Oppositional Defiant Disorder…A description or a diagnosis?

Angry GirlOur current blog series… Dissecting the DSM-5…What it Means for Kids and Families, continues today with an examination of the recently updated diagnostic criteria for Oppositional Defiant Disorder.

Mental health professionals working with kids and families are often asked to intervene when children chronically exhibit angry or disrespectful behavior. The causes of this behavior are often complex, but typically are grounded in two very different biologic predispositions…referred to in the DSM-5 as disinhibition/constraint and negative emotionality.

My problem with the diagnosis of Oppositional Defiant Disorder (ODD) is that establishing the diagnosis doesn’t really tell you anything about what to do to treat it. Consider it a “lite” version of Disruptive Mood Dysregulation Disorder without the severe, protracted tantrums or meltdowns.

In the DSM-5, the eight diagnostic criteria for ODD were regrouped into three categories: Angry/Irritable Mood (loses temper, touchy/easily annoyed, angry/disrespectful), Argumentative/Defiant Behavior (argues with authority figures/adults, defies/refuses to comply with rules/requests from authority figures, deliberately annoys others, blames others) and Vindictiveness. Kids are required to have four or more symptoms for at least six months, criteria have been included to emphasize that the behavior is beyond the norm for the child’s developmental age and specifiers for severity have been included. In addition, kids with ODD may now be diagnosed with Conduct Disorder as a comorbid condition.

Some kids are disrespectful and defiant because of issues with self-control. This corresponds to the angry/irritable group. One way of considering their behavior is to view them as impulsively defiant…they argue with parents and authority figures without stopping to think about the issue that upsets them or why they’re upset. It’s not unreasonable to question whether this subtype of kids diagnosed with ODD would be better described as having ADHD, with the defiant behavior representing difficulties with emotional self-regulation associated with the executive functioning deficits central to our understanding of ADHD. In fact, one of the criticisms the folks from Shire Pharmaceuticals faced when they sought FDA approval of Adderall XR for ODD was the question of whether ODD was truly a stand-alone diagnosis-since 79% of the kids in their study were diagnosed with ADHD in addition to ODD.

Other kids are disrespectful and have difficulty with transitions because of their inability to let go of their mental script of how a given interaction or situation should unfold. They correspond to the argumentative/defiant group. They perseverate or get “stuck” on their idea of how things should be and escalate in situations where they perceive adult intrusion into their sense of control. The first group is defiant because they can’t stop and think. The second group is defiant because they can’t let go of their thoughts of how things should be. We know that kids who “ruminate” or perseverate are prone to problems with anxiety and/or depression as they get older.

What we do to help is contingent on our conceptualization of the cause of the defiant behavior. If they have difficulties with self-control related to ADHD, we’ll treat the ADHD. If they’re rigid, inflexible and perseverate, we might look at cognitive strategies or behavioral interventions to help. Use of the ODD label…a diagnosis lacking specificity from other conditions-adds little to our understanding of how to best help address the behavior that led parents to seek professional help.

Photo courtesy of http://www.freedigitalphotos.net.

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Key Ministry’s mission is to help churches reach families affected by disability by providing FREE resources to pastors, volunteers, and individuals who wish to create an inclusive ministry environment. We have designed our Key Catalog to create fun opportunities for our ministry supporters to join in our mission through supporting a variety of gift options. Click here to check it out! For a sixty second summary of what Key Ministry does, watch the video below…

About Steve Grcevich

Dr. Stephen Grcevich serves as Chairman of Key Ministry, a non-profit organization providing free training, consultation, resources and support to help churches serve families of children with disabilities. Dr. Grcevich is a graduate of Northeastern Ohio Medical University (NEOMED), trained in General Psychiatry at the Cleveland Clinic Foundation and in Child and Adolescent Psychiatry at University Hospitals of Cleveland/Case Western Reserve University. He is a faculty member in Child and Adolescent Psychiatry at two medical schools, leads a group practice in suburban Cleveland, and continues to be involved in research evaluating the safety and effectiveness of medications prescribed to children for ADHD, anxiety and depression. He is a past recipient of the Exemplary Psychiatrist Award from the National Alliance on Mental Illness (NAMI). Dr. Grcevich was recently recognized by Sharecare as one of the top ten online influencers in children’s mental health.
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One Response to Oppositional Defiant Disorder…A description or a diagnosis?

  1. Ann Holmes says:

    Thanks, Steve! I hope some of your colleagues are reading this series as it is so reasonable and wise. I am certainly benefiting.

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