How We May Be Letting Kids With Behavioral Diagnoses Down

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It had been a hard year. I held my 13-year-old body in a chair across from my then-therapist. We were talking about what was wrong with me; at least, that's how I thought of it.

In the year that had unfolded as clinicians tried to determine what I needed, I had been given what felt like a new mental health diagnosis every other month. Some I related to, others I did not. All felt hurtful. I had made it my mission to convince her I didn't have any of it.

This is how our sessions went. I sat down and sometimes played with her guitar. We argued about my diagnosis, which she felt was essential for me to accept. I got upset. My mom took me home.

This time, the session ended early. She brought my mom in. "You know, I've talked to Jennifer a few times now. I don't know what's going on with her. She probably has an oppositional defiant disorder, and I don't treat that." That was our last session.

As I read about my new label at the local library, I had tears. In my adolescent mind, she not only thought I was sick; she thought I was a "brat," too.

While my adult brain understands that the diagnosis is more complex than this and ideally should not stigmatize a child, questions remain.

Oppositional Defiant Disorder

Oppositional defiant disorder, or ODD, is a condition associated with rule-breaking, negative attitudes, and behavior that is annoying to others ("frequently annoys others" is listed as a criterion in the DSM-5). It is almost unheard of as a diagnosis given to adults and often not a treatment target in adults diagnosed as children.

Diagnosis and treatment of the disorder is focused on behavior. While neurological evidence exists for the diagnosis of many conditions listed in the DSM, it is mysteriously lacking with ODD, particularly when the disorder is set apart from ADHD, an extremely common comorbidity.

While the DSM has an entire section dedicated to diagnoses typically assigned in childhood, it is rare for a diagnosis to disappear once a person turns 18. ODD is specifically considered a "disruptive behavior disorder"; it can be asked to whom the behavior is disruptive. Often, the concern is for the well-being of the adults surrounding the child rather than the child.

Who Gets Diagnosed With ODD?

Among the many criticisms of oppositional defiant disorder is its diagnostic pattern.

Poverty is among the highest risk factors for the diagnosis of oppositional defiant disorder (Granero et al., 2015; Costello et al., 2003). This makes sense. When our basic needs are not met, it is difficult for anyone to be at their best.

In addition, the social norms and needs vary greatly among socioeconomic groups. Is it fair to diagnose a child living in an area with high levels of community violence with a single parent who is working and unable to be home as much with an oppositional defiant disorder when they show up to school with a rougher presence? This is perhaps especially true if you are comparing their behavior to that of another child living in a two-parent home in a wealthy neighborhood.

Race is also a predictor for the diagnosis of oppositional defiant disorder. ODD is diagnosed at a significantly higher rate in Black and brown children. While racial disparities are common in several medical diagnoses, with ODD, there appears to be a more straightforward bias. A research study that simply showed the faces of youth, asking participants to identify which youth had "ODD," found that participant clinicians were more likely to rate Black and brown children as likely to have ODD than white peers (Stroessner et al., 2023).

Among the criteria for oppositional defiant disorder are power-focused criteria, such as "often argues with adults." Disruptive behavior disorders, like oppositional defiant disorder, have also been associated with running away from home. Maybe it's time we asked: What are these youths running away from?

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A Diagnosis of Blame

Several clinicians have expressed concerns related to the mischaracterization of youth diagnosed with oppositional defiant disorder. The diagnosis places the blame on the child with an assumed origin of a pattern of poor behavior. It ignores other factors that could be at play, such as family dynamics or trauma (Beltrán et al., 2021).

The behavior-focused nature of interventions created for oppositional defiant disorder typically involves empowering parents through the amplified use of reward and punishment. The reasons for the behavior are seen as irrelevant. The young person is disempowered.

For youth living with trauma or attachment-based difficulties, which commonly present with behaviors that overlap with ODD, this removal of control can be destabilizing. The co-occurrence between ODD and childhood trauma is so significant that some clinicians have proposed a model of understanding the behaviors as survival strategies built from the emotion dysregulation that accompanies trauma (Ford, 2002). If these root issues are not dealt with, iatrogenic effects can be expected.

Another concern is that oppositional defiant disorder is often diagnosed through interviews and behavior rating scales from parents and teachers. When the adults interacting with a youth do not have a good relationship with them, or when a child has become particularly "difficult" in a classroom, it can be asked how accurate these will be.

Parent-report diagnostic tools may also be misleading, or even weaponized; in family systems wherein youth are scapegoated, for example, parents almost always hold very negative attitudes toward the child. The kid is blamed for the family's issues. A diagnosis of oppositional defiant disorder may only serve to strengthen this unhealthy dynamic while delaying relationship-focused family interventions that the family needs.

Also of strong concern is that a history of child abuse, particularly physical abuse, is a known risk factor for ODD (Burnette, 2013). Are we blaming children for common reactions to abuse and other trauma? Is our field re-traumatizing them?

Misdiagnosis

The list of child-onset mental health conditions that can present with behavioral problems is long. Irritability is a hallmark of child and adolescent mood and anxiety disorders. Impulsive youth living with attention-deficit/hyperactivity disorder (ADHD) often struggle with following rules. Post-traumatic stress disorder and reactive attachment disorder can cause an intense need for control and distrust of adults, often showing up as defiance.

While behavioral treatment may reduce the behaviors that adults find troubling in these kids, it is unlikely to address the complex needs associated with these additional diagnoses. Even outside a formal diagnosis, defiance can often be interpreted as a relational problem rather than a behavioral problem.

Neurodivergent youth might also act in ways that neurotypical adults might view as oppositional. In addition, a fixed mindset and conservation of precious cognitive resources through frequent use of "no" are features of a phenomenon in some autistic individuals described in the UK as "pathological demand avoidance" or "persistent demand for authority." These youth need understanding and tools to feel comfortable as neurodivergent people in a world designed for neurotypical people, not behavior modification.

A Call for Action

Regardless of what we call it, children qualifying for a diagnosis of oppositional defiant disorder and their families deserve help. A thorough assessment evaluating biological, psychological, and social causes is a meaningful place to start. When psychological therapies are needed, these must come from a relational and trauma-informed lens.

Rarely is individual intervention enough to meet the needs of a youth who could be diagnosed with ODD. Supports at school, at home, and in the community are also necessary.

In his book, The Explosive Child, Dr. Ross Greene details collaborative and proactive solutions (CPS), a strategy for meeting the needs of these young people. In the words of Dr. Greene, "Kids do well when they can." Similarly, adults do well when they can; this includes therapists, parents, and teachers.

Through a compassionate approach, we can take the blame away from youth presenting with challenging behaviors and move toward something positive for all.