Beyond “Oppositional Defiant Disorder”

Dan Shapiro

 Attention Magazine April 2020

 Download PDF

“He’s got oppositional defiant disorder.” Maureen would never forget those words. Her five-and-a-half-year-old son was certainly a handful. At home, Timmy had tantrums all the time. It seemed impossible to get him to do the smallest of things. During the first weeks of kindergarten, he was already getting into all sorts of trouble. He would not sit in circle time and he got too physical with some of the other kids on the playground.
All of that was stressful enough. But when the pediatrician gave this “ODD” diagnosis, it felt like she’d been hit in the head with a sledgehammer. She went online and read, “ODD can lead to juvenile delinquency and conduct disorder.” She pored over books on behavior management for defiant children that emphasized the use of rewards, punishments, and time-outs. She tried all of that and Timmy’s behavior only got worse. Why did Timmy have so much trouble? She felt anxious and confused, angry and alone. What could she do to help him?

The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013 by the American Psychiatric Association, includes the diagnosis oppositional-defiant disorder. The manual suggests that this diagnosis should be made if the following symptoms are present for more than six months: often and easily loses temper, frequently touchy and easily annoyed by others, often angry and resentful, argumentative and defiant, often argues with adults or people in authority, often actively defies or refuses to comply with adults' requests or rules, often deliberately annoys or upsets people, often blames others for his or her mistakes or misbehavior, often spiteful or vindictive.

I hope to make a strong case for sending this harmful diagnosis to the junkyard.

“I would if I could”

Whether inborn or conditioned, children have brain-based differences over which they have little control. These differences underlie your child’s challenging behaviors. Noncompliant or oppositional behaviors are not the result of willful disobedience. Even if you feel like it some days, your child does not wake up each morning plotting how to make your life miserable. Just as important, parents also “would if they could.” After all, parents have their own behavioral styles, skill deficits, and environmental stresses, too. Some parents have had less-than-optimal childhood experiences or adult role models. In any case, difficult children can make the most wonderful parents feel incompetent. And what good does it do to label a child as “oppositional-defiant,” or dwell on unmet expectations? Here, I will outline reasons for moving away from this meaningless label—beyond blame, guilt, and shame—toward true understanding and practical solutions.

For each child and each situation, knowing what to do begins with careful assessment. “Oppositional-defiant children,” “noncompliant children,” and “explosive children”—even “ADHD children,” “autistic children,” “anxious children” and so on—are far more different from one another than they are alike; that is, of course, if you move beyond these diagnostic categories and take the time to really get to know them as individuals! Meaningful assessment allows you to see the true sources of your child’s behavior and then individualize your approach.

Behaviors as secondary symptoms, not primary diagnoses

Maureen took Timmy to see Dr. Jones, a specialist in childhood development and behavior. Dr. Jones said to her, “Children do not misbehave on purpose. Let’s figure out why Timmy is having these problems with self-control. Then we’ll know what to do about it.”

The so-called diagnosis of ODD should be thrown away. This label is too broad, too simplistic, too pejorative, too negative, too confusing, and too permanent-sounding. Many children do have oppositional and defiant behaviors—but for many different and ever-changing reasons. The question should not be “Does your child have ODD?” or, “What do we do with children who have ODD?” Rather, it should be: “For this child, at this phase in his or her life, in this situation, where do the oppositional-defiant behaviors come from?” Furthermore, “How do we address these issues at their source?”

Just like fever is a common symptom of many possible microscopic diseases, oppositional-defiant behaviors are always secondary to a combination of developmental differences and life circumstances. Fever can be caused by cancer, heat stroke, lupus, strep, the flu, and more. But it would be foolish to treat all of these varied causes of fever the same way. Tylenol is not the one and only answer. Likewise, oppositional-defiant behaviors have many different causes upon which management should depend. There is not one preferred behavior management strategy—such as time-out—for every noncompliant behavior.

