O.D.D. Does Not Exist

Oppositional Defiant Disorder is not a valid diagnosis approximately 99%* of the time

As promised at the end of a previous article, I will explain how my research and experience combined have taught me that Oppositional Defiant Disorder (ODD) is not a valid diagnosis approximately 99%* of the time.

Please note: 99% is an entirely made-up statistic, however I will provide evidence to explain how and why I have formed this opinion.

Oppositional and Defiant

Also known as one stressed out kid lacking coping skills.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines ODD as a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviour towards authority figures (American Psychiatric Association, 2013).

The DSM-V diagnostic criteria for ODD requires a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms, and exhibited during interaction with at least one individual who is not a sibling.

Exclusion Criteria

Prior to diagnosing Oppositional Defiant Disorder, clinicians must differentiate between a number of other conditions that may present with similar symptoms (Aggarwal & Marwaha, 2020).

I’m going to list each of the current diagnostic criteria and provide evidence for how each symptom can be attributed to a different underlying condition.

Often loses temper

Children with ADHD often struggle with emotional regulation (Barkley, 2015). Dr. Barkley has been saying that emotional dysregulation is a key component of ADHD for many years, yet the DSM-V still has not caught up to what the research and the experiences of clinicians and people with ADHD have clearly demonstrated.

Cavanagh and colleagues (2017) concluded that O.D.D. is best conceptualized as a disorder of emotional regulation, rather than a disruptive behaviour disorder.

As I’ve mentioned previously, combine emotional dysregulation and impulsivity — both key symptoms of ADHD — and you quite easily end up with “frequently loses temper”.

Is often touchy or easily annoyed

Well, that can be a result of just about anything, but okay.

A direct link has been found between child anxiety and irritability, even after accounting for comorbid depressive disorders and O.D.D. (Cornacchio et al., 2016).

Irritability is a transdiagnostic symptom — meaning it is seen across multiple diagnoses — in oppositional defiant disorder, depression, and anxiety, all of which are highly comorbid disorders (Ezpeleta et al., 2020).

Clinicians would have to rule out all the other possible causes of being “easily annoyed”, such as depression, anxiety, stress, and overload due to neurodivergence (ie. ADHD, autism).

For both of the above criteria, there is yet another explanation: sensory processing disorder (SPD), or sensory processing impairments. Individuals with SPD have impaired responses to, processing of, and organization of sensory information.

In people with SPD, their brains cannot process sensory inputs correctly, causing inappropriate behavioural and motor responses that affect learning, coordination, behaviour and language. SPD can lead to stress, anxiety, and even depression (Galiana-Simal et al., 2020).

SPD is highly comorbid with both ADHD and autism (Dellapiazza et al., 2021). A significant relationship has been found between sensory processing problems and high levels of aggression (Mangeot et al., 2001), and further researchhas shown that sensory dysfunction in children with ADHD can affect the regulation of emotions and lead to behaviour problems (Molagholamreza Tabasi et al., 2016).

Is often angry and resentful

Children are developmentally unable to self-identify as having anxiety or sensory processing issues. For one thing, even clinicians have difficulty diagnosing these conditions accurately in children. Secondly, if you’ve always had SPD or anxiety, then how could you know what it’s like to not have them?

Imagine experiencing sensory overresponsivity, meaning your senses are heightened. Perhaps your clothing always feels itchy, sounds others perceive as moderate are extremely loud, or lights are blindingly bright.

You can’t ask someone to turn down the volume on the world or adjust the contrast, so you endure until you reach your limit. Might you feel angry too, if this was your daily experience?

Every day children are overwhelmed by their senses, but they may not be able to understand or explain what is happening. Every day children struggle with anxiety and emotional dysregulation, but adults in their lives assume their “misbehaviour” is intentional.

Wouldn’t you be angry and resentful if the adults in your life who are supposed to care for, guide, and support you assume that every single mistake you make is because you are willfully being vindictive, defiant, and oppositional?

