The Trouble with ODD
A very common diagnosis found in the charts of children across the country is oppositional defiant disorder. This morning I stumbled across a post about diagnosis and in some of the comments there was mention of this diagnosis. Let me begin by just listing a few of the criteria here.
From the 2013 American Psychiatric Association Diagnostic and Statistical Manual 5th Edition (DSM-5):
"is often touchy or easily annoyed....is often angry and resentful...often argues with authority figures or, for children and adolescents, with adults....often actively defies or refuses to comply with requests from authority figures or with rules"
This is a not a full listing of all of the criteria, but simply a few highlights. It sounds awful right? It conjures images of bratty, spoiled, and entitled children who are simply in need of some good old fashioned hardline discipline. Let me state something here though. This diagnosis is a reflection of a problem with conceptualization. Unfortunately a lot of diagnoses in mental health takes the approach of looking at symptoms and checking to see what diagnosis best fits. At face value this makes sense, as it is a traditional approach to medical diagnoses. You have a fever and gastrointestinal symptoms so you have the flu. There is however an obvious difference between identifying the flu and a diagnosable mental health disorder. The implications are immense for children because they are often unable to protect the information about their disorder(s). It lies in the hands of responsible adults to make sure this information is protected and contextualized.
Rather than clinicians looking at symptoms and using the DSM-5 as a reference checklist, it is our responsibility to try and understand the people that we work with from a developmental and historical context. The amount of children diagnosed without an understanding of their developmental history is staggering. I have seen PTSD and attachment problems overlooked countless times. Mood disorders are also often ignored in children and dismissed as normative or as childish behavior. In the case of oppositional defiant disorder the symptoms you see referenced above are reactionary. Children with this disorder are struggling with other problems that they are not well equipped to manage. As a result it manifests itself behaviorally. This in itself should not be shocking. Children are in the process of developing coping strategies and defense mechanisms. They are not equipped as adults are to deal with significant stressors, problems in their relationships, or with mood symptoms in the same way we are. Instead they act and react with difficult behavior.
So for the clinicians that read this blog, I implore you to take a step back and look at the child's context and the child's development before making a diagnosis. If you stumble across a child with this disorder that has had a good developmental history and quality caregiving, please contact me. I want to know and understand this case. For parents or others that read this, always, always question the diagnosis. You will do yourselves and the children in your life a service if you do. How a child is seen has a massive, wide reaching impact on how the child is treated.