Why I Don’t Diagnose Oppositional Defiant Disorder (Part 1 of 4)


by James Wiley, MD, FAAP  – @adddoc

Okay, I have diagnosed it. On occasion, I still might diagnose a young person with it. However, every time I think ODD, I ask myself “What is making this kid so angry and defiant?”  And if I do diagnose ODD I consider it my failure to answer that question.

Almost all of the DSM 5 diagnoses, including ODD, have the same final criterion; the symptoms are not better explained by something else. I think ODD behaviors almost always arise from other diagnoses or social situations. Failure to consider this criterion leads to significant over diagnosis of ODD, which is too often cited as the most common co-occurring condition along side ADHD.

This week I’d like to further discuss some common conditions and situations that replace the diagnosis of ODD in my practice. In this four part blog series, we will delve more into these conditions and situations that may better explain those symptoms that resemble ODD.

First and foremost-untreated or under treated ADHD.  Kids with ADHD wake up and go to bed listening to a recording of negative messaging—“Don’t!”, “Quit doing that!”, “That’s annoying!”, “You forgot-AGAIN?”, “Be still.”, “Be quiet.”, “You’re too loud.”, “You’re moving too fast.”, “Hurry up-slow poke.”, “Stop!”, “You’re lazy.”, “You’re not working to potential.”, “You did this yesterday-you’re just not trying hard enough.”  As you read this are you feeling a little oppositional? While we parents fear over medication with good reason, if your child is oppositional and the above tape is playing in his/her head then ask your doctor about increasing the stimulant medication. If that doesn’t work change the class of stimulant-amphetamine to methylphenidate or vise versa and titrate to the dose that puts the ADHD symptoms in remission without significant side effects.

Once ADHD has been diagnosed and treatment has started, oppositional-type behaviors can further be masked by other co-morbid conditions. In this series, we’ll look at anxiety disorders, obsessive-compulsive disorder, Tourette’s disorder, learning disabilities, and depression.

Anxiety Disorders

One symptom that can appear to be oppositional disorder is also one of the most overlooked DSM 5 symptoms of anxiety–irritability. Very anxious kids are often very irritable. Think of it this way: anxiety is getting on their nerves, so it’s really easy to get on their last nerve.  When they hit that threshold there can be an explosion, (sometimes a nuclear one!). It can be something as simple as a request to take the trash out or a reminder about homework. Anxious kids are often non-complaint.  They won’t go outside because of bug phobia, they melt down about going to school because of social phobia or separation anxiety. “This doesn’t make sense!” parents will say, “There’s nothing for her to worry about!”  Right!  That’s why we call it a DISORDER. Healthy anxiety creates a flight or fight response in the brain. Anxiety disorders create that same reaction. We either avoid the situation (play sick to avoid school, stay inside to avoid bugs) or we fight–which in anxious kids can look like aggression, meltdowns or tantrums. They will kick teachers, push peers, and yell that they hate their parents when put in situations that exceed their ability to cope with an anxiety trigger such as crowds or bad weather.