In fact, research has shown that adult interpretations of children’s behaviour has a direct impact on the adult’s response, intervention outcomes, and on how both the children view themselves and how adults view the children (Kil et al., 2021).

Essentially, if an adult blames the child, then the adult and child both feel powerless to do anything to help or change the situation. A child does not have the neurological development, nor the skills, to address complex behavioural or emotional issues.

When the adult recognizes their role in the child’s behaviour, and how they can adapt both their own behaviour and the environment to better meet the needs of the child, then progress can be made.

“Diagnoses — such as ADHD, oppositional defiant disorder, bipolar disorder, depression, an autism spectrum disorder, reactive attachment disorder, the newly coined disruptive mood regulation disorder, or any other disorder — can be helpful in some ways. They “validate” that there’s something different about your kid, for example. But they can also be counterproductive in that they can cause caregivers to focus more on a child’s challenging behaviors rather than on the lagging skills and unsolved problems giving rise to those behaviors. Also, diagnoses suggest that the problem resides within the child and that it’s the child who needs to be fixed.” (Greene, 2014).

Often argues with authority figures or, for children and adolescents, with adults

I am so tired of adults complaining about children having minds of their own and being willing to speak up or ask questions. I am also tired of adults expecting unquestioning obedience before making an effort to develop a trusting relationship with the child first.

Other neurodivergent populations are prone to being opinionated and strong-willed (to overgeneralize), such as twice exceptional and gifted children (Lovecky, 2004):

“Gifted children with ADHD argue wth parents and teachers about problem behaviours. They have a very difficult time accepting the authority of adults unless they see it as reasonable or just. Gifted children with ADHD feel equal to adults and think logical arguments ought to decide outcomes.” — Deirde V. Lovecky

So some children don’t follow blindly, and they believe logic and reason should be in charge, rather than someone who happens to be taller or because they have a job with a fancy title.

Sounds right to me.

Often actively defies or refuses to comply with requests from authority figures or with rules

Most gifted children question accepted ways of doing things. They need reasons why they had to be done in certain ways. Like other gifted children, those with ADHD also can be nonconformists and question authority due to the intensity of their beliefs and feelings about issues (Lovecky, 2004).

In a lot of cases, being willing to challenge authority and stand up for what you believe in is a strength. Sure, children (and some adults) need to refine these skills and develop tact, but I am in favour of children learning to respectfully speak their minds, rather than expecting blind obedience.

The final conflating variable I will discuss is insecure attachment. Research has shown that about 80% of children with O.D.D. have an insecure style of attachment (Kaźmierczak-Mytkowska et al., 2021).

Children learn how to regulate their own emotions through co-regulation with adults (Silkenbeumer et al., 2016). This requires a relationship with secure attachment. In a secure relationship, children feel safe and supported. (Hoffman et al., 2017).

A relationship is considered insecure when it contains elements of mistrust, anxious or avoidant elements, and lacks a secure base. Abnormal patterns of regulating emotions are an element of an insecure relationship (Kaźmierczak-Mytkowska et al., 2021).

Picture a child or adolescent who grew up with an insecure parent-child relationship. They didn’t have a primary caregiver who made them feel safe and supported, so they didn’t learn adaptive emotional regulation skills. It really isn’t surprising, then, if that child later has difficulty trusting other adults in their life and struggles with self-regulation.

Instead of being shown compassion, and having adult figures help them co-regulate and develop those missing skills, the child or teen is then labelled as “defiant”. Their mistrust of authority figures is considered willful disobedience. These children come to internalize these labels, view themselves as oppositional and noncompliant, and so the self-fulfilling prophecy continues.

“When we become untrustworthy, children are less likely to cooperate.”
— (Luvmour, 2017)

Often deliberately annoys others

Okay, seriously?

I’m not sure how a clinician can infer the intent of a child’s behaviour, but even if we assume this is the case, why? What need is the child seeking to have met by “deliberately” annoying others?

Are they trying to connect, but don’t have the social skills? Are their feelings hurt, and they’re trying to set things right, but don’t know how? There are many possibilities that exist outside of a behaviour disorder.

“When we view behaviours as intentional, we tend to use disciplinary strategies aimed at a surface target rather than the underlying cause of the behaviour.”

— (Delahooke, 2019)

Often blames others for his or her mistakes or misbehaviour

This one goes all the way back to human evolution. If a child is afraid of getting in trouble, this causes them stress, which elicits a fight-or-flight response in their brain (Porges, 2011).

When people feel backed into a corner, either literally or metaphorically, this often ignites their fight response. When someone feels attacked they are more likely to become defensive and try to deflect the blame onto others. These are adaptive responses to perceived threats which emerge from the instinctive drive toward self-protection (Delahooke, 2019).

Has been spiteful or vindictive at least twice in the past 6 months

I mean, do I really need to break this one down?

Some synonyms for spiteful and vindictive include malicious, vengeful, and cruel. Did I mention that a person must be under the age of 18 in order to be diagnosed with O.D.D.? In fact, the DSM-V indicates that O.D.D. symptoms gradually develop and become apparent in the preschool years, usually before a child reaches eight years of age (American Psychiatric Association, 2013).

So now we’re labelling preschoolers as spiteful and vindictive?

“When we appreciate children’s behaviours for what they are telling us about the child’s internal life, we experience a paradigm shift, moving from viewing behaviours negatively to seeing them as providing useful information.”— (Delahooke, 2019)

Paradigm Shift

Essentially, the symptoms of Oppositional Defiant Disorder can all be attributed to stress, other disorders, neurodivergence, or a combination thereof:

Anxiety
Overwhelm
Sensory overload
Fear
Insecure attachment
Trauma
…and so on.

“When a child is challenging, it’s a sign that something is getting in the way of the child meeting a demand.”— (Delahooke, 2019)

Instead of labelling, shaming, and punishing children for having unmet needs and lagging skills, let’s come alongside them. Our job as adults is to help children feel safe and cared for and to learn the skills they need to become their best selves.

Diagnoses can be extremely important and helpful when they give us a clearer picture of what is going on for someone. A diagnosis can help inform the type of support that will be most helpful for a child and can help families find the right resources for themselves and their children.

A label, on the other hand, is unhelpful. Labels perpetuate stereotypes, stigma, and assumptions. I posit that in approximately 99% of cases, O.D.D. is simply a label, and not a useful diagnosis.

Missed the first article?

Stop Calling Children “Defiant”

And the follow-up, I’d Like to Rewrite the DSM, Please

References

Aggarwal, A. & Marwaha, R. (2020). Oppositional Defiant Disorder. In: StatPearls [Internet]. StatPearls Publishing. [https://www.ncbi.nlm.nih.gov/books/NBK557443].

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). [https://doi.org/10.1176/appi.books.9780890425596].

Barkley, R. A. (Ed.). (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). The Guilford Press.

Cavanagh, M., Quinn, D., Duncan, D., Graham, T., & Balbuena, L. (2017). Oppositional Defiant Disorder Is Better Conceptualized as a Disorder of Emotional Regulation. Journal of Attention Disorders, 21(5), 381–389. [https://doi.org/10.1177/1087054713520221].

Cooke, J. E., Kochendorfer, L. B., Stuart-Parrigon, K. L., Koehn, A. J., & Kerns, K. A. (2019). Parent–child attachment and children’s experience and regulation of emotion: A meta-analytic review. Emotion, 19(6), 1103–1126. [https://doi.org/10.1037/emo0000504].

Delahooke, M. (2019). Beyond Behaviors: using brain science and compassion to understand and solve children’s behavioral challenges. PESI Publishing.

Dellapiazza, F., Michelon, C., Vernhet, C. et al. (2021). Sensory processing related to attention in children with ASD, ADHD, or typical development: results from the ELENA cohort. European Child & Adolescent Psychiatry 30, 283–291. [https://doi.org/10.1007/s00787-020-01516-5].

