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ODD - a problem of misdiagnosis?

Published: 22 Jun 2020 | ADHD & Me

Often children who lash out or refuse to follow direction are thought to have Oppositional Defiant Disorder (ODD), which is characterized by a pattern of negative, hostile, or defiant behavior. But there are a number of other issues that could lead to a child being oppositional or out of control in school or at home. Dr. James Wiley explains why it is so important not jump to conclusions too quickly.

 

Why ODD can be misdiagnosed

When we're making mental health diagnoses, the thing that strikes me is that the last criteria for ODD listed in the DSM-5 diagnostic manual is almost always “not better explained by something else”. In other words, there's not another condition that better explains the patient's symptoms. We know that there is this crossover between oppositional defiant behavior and other mental health diagnoses. Therefore, for me, I always feel like a failure when I do diagnose ODD, because I want to find some other reason for their behavior.

Whether that is the result of untreated ADHD and all the negative messages kids receive because of this, whether it's because of a need to do things in a certain way for OCD sufferers or whether someone’s autism means they can't comply with your request to work in a group. Depression can also influence behavior - kids with depression may not be motivated and feel that they couldn't care less what the consequences of their actions are. With depression in kids, it's not just this feeling of sadness but another predominant symptom is a total apathy and a lack of interest.

Anxiety too can influence ODD like symptoms. Anxious people by definition can be irritable and fatigued or easily agitated. When anxious children feel cornered or their anxiety levels increase, they very often show their teeth and their claws or they shut down or don't participate. They avoid situations. A perfect example of this would be the child that won't do the public speaking assignment at school. They will take a zero or fail public speaking, but they're not going to get up on the stage.

 

Ways to further our understanding of defiant behavior

As a pediatrician specializing in the care of youth with ADHD and co-morbid conditions, I find the presentation of ODD symptoms to be complex and consideration should be given to other causes for these behaviors before labeling them ODD. Looking for the clues for other conditions, for me in my practice, is the key to helping kids with ODD to get better. I ask myself: why are they oppositional and defiant? What is their underlying reason? I must also consider other external factors - perhaps the patient's parents are going through a nasty divorce or they're being bullied at school. Perhaps they're insecure for any number of reasons, financial or otherwise. There are other things that leads to these types of behaviors. I always say that kids that ‘can do’ seem to manage okay. Kids that 'can't do' end up being labeled or viewed as one of three things: they either shut down or they are the class clown or they meltdown.

Those are the three behaviors that you're likely to see in children or who are stressed or overwhelmed. I think girls tend to shut down and boys tend to act out but that's not always the case. We've certainly learned in recent years that you can't paint with a gender brush because it's too broad. But often, this is the case.

Read more about ODD and ADHD in Dr. Wiley's feature ADHD and ODD - what's the treatment?