]. More recently, Lin et al. (2019) found
that harsh parenting practices were directly and indirectly related to child ODD symptoms
through child emotion regulation [15]. Additionally, parental emotional abuse of the child
was associated with child depressive symptoms directly and indirectly through child
emotion regulation. In a longitudinal study, Jiang et al. (2020) asserted that children’s wave
3 emotion dysregulation mediated the longitudinal associations between mother–child
relationship quality and children’s wave 3 ODD symptoms [71].
Furthermore, children’s emotion regulation has also been verified as a moderator to
the parent–child interaction and ODD symptoms [68]. Dunsmore and colleagues (2013)
used a sample of 79 parent–child dyads (children’s age ranged from 7 to 14 years) and
illuminated that when children were high in emotion lability/negativity, mothers’ emotion
coaching was associated with fewer child ODD symptoms, supporting the potential of
maternal emotion coaching as a protective factor for children with ODD, especially for
those high in emotion lability [68]. Additionally, children’s specific temperament might
moderate the link between parent–child interaction and child ODD symptoms. For instance,
prior research has indicated that the more a father responded sensitively to the child, the
less likely the child was to display OD behavior and this relationship was stronger the
angrier a child’s temperament [69]. Moreover, Burnette (2013) clarified differences between
factors affecting ODD symptoms in girls and boys [43]. Specifically, the significant link
between parental physical abuse and ODD symptoms was found in girls but not boys.
However, parental emotional responsiveness was a significant predictor for boys only.
3.4.5. Three-Level Multiple Family Factors Framework

Drawing upon the existing research, we developed a three-level multiple family factors
framework that integrates the multilevel family factors model [9] and aforementioned
family risk factors, and their interactions (see Figure 2). It is important to note that causality
is likely bidirectional: Children’s ODD symptoms influence family factors at different levels
as well as vice versa [71,106]. Due to the space limitation and our primary focus of the
model (i.e., the hierarchy of family factors at different levels and their effects on child ODD
symptoms), the mutual linkages are not further elaborated in this review.
The three-level multiple family factors framework provides groundwork for research
to better describe the interplay of family risk factors at system, dyadic, and individual
levels and explain how these interactions affect the emergence and exacerbation of child
ODD symptoms in the family system. Additionally, the three-level multiple family factors
framework highlights the importance and necessity of understanding child ODD symptoms
within the family context.

Figure 2. Three-level multiple family factors framework. Note that there also may be bidirectional
relations and interactions among family factors and child ODD symptoms.
3.4.6. Future Prevention and Intervention Efforts

This multilevel family systems theory prominently expands our understanding of
the occurrence, maintenance, and development of child ODD symptoms. Based on our
broadened perspective, rather than viewing ODD symptoms as solely and independently
arising from children’s individual dysfunction, we propose that child ODD symptoms are
embedded in and influenced by multiple levels of family factors (the system, dyadic, and
individual level). Because child ODD symptoms undoubtedly hinge on comprehensive
family matters, family members must consider their role in and responsibility for child
ODD symptoms. This proposed multilevel family factors theory opens a more systematic
and global view to explore prevention and intervention strategies.
An accumulation of evidence suggests that intervening with ODD is a comprehensive
family matter [107]. Additionally, intervention strategies with multiple components are inclined
to more effectively and promptly eliminate or decrease child ODD symptoms [108,109]. As
such, future intervention and prevention efforts should carefully consider how family factors at
multiple levels are related to child ODD symptoms, then target multiple levels in the family
system, rather than solely focusing on child dysfunctional characteristics.
4. Discussion
Based on publications in the past two decades, we summarized familial risk factors
which are implicated in the etiology and maintenance of child ODD symptoms. Based
on this summary, we developed a multiple-level framework describing the mechanisms
underlying the pathway from familial risk factors to ODD psychopathological symptoms.
Particularly, from the perspective of the family systems theory, we divided these familial risk
factors into three different levels, including the system level, dyadic level, and individual
level (see Figure 2). From this perspective, children are at the highest risk for developing
ODD symptoms when confronting prominent problems in system level (e.g., lower SES,
family dysfunction), dyadic level (e.g., marital conflict, poor parent–child interaction), and
individual level (i.e., individual parent and child characteristics, cognitive factors, and
emotion factors).
We also explained the underlying mechanism between familial risk factors and child
ODD symptoms. Simply stated, there are significant interactive effects among various famil-
ial risk factors, which serve as both mediators and moderators in this process. Specifically,
indicators of the system level are the most distal risk factors of child ODD symptoms in
the family system, and the link between system level factors and child ODD symptoms are
prone to be mediated and moderated by factors at dyadic and individual levels. Indicators
on the dyadic level are more likely to be associated with child ODD symptoms directly
and indirectly via individual-level factors. Moreover, indicators on the parent and child
individual level are the most proximal risk factors of ODD symptoms and are inclined to
contribute to child ODD symptoms in a direct manner.

