ODD: What is it really, and why we should get rid of it
ODD means Oppositional Defiant Disorder. Most have heard of it, and most people, when they picture ODD, think of a kid who is just plain obstinate. You tell them to go left, and they either go right, or, more commonly, just say no. But ODD is actually more than that. In this blog, I'll tell you what ODD really is. And then, I'll make an argument for why I think we should get rid of the diagnosis - or at least change the name - in professional psychology.
The DSM-5 describes ODD as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four of the following symptoms:
Often loses temper
Is often touchy or easily annoyed
Is often angry and resentful
Often argues with authority figures or adults
Often actively defies or refuses to comply with requests from authority figures or adults
Often deliberately annoys others
Often blames others for his or her mistakes or behaviors
Has been spiteful or vindictive at least twice within the past 6 months"
There are some other specifiers after these criteria, but these 8 criteria give you the core ideas.
There is also an incredibly high overlap between ODD and ADHD. In fact, in my career, I have NEVER seen a kid with a diagnosis of ODD that did not at some point in the past also have a diagnosis of ADHD. They go hand in hand, really.
You see, one of the core features of ODD that is not listed above is that kids with ODD are also usually pretty impulsive. This is what causes them to behave the way they do when they're feeling angry/irritable. Think of it this way. Most of us, when we're in a bad mood, don't want to do what others tell us to do. We'd rather do something we enjoy or at least something neutral, to help us get out of that bad mood. When someone comes and tells us to do something anyway - like a chore, task, or something for our jobs - we may have an impulse to just tell them "no." We, in fact, may imagine incredibly satisfying ways to reject those orders. However, we don't act on those impulses, usually. Instead, we suck it up and do it anyway, because we can reason that the cost is not worth it and that it's easier or better to just do the task and get it over with.
A person with an impulse control problem, however, may not be able to reject the impulse to act on those wishes. Furthermore, a core problem in ADHD is a weakened ability to forego immediate rewards in lieu of longer term gains. People with ADHD, instead, tend more often than those without ADHD to just go for the thing that feels immediately good. Their brains don't stop to think, "I can get a better reward if I wait." Instead, the brain just gets tunnel vision for the immediate reward in front of them and suddenly that's the only thing that matters. So, when a kid is in a bad mood and they think (usually unconsciously), "I really don't feel like doing that right now so I'm just gonna say no." AND they have ADHD/impulse control problems, often they are going to get tunnel vision on how good it will feel to say "no," so they do it!
What separates ODD from ADHD is the underlying CHRONIC irritable/angry mood. To me (and to most good clinicians), ODD is a mood disorder. That's the core problem. Their mood is chronically angry/irritable. It's not an "every once in a while" kind of thing. It's a repetitive, several-times-a-week mood state, and its often there without any particular triggers. And like anyone when you're cranky, these kids don't want to add to the crankiness by having to do things they don't feel like doing - chores, homework, etc. Furthermore, the fact that others are trying to force them to do these things when they're feeling so chronically cranky is a reason they tend to blame others for their problems. It's YOUR fault. YOU'RE making me mad.
This isn't true, per se. Of course you're not making the kid mad. They were already feeling that way, and the demands and responsibilities are making them feel worse.
But it's this feature of ODD that most often gets overlooked. Kids with ODD aren't seen by others as being depressed or grumpy, they're seen as being willfully disobedient. And yes, that's what it seems like on the surface. You know they're capable of doing what you ask of them, but their refusal to do so suggests willful defiance. And I guess there is some willful defiance in there, but the real driver is that depressive, irritable mood from which they can't seem to escape. And that's all they want. To escape from that grumpy mood.
And this is why I think ODD needs to go, as a diagnosis. To expert clinicians, we understand ODD as a parsimonious way to describe a kid with the combination of ADHD-like impulse control problems AND depressed/irritable mood. However, when everyone else hears ODD, they think, "kid who is a little 'you know what' and rarely does what they're told."
This mindset creates a problematic cycle where the symptoms of ODD are only made worse by adults who refuse to work with them and "see" them for what they are. When adults and authority figures feel defied, they tend to want to retaliate by putting their foot down - "I'm in charge here."
