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The Myths of Oppositional Defiant Disorder

Does a diagnosis of ODD help or hurt children and families?

Key points

  • Oppositional defiant disorder (ODD) is a common diagnosis that people often only treat with behavioral plans.
  • Symptoms of ODD are general in nature and common to other diagnoses and problems.
  • Determining ODD's symptoms' underlying causes helps build a more effective treatment plan.
  • ODD has taken on a judgmental tone of blaming kids and parents alike for "bad behavior."
Nicoleta Ionescu/Shutterstock
Source: Nicoleta Ionescu/Shutterstock

My child is holding us hostage!

“Everything is a fight. Nothing is easy”!

I can’t begin to count the number of patient evaluations or school consultations I have done over thirty years that begin with these words. Parents and kids usually struggle with this dilemma long before they get a psychiatric consultation.

In school, teachers and paraprofessionals, social workers, psychologists, and administrators have often spent hours huddling about these students, with emails and phone calls flying between home and school.

Emotions run high in these situations–in the children and the adults. Children’s meltdowns disrupt everyday life, and parents feel they are being held hostage to the child’s refusals. Parent meltdowns are not uncommon either–that’s understandable given the hopelessness and helplessness stirred up when this happens.

Usually, parents and schools have employed many behavior plans–sticker charts, reward systems, time-outs, and loss of privileges, and nothing seems to work. Parents don’t want to hear about another behavior plan or how they can do “better” or be more persistent with it.

Teachers are often deeply frustrated when classroom behavior plans don't work. And quite often, somewhere along the line, someone has told the parents that their child has oppositional defiant disorder–or ODD.

What Is ODD?

ODD is a psychiatric diagnosis. A version of it has been in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) since DSM III in 1980. ODD symptoms include angry/irritable mood, argumentative or defiant behavior, and sometimes being vindictive or spiteful.

ODD is not a mood or an anxiety disorder. It’s not ADHD or autism spectrum. But it is found to overlap with these conditions much of the time. Studies have shown that kids diagnosed with ODD have a 90 percent chance of risk of a mental health disorder diagnosis at some point in their lifetime.

ODD seldom stands alone, yet many children get this as their primary diagnosis, even though it is nonspecific. Over the years, ODD has become a shorthand for “difficult children, " assuming it is a behavior problem. Therefore it is treated primarily with behavioral interventions that often don’t work. These behavioral interventions often result in blaming the child for not trying hard enough or not wanting to do better.

Parents may get blamed for not “sticking to the behavior plans”–they are “caving.” And teachers who have so much else on their plate are asked to use behavior plans in the classroom but given few alternatives when those plans don’t work.

ODD is a general set of symptoms that can be the final common pathway of many different problems and situations. It’s like a fever. It’s a signal that something is wrong, but on its own, we don’t know what’s causing it. The list of problems that could underlie a child’s pattern of not doing what they are told is long and often accompany multiple and layered causes. Many–if not most–of these problems won’t “get better” with stronger or more intense behavior plans. For many of them, behavior plans will make things worse.

Oppositional Behavior Is Part of Growing Up

All kids are oppositional at times–it’s part of typical development. Some kids are more “persistent” than others temperamentally. They may take longer or more indirect routes to change their behavior, but they will get to it.

Children eventually meet age-appropriate demands because they are developmentally ready to do so and because the environment gives them feedback about their responses. Negative outcomes occur for refusing to do things, and positive outcomes occur for doing what they are asked to do.

The challenge for the kids labeled “oppositional defiant” is that they don’t change their behavior in response to the usual consequences. These kids also exhibit responses that are inconsistent with their developmental stage– i.e., tantrums are typical for a two-three-year-old but not for an eight-year-old.

Nicoleta Ionescu/Shutterstock
Source: Nicoleta Ionescu/Shutterstock

What Problems Can Cause “Oppositional” Symptoms?