Overall, our study outlined the direct and indirect influences on the development,
maintenance, and modification of child ODD symptoms, including overall family func-
tioning, interparental relationship, parent–child relationship, parent characteristics, and
child characteristics. Based on this information, we recommend that future research focus
on multiple levels of familial risk factors related to child ODD symptoms, rather than
focusing on individual child psychological functioning. Additionally, our review pro-
vides contextual information to guide the development of more effective prevention and
intervention strategies.
Throughout the review, we found multiple levels of risk factors in the family system
that contributed to the occurrence and development of child ODD symptoms [5]. These
multiple levels of risk factors included factors of impaired family socioeconomic status
(SES) and family dysfunction on the system level; factors of marital conflict, maladaptive
parent–child relationships, and poor parenting practices on the family dyadic level; and
factors of parent and child characteristics on the individual level. In addition to these
factors documented in current review, we also believe that there are still more factors linked
to ODD symptoms. Logically, this suggests that ODD is a multiple-risk-factor consequence
rather than a single-child-individual problem.
Taking both parent–child interaction and child individual factors into consideration,
the three-level multiple family factors extends Vose’s (2010) work, which proposed a
multiple-level assessment of family functioning [17], involving whole family, dyad (i.e., in-
terparental relationship), and parental individual levels. Specifically, in the three-level
multiple family factors framework, we expanded on the family factors at the dyadic level.
In addition to interparental relationship, we also include the parent–child relationship.
Additionally, for family factors at the individual level, in addition to parental individ-
ual factors (including both paternal and maternal individual factors), we include child
individual factors.
In this review, our proposed three-level multiple family factors framework urges
researchers, practitioners, teachers, and parents to conduct prevention and interventions
for child ODD symptoms from the perspective of multilevel family factors theory. That
is, we must focus on risk factors of different levels, not solely on child individual factors.
Furthermore, for children with ODD symptoms, addressing multiple factors in the family
system will prove more effective than treating children in isolation of their environment,
most importantly, the family context. Our proposed framework also clarifies the interactive
effects among various familial risk factors, by examining the influences of both mediators
and moderators. Particularly, research that investigated factors at the system level was
limited. The majority of studies highlighted the mediated role of the dyadic and individual
levels of factors in the pathway from system-level risk factors to child ODD symptoms.
Furthermore, factors at the dyadic level were extensively examined. Our review addresses
the important roles of marital conflict and impaired parent–child interaction at the dyadic
level in the mechanism underlying the etiology of child ODD symptoms [23,45].
Additionally, it is important to note that, factors at the dyadic level may function in
two different ways in the family process [28]. First, factors at the dyadic level are related
to child ODD symptoms directly and indirectly via individual parent and child factors.
Second, dyadic-level factors serve as important mediators linking the system level factors
and child ODD symptoms. Moreover, according to our review, parental and child factors at
the individual level in the family system may account for the variance of the development
of child ODD symptoms. Additionally, individual parent and child factors, as proximal
factors, are more inclined to play a moderated and mediated role in the association between
distal family factors and child ODD symptoms in the family system. More studies that
combine longitudinal and experimental design with moderator/mediator analyses are
needed to further explore the interactive mechanism in the pathways from multilevel
familial risk factors to child ODD symptoms.

