Why I Don’t Diagnose Oppositional Defiant Disorder (Part 2 of 4)

by James Wiley, MD, FAAP – @adddoc

In this series we are talking about how co-morbid conditions can mask themselves as oppositional-type behaviors. In part one we discussed the importance of starting ADHD treatment and introduced anxiety as a common co-morbid cause behind this type of behavior. The next disorders we will discuss are obsessive-compulsive disorder and Tourette’s disorder. 

I don’t think a parent has ever come in and said, “I think he has OCD”.  Here are some clues that help expose OCD as the cause of a kid’s irritable, angry, or oppositional behavior.

“He’s very particular.”

“He hates tags, he can’t stand socks with seams, and he only wears one kind of underwear!” “He will refuse to put on a pair that looks just like the favorite pair.”

“She’s a perfectionist, but only on certain things. She will cry and scream over the smallest things.”

“He won’t go to centers.  He melts down.  He won’t shift from one activity to another and the teacher is at her wit’s end.”

“He is a picky eater.  If I buy the wrong brand of chicken fingers there is going to be a two-hour fit about it.”

“She won’t do her work.  She just sits there holding her pencil and staring.  When she does start she will retrace certain things over and over.  She constantly erases in frustration so she never finishes things.  Her teacher is at her wit’s end!”

“He holds a grudge.  He’ll remember being wronged for weeks, months, even years.” “He asks the same question over and over, even though he knows the answer.”

“If she wants to tell you something, it needs to be right then and she wants your undivided attention and for you to listen to more detail than you can bear hearing.  If you don’t listen she will start over!”

Kids with OCD are constantly frustrated because they are stuck on A while the rest of the world is on B or transitioning away from A. They HAVE to finish A.

“But it makes no sense”, parents say, “he can’t have OCD, his room is a wreck”.  Kids are only obsessive-compulsive about what they are obsessed with and ADHD kids are seldom obsessed with being tidy and clean!  Remember too, that hoarders have OCD-their obsession is that they may need a paper bag from a fast food restaurant and their compulsion is not throwing anything away.  OCD kids look ODD because they ARE oppositional.  They are stuck doing ‘their thing’ and you need them to do ‘your thing’.

If your kid is melting down and exhibiting oppositional behavior ask these questions:

Is it during transition time?

Is it triggered by some common theme?  Example- Boy noted to be ‘aggressive and impulsive’ because he recurrently pushed kids off of swings on the playground.  It turns out that it only happened when another child got in “his” swing!

Obsession: “My swing!”

Compulsion: “You’ve got to go!” (PUSH)

OCD kids—my way or the highway.  ODD kids—any way but your way. *

Tourette’s Disorder

See above and add that many teachers misunderstand tics as willful behavior and point to the fact that the kid can control them (to some extent) as evidence of this.  Tourette’s Disorder commonly occurs with ADHD and heightens the impulsive behaviors of ADHD.