When I evaluate a child who is described as oppositional, I try to start by changing the assumption that the child is oppositional on purpose–that they are willfully refusing to do things and willfully not changing their behavior in response to consequences.

I encourage family and school staff to describe the child as “struggling with meeting demands”–not choosing to oppose them. I like the term “reflex refusals” as a more neutral way of describing these patterns. These kids' responses are symptoms–not willful or manipulative behaviors. But what are they symptoms of?

The following list includes many– but not all–of the potential underlying causes for reflex refusals and irritability–that would fall under a diagnosis of ODD:

  • ADHD
  • Anxiety disorders including separation anxiety, generalized anxiety, and social anxiety disorders
  • Selective mutism
  • Autism spectrum disorder
  • Obsessive-compulsive disorder
  • Depression and related disruptive mood dysregulation disorder
  • Mania and psychosis
  • Learning difference
  • Speech and language delays
  • English as a second language
  • Chronically fatigued
  • Chronically hungry
  • Grief/loss
  • Family stress and conflict
  • Trauma–acute or chronic and ongoing
  • Attachment disruptions
  • Pain–such as headache or menstrual cramps or intestinal distress–and many others
  • Other medical problems undiagnosed or not spoken about
  • Embarrassment or social conflicts–bullying
  • Eating disorders
  • Substance use
  • Overly restrictive authoritarian parenting
  • Overly permissive parenting
  • Being given demands that don’t meet a child’s developmental skill level

The Social Story of “Oppositional” Behaviors

The diagnosis of ODD–the perception of a child being “difficult”–is also a social construct, vulnerable to deeply embedded filters such as racism. Extensive research has shown that children of color are much more likely to be seen as "difficult" or "defiant" than white children. Other filters can include sexism, for example, when girls are more likely to be seen as difficult if they exhibit behaviors typically seen as "masculine."

Ableism is a filter through which ability is presumed, and disability is ignored or dismissed, judged or rejected. It harms everyone with a disability and is a long, minimized, deeply harmful cultural phenomenon.

In the case of ODD, ableism is behind the assumption that all children are able to meet adult demands at all times, and if they don't, it's because they "just don't want to."

The disabilities that lead to reflex refusals are often not easily seen from the outside, so presuming ability is even more likely. Once children are labeled as a "problem," this takes on a life of its own. The child believes it, and people around them believe it, which can have devastating consequences for a child’s development.

Treating Underlying Problems Is Essential for Success

As you can imagine, many of the issues discussed here don’t respond to behavior plans alone. We must find out what’s going on before implementing effective interventions. If we just keep expecting kids to “behave” when they can’t change their behavior, the child ends up feeling hopeless, despairing about themselves and/or angry and disaffected from family and school. Assigning and imposing a behavior plan when it is the wrong tool can cause many negative outcomes.

 Nicoleta Ionescu/Shutterstock
Source: Nicoleta Ionescu/Shutterstock

Children and adolescents who present with reflex refusals need a thorough assessment by a professional who will obtain a detailed developmental, medical, psychiatric, family, and educational history. They will also talk to and directly observe the child. The evaluator may also order or review psychological or medical testing reports along with symptom scales such as a Conner's scales (for ADHD patterns) or a Child Depression Inventory (to identify possible depression). Identifying underlying and associated conditions and concerns will provide helpful information to build effective interventions rather than applying the "one size fits all" approach to behavior plans.

The professional evaluation may find child-centered diagnoses such as ADHD, and/or it may uncover environmental problems such as a mismatch between demands and skills or past or present trauma. Armed with this information, children, families, and schools can create interventions that have a higher likelihood of success, decreasing frustrations, and feelings of hopelessness in the whole system.

Behavior plans aren't inherently bad or ineffective but are only one tool. And if e applied without addressing the problems underlying behavioral symptoms, they won't work and can backfire.

Taking ODD at face value doesn’t serve anyone–especially the child. Seeing it as an emotional/behavioral "fever" and figuring out what’s behind it will help kids do and feel better and help families thrive.

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