Also, let’s keep in mind that oppositional-defiant behaviors do not always represent disorder in the child. Rather, challenging behaviors can signify appropriate reactions of a child to disorder in his or her environment, such as inappropriate expectations or demands. Some childhood oppositional-defiant behaviors can represent the normal and healthy development of autonomy.

Understanding the whole child

Dr. Jones interviewed Maureen. He asked her and Timmy’s teachers to complete questionnaires and diagnostic rating scales. Dr. Jones observed Jimmy in his kindergarten classroom and spoke with the special education coordinator. Then he saw Timmy in his office. They played together and Dr. Jones put Timmy through some simple developmental tests.
Dr. Jones met with Maureen and explained that Timmy had a common combination of issues: ADHD, learning difficulties, and trouble controlling his mood. He outlined a comprehensive approach that included medication for ADHD, proactive parent behavior management training, and an individualized education program at school. He also emphasized the importance of finding activities for Timmy that nurtured his natural strengths and interests.
Dr. Jones told Maureen, “There will still be bumps along the road but there’s nothing about Timmy’s problems that we can’t manage. I’m confident that Timmy will do much better. He’s a good kid with a promising future.”

Most children with challenging behaviors do not have just one underlying problem. Usually, they have a constellation of developmental differences, all existing in dynamic interplay. When thinking about diagnosis, too many parents and professionals fall into an either/or trap. They confine themselves to considering whether a child has “this or that,” for example, ADHD or learning disability. It’s not one thing or another. Rather, it’s “this and that and that and that.” For example, ADHD and learning disabilities and anxiety and environmental stresses. In no case does the simplistic and superficial diagnosis of ODD prove adequate or useful.

As taught by Dr. Mel Levine, most children have “dysfunction at the junction of the functions.” This means that if you look at just one aspect of a child’s profile, you might say, “No big deal.” And then if you look at another one of your child’s developmental differences, again, you would be right to conclude, “This kid should not be having trouble just because of that.” It’s like the parable of the many blind men who try to identify an elephant by each touching just one isolated body part. If you view each aspect of your child’s complicated profile separately and out of natural context, you will often be misled. Oversimplification leads to confusion.

It’s more accurate and useful to examine all the different aspects of your child’s profile. How do all the pieces overlap and affect one another? This interplay of developmental differences is not hidden. You just need to know how to look. And look you should because the “junction of the functions” can be a very big deal. An ODD “diagnosis” stands smack in the way of this kind of multidimensional analysis.

Understanding the child’s whole world

Children do not exist in a vacuum. Their developmental differences are embedded within contexts and relationships, and across family members, peers, school, and community. These complicated systems and cultures are just as relevant as neurobiology in understanding the source of your child’s behavior. Your family has an impact on your child’s behavior and your child’s behavior has an impact on your family. Understanding your child must include an understanding of these larger systems.

Effective management strategies take into consideration the systems within which the child lives, not just the child. For example, oppositional-defiant behaviors should be handled very differently when they occur in the context of inappropriate expectations at school or home, inadequate schools, poverty, abuse, bullying, difficulties with peers or siblings, poor housing, divorce, medical illness or minority stress (such as, racial, religious, or LGBTQ.) Certainly, such environmental stresses do not represent a disorder within the child.

Dr. Jones spoke with Maureen about her own life stresses. She was a single mom. Money was tight. Other moms kept their kids away from Timmy and she felt isolated in the neighborhood. She admitted to feeling depressed much of the time. She couldn’t afford the time or money to go for her own therapy. Dr. Jones told her about an evening CHADD support group for parents of children with ADHD. It really helped. She and the other parents shared stories and ideas. She made a few good friends. Timmy’s behavior improved. He seemed happier. Maureen felt better too. There was hope after all.

Dan Shapiro, MD, is a developmental-behavioral pediatrician in Rockville, Maryland. He is the author of Parent Child Journey: An Individualized Approach to Raising Your Challenging Child (from which this article is adapted) and Parent Child Excursions: ADHD, Anxiety and Autism (just published).