Limitations and Recommendations

We acknowledge several limitations in our review. First, we caution that the factors
we have proposed to be related to child ODD symptoms are solely from family domains.
We note that family domains are only part of the multiple pathways to the occurrence,
maintenance, and development of child ODD symptoms. Although Bronfenbrenner (1979)
considered the family system as the most proximal environment children confronted [110],
there are possible risk factors that we need to consider in other domains (e.g., peer interac-
tion, neighborhood environment, and social environment).
Second, we solely focused on the psychosocial factors. With strong biological correlates,
additional factors, such as genetic, neurophysiological, neuroendocrine, and neuropsycho-
logical causes, should be underscored.
A third limitation, our study predominantly focused on the hierarchy of family factors
at different levels and their effects on child ODD symptoms, the mutual linkages are not
further elaborated in this review. However, the interplay of multilevel family factors
and child ODD symptoms might initiate transactional feedback loops. Further research
should underscore the reciprocal relationships between multi-level family factors and
child ODD symptoms. Subsequently, although the selected literature addressed ODD or
ODD symptoms, some of the literature also included CD/ODD or ODD with CD/ADHD.
Therefore, we should be careful in our interpretation and comparison of data across studies.
Future studies need to verify the three-level multiple family factors framework in the pure
ODD group.
An increasing number of research studies have identified various moderators and
mediators in the pathway to the development of child ODD symptoms. Over time, these
efforts have identified prominently interactive effects among multilevel familial risk factors.
Therefore, future researchers should pay more attention to the comprehensive and system-
atical mechanism underlying the occurrence of ODD symptoms. When considering the
multiple pathways to ODD, in addition to carrying out research that replicates and expands
upon the multiple risk factors, it is essential to examine the interactive effects among risk
factors of multiple domains.
5. Conclusions
Overall, this review focused on the roles of familial risk factors in the etiology, main-
tenance, and development of ODD symptoms. These risk factors included lower family
socioeconomic status (SES) and family dysfunction on the family system level; marital
conflict and maladaptive parent–child relationship on the family dyadic level; individ-
ual parent factors, such as parental psychopathology, parental negative attribution style,
parental emotion factors; and individual child factors, including difficult temperament,
emotion dysregulation, impaired social cognition, and lack of empathy on the individual
level. During the examination, the interactive mechanism among various risk factors was
emphasized, which further accounted for the development of child ODD symptoms in
the perspective of the family systems theory. Additionally, according to the review, when
designing and developing family-based interventions and educational guidance to address
child ODD symptoms, researchers and practitioners must lay an extreme emphasis on
the dynamic and interactive effects of multiple levels of family factors that influence the
emergence and exacerbation of ODD symptoms. As well, both the initial predictors and
the mediators/moderators of child ODD symptoms should be taken into consideration,
rather than focusing solely on the individual child-related factors.
Author Contributions: Conceptualization, X.L.; methodology, T.H. and S.H.; software and validation,
P.C.; investigation and resources, T.H. and P.C.; Supervision, X.L.; Writing—original draft, X.L. and
T.H.; Writing—review & editing, M.H. and S.H.; project administration and funding acquisition, X.L.
All authors have read and agreed to the published version of the manuscript.

Funding: This research was funded by [The National Nature Science Foundation of China] grant
number [31800935, 32071072], and [The National Social Science Foundation of China] grant number
[18AZD038].
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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International Journal of

Abstract: Oppositional Defiant Disorder (ODD) is characterized by a recurrent pattern of an-

Academic Editor: Paul B. Tchounwou

1.2. ODD and Maladaptive Family Environment

1.3. Multilevel Family Factors

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

2.1. Literature Search

Figure 1. Flow diagram of study selection.

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

2.2. Eligibility Criteria

Table 1. Descriptive information of studies included in the review (n = 62).

Characteristic n % Study Sample

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

3.1.2. Family Function

3.2. Family Dyadic Level

3.2.2. Parent–Child Interaction

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

3.3. Family Individual Level

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

3.3.2. Child Individual Level of Factors

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

3.4. Multi-Level Family Factors Interactions

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

3.4.4. Mediation/Moderation Effect between Parent–Child Interaction and Child

3.4.5. Three-Level Multiple Family Factors Framework

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

3.4.6. Future Prevention and Intervention Efforts

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Limitations and Recommendations

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

Maíra Sobieski - [email protected] - CPF: 022.578.040-23

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