Adults respond differently, though, when they see a child is "sad," or "struggling emotionally." They instead are drawn to such kids, wanting to help them feel better.
So, instead of ODD, I think it is better to diagnose children, when it fits, with two comorbid conditions - ADHD and a depressive disorder. These conditions fit the clinical presentation just as well, but they remove the "tag" of an oppositional, defiant kid. Instead, they assign a different label - a kid who is hurting and who needs to learn skills to manage that hurt. It refocuses parents and other caregivers (teachers, for example) toward teaching a child important skills of frustration tolerance and general mood modulation. Once these things are taken care of, parents (and other adults) will note another pleasant side effect - kids become more compliant and agreeable.
Of course, it's not a magic fix. Kids are going to exert their independence from time to time - even more so as they get older. And this means that they're not going to follow every request or task demand. But, over time, if managed right, and if they can learn healthy frustration tolerance, these kids can become much better at fulfilling demands and responsibilities, with much less frequent and/or intense defiance.
One more thing that I think is important to know is that kids with "just plain old ADHD" can also have mood problems. Usually these are going to happen when they're under stimulated (bored) or overstimulated, or when their stimulant meds start to wear off. In this case, the mood symptoms are more intermittent and there is better "recovery" in between. I often tell parents to think of what it would do to your mood if your brain was literally bored all the time. This is what chronic understimulation feels like to kids with ADHD, and it's why they also get grumpy sometimes.
Still, in pure ADHD, the grumpiness isn't as frequent as is seen in ODD, and the grumpiness doesn't lead to defiance, as much as it does to just pure emotional meltdowns (crying, destructive behaviors, running away, etc.). Even though there are mood symptoms in ADHD, ADHD isn't a mood disorder. ODD is. In ODD, irritable mood is the primary problem. In ADHD, chronic sensitivity to stimulation (being under- or over-stimulated) (and executive dysfunction) is the core problem.
The difference can be hard to recognize if you've not well-trained and well-practiced, with enough experience to tell the difference. But the reason the difference matters is because it influences what problems you focus on in intervention. If the core problem is chronic mood, you need to focus on modulating that mood. If the core problem is problems with stimulation, you need to focus on stimulating them properly.
But the details of intervention are complex and beyond the scope of this blog. Perhaps I'll address those in another blog another time.
For now, what I want you to focus on is the fact that if someone has diagnosed your child with ODD, what they are likely trying to tell you is that your kid has a mood disorder and that we need to do what we can to help them with their mood. In simpler terms, your child is depressed. No. Childhood depression doesn't usually look like adult depression. There isn't that sad, mopey, listless, low-energy shadow that is depicted in commercials for depression medication. Rather, most often, depressed kids are a mixture of grumpy, anxious, tearful, sad, and a whole host of other feelings/behaviors that rarely get recognized as depression/moodiness.
Personally, I'd rather kids be diagnosed with ADHD and a Depressive Disorder, but as long as the diagnosis of ODD exists, you'll still see it used by some. But don't let the label trick you into thinking your kid's just a butthole. No, instead, refocus your energies on helping your kid learn ways, when they're frustrated, to actively manage that feeling with healthy coping skills. Once those feelings are under control, then they can go about doing all those daily tasks you keep asking them to do.
This doesn't mean you can't give them daily tasks though. It just means that when it comes to completing those tasks, you need to put your energies toward helping them solve the problem of their emotions so that they CAN then do the tasks, rather than getting stuck in a power struggle of whether or not they actually do them.
If you want to learn more about what kinds of therapies we usually recommend for these kinds of issues in kids, you can look here: https://effectivechildtherapy.org/concerns-symptoms-disorders/symptoms/rule-breaking-acting-out/
Note: my description of ADHD here is not complete, and there is more to ADHD than the little bit I covered here. Please don't take this blog as a complete depiction of ADHD. Honestly, the same is true for ODD. Volumes could be written on the intricacies of any mental health condition. My blogs, though, are meant to be briefer overviews for a general audience. So, please allow me a bit of leniency in not necessarily mentioning everything that could be said about these disorders, or any that I write about.