Most children can have oppositional and defiant behavior (this is developmentally appropriate in young and latency age children) but that does not mean they qualify for a diagnosis of ODD. The key is that it has to be pervasive and across settings to consider a diagnosis of ODD. It also has to be present in that pervasive manner for at least 6 months. The DSM 5 outlines that a particular symptom has to be a departure from normal development or occur excessively and therefore be leading to functional impairment. For example, temper outbursts are common in preschool-aged children but can be considered abnormal if they occur on most days and the child is frequently asked to leave school.
Studies in young children (ages 2-5 years old) with pervasive oppositional and defiant behaviors have shown that these children go on to have diagnoses in the depression and anxiety realms rather than in the disruptive disorders realms when they reach latency age. Oppositional behavior as a young child is seen as a bigger risk factor for depression and anxiety rather than ADHD and ODD. Children with ODD are at risk for substance abuse and suicide in adulthood.
It has been argued that ODD is used as a descriptive to capture a constellation of symptoms rather than implying a cause behind the symptoms. That may have been the original intention behind adding the diagnosis to the DSM diagnostic manual. But in society and even among mental health and medical professionals, a child who is said to have ODD can be pre-judged and assumed to have more “control” over his behavior than might actually be true. Many times, a judgment is made that “nothing can be done” to help a child with “ODD”. This way of thinking is a disservice to a child presenting for help. As stated in Part 1 of this series, it is important to assess for co-morbid conditions that may better explain the symptoms of ODD and refer the family for behavioral therapy with a strong parent management training and collaborative problem solving component.
It has been shown that an early diagnosis of ODD delays establishing a more appropriate diagnosis that better explains a particular child’s symptoms. This has been seen in children who more accurately have ADHD or a depressive disorder or learning disability or be mild on the autism spectrum. As a reiteration, ODD should be considered a diagnosis of exclusion, meaning a clinician should assess for other mental health and/or environmental concerns that could be a reason behind a child’s oppositional behaviors prior to considering a diagnosis of ODD.
It is our hope that this series on the diagnosis of Oppositional Defiant Disorder has helpful answer questions about the diagnosis and treatment, helped providers feel more comfortable in when it is appropriate and useful to include the diagnosis in a clinical formulation for a particular child, and when it might do more harm than good. As a reminder, SmartCare BHCS is available to families to find particular referrals for behavioral health needs and SmartCare PC2 is available for provider consultations on specific cases.
Here is another resource for more information on ODD: