Oppositional Defiant Disorder

When well meaning advocates for kids with mental health issues speak of “labeling” a kid . . . one of the “labels” that they talk about is Oppositional Defiant Disorder, aka ODD.  This is an issue that goes way back to when the disorder was first characterized and diagnostic criteria were formalized.  The criteria for the disorder includes endearing characteristics like deliberately annoying others, arguing with adults, being angry and resentful, spiteful and vindictive . . . in short, a kid that behaves badly.  Notice, I did not say a bad kid.  Just a kid that behaves badly.  But sometimes, that badly is real bad.  It can create a huge disruption for teacher, family and neighborhoods. 

Back in my days on the inpatient unit (running it that is, not as a patient), we psychiatrists were getting in trouble with one of the well meaning insurance carriers that was managing the kids with medical assistance (aka welfare) for diagnosing kids with ODD.  They were upset that we seemed to diagnose every kid with ADHD/ODD . . . “the seven letter diagnosis”.  They thought we were calling the kids “bad”.  I was just diagnosing.  The worst thing that we, as diagnosticians and prescribers of treatment can do, is to NOT diagnose a pattern of behavior that meets criteria because we are afraid of offending someone.  That is like not diagnosing Schizophrenia because it has “such a stigma”.  You sure would not want your doctor to not diagnose cancer or hemorrhoids just because there is a stigma attached to it, would you?  Without an accurate diagnosis, I cannot render adequate treatment.

So, what is ODD.  Obviously there are books written on this and I, with my inestimable wisdom, will try to summarize in one paragraph all you really need to know . . .

Oppositional Defiant Disorder is, in my book, a red flag.  It is an indication that there is something else going on. I have never . . . I repeat . . . NEVER . . . seen a kid that meets criteria for ODD and did not meet criteria for some other diagnosis.  It is as if the oppositional and defiant behavior is a coping strategy for dealing with other issues.  Or a poorly functional reaction to other issues that are NOT being dealt with.  When a kid presents with significant ODD symptoms, I look for a range of other psychiatric illness including ADHD, depression, anxiety, or trauma.  If a kid has difficulty with impulse control and attention (ADHD), they will often react badly to parent/teacher intervention and get angry.  If a kid is very depressed, they will tend to be irritable and argumentative.  If a kid is very anxious, he might react angrily when he is put in the position of dealing with his anxiety (eg, school refusal).  If a kid is traumatized, they can react in an angry and oppositional manner as a way of controlling their surroundings.

The treatment strategy for ODD certainly include medications for irritability and anger (see my other blarticles about that), but the most important facet of treatment is to look for and treat the underlying cause of the oppositional behavior.  If I do not treat the underlying cause, I cannot get the oppositional behavior under adequate control.  The take home message about ODD is this:  Resist the temptation to consider the kid a “bad” kid, and think of him or her as a kid with something else going on.  Something that can and should be treated and addressed. 

 –Dan Hartman, MD

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