Ezpeleta, L., Penelo, L., Navarro, J. B., de la Osa, Núria, Trepat, E. (2020).
Transdiagnostic trajectories of irritability and oppositional, depression and anxiety problems from preschool to early adolescence. Behaviour Research and Therapy, 134. [https://doi.org/10.1016/j.brat.2020.103727].

Galiana-Simal, A., Vela-Romero, M., Romero-Vela, V., Oliver-Tercero, N., García-Olmo, V., Benito-Castellanos, P., Muñoz-Martinez, V., Beato-Fernandez, L. (2020). Sensory processing disorder: Key points of a frequent alteration in neurodevelopmental disorders, Cogent Medicine, 7:1. [https://doi.org/10.1080/2331205X.2020.1736829].

Greene, R. W. (2014). The explosive child: a new approach for understanding and parenting easily frustrated, chronically inflexible children. Revised and updated. Harper.

Hoffman, K., Cooper, G., Powell, B., Benton, C. M. (2017). Raising a secure child. Guilford Publications.

Kadir, A. (2017). Insecure Attachment. In: Zeigler-Hill V., Shackelford T. (eds) Encyclopedia of Personality and Individual Differences. Springer. [https://doi.org/10.1007/978-3-319-28099-8_2025-1].

Kaźmierczak-Mytkowska, A., Butwicka, A., Lucci, K.D., Wolańczyk, T., Bryńska, A. (2021). Attachment in adolescents with attention deficit hyperactivity disorder and oppositional defiant disorder. Psychiatria Polska, 212, 1–15. [https://doi.org/10.12740/PP/OnlineFirst/130366].

Keating, J., Bramham, J., Downes, M. (2021). Sensory modulation and negative affect in children at familial risk of ADHD. Research in Developmental Disabilities, 112. [https://doi.org/10.1016/j.ridd.2021.103904].

Kil, H., Aitken, M., Henry, S. et al. (2021). Transdiagnostic Associations Among Parental Causal Locus Attributions, Child Behavior and Psychosocial Treatment Outcomes: A Systematic Review. Clinical Child and Family Psychology Review, 24, 267–293. [https://doi.org/10.1007/s10567-020-00341-1].

Lovecky, D.V. (2004). Different Minds. Gifted Children with AD/HD, Asperger Syndrome, and Other Learning Deficits. Jessica Kingsley.

Luvmour, Josette. (2017). Grow together: parenting as a path to well-being, wisdom, and joy. CreateSpace Independent Publishing Platform.

Mangeot, S. D., Miller, L. J., McIntosh, D. N., McGrath-Clarke, J., Simon, J., Hagerman, R. J., & Goldson, E. (2001). Sensory modulation dysfunction in children with attention-deficit-hyperactivity disorder. Developmental medicine and child neurology, 43(6), 399–406. [https://pubmed.ncbi.nlm.nih.gov/11409829].

Molagholamreza Tabasi F, Aliabadi F, Alizade Zarei M, Qorbani M, Rostami R. (2016). Survey of behavioral problems and sensory processing in children with attention deficit/hyperactivity disorder. Iranian Rehabilitation Journal, 14(1), 63–68. [https://dx.crossref.org/10.15412/J.IRJ.08140110].

Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W.W. Norton.

Shimshoni, Y., Lebowitz, E., Brotman, M., Pine, D., Leibenluft, E., Silverman, W. (2020). Anxious-Irritable Children: A Distinct Subtype of Childhood Anxiety? Behavior Therapy, 51(2), 211–222. [https://doi.org/10.1016/j.beth.2019.06.005].

Silkenbeumer, J., Schiller, E., Holodynski, M., Kärtner, J. (2016). The Role of Co-Regulation for the development of social-emotional competence. Journal of self-regulation and regulation, 2. [https://doi.org/10.11588/josar.2016.2.34351].

O.D.D. Does Not Exist