About the diagnosis oppositional defiant disorder, ODD

For some years I have been thinking about how we use certain diagnoses. One of the diagnoses used in very different ways is the diagnosis oppositional defiant disorder, ODD. Often when I ask colleagues why they’ve made the diagnosis I get the reply that the child met the criteria. That’s actually quite logic, but I still want to problematise the use of the diagnosis because I have often found that it hasn’t benefited the children who’ve got it.

Studies considering the course of the disorder from being an adult and backwards have shown that many people with antisocial personality disorder have had ODD symptoms as children. That’s the argument you most often hear for making the diagnosis; because then you can be prepared for difficult problems later in life. However, studies made the other way round, from being a child and forwards, have shown that symptoms (not a diagnosis) of ODD do not mean worse prognosis for other than depression unless you have an ADHD diagnosis (which is the major predictive factor when looking for comorbidity). Mannuzza et al 2004 is a good example of such a study. Other studies however have shown that by getting a diagnosis, ODD becomes the greatest predictor.

If you put these studies against each other, you see that symptoms of ODD are in fact not a powerful predictor of later antisocial behaviour unless you get an ODD diagnosis. That’s troublesome. Therefore, in the process of revising DSM 5, there were major internal differences of opinion among the experts on how the diagnosis should be formulated, summarised in Moffitt et al 2010: Research Review: DSM 5 conduct disorder: research needs for an evidence base. In paragraph 11 of the article (which is the great summary article on conduct disorder before the DSM 5), they outline in short the criticism of the diagnosis, and then describe how they look at the overall picture of the predictive value of the diagnosis:

”The hypothesis of continuity among ODD, CD, and ASPD has not been widely studied. Nevertheless, the available studies have used two longitudinal designs, follow-forward and follow-back. As a rule of thumb, the two designs reveal complementary pictures regarding continuity. Follow-back studies show that most CD children had prior ODD, and most (if not all) ASPD adults had prior CD. In contrast, follow-forward studies show that most ODD children do not develop CD, and most CD children do not develop ASPD. Thus, adult ASPD indicates a longstanding history of antisocial disorder from early life. However, children who begin life with an antisocial disorder need not progress toward ASPD. Indeed most such children recover (as noted in this article’s section on CD subtypes).”

So my opinion is that you should be careful to make the diagnosis because of a possible risk of the diagnosis in itself having a negative prognostic value.

Then there are other points of criticism:

Something I’ve also noticed is that not all doctors and psychologists make the diagnosis. The diagnosis is primarily used on children who are difficult to get to cooperate in psychological assessment. Thus, it’s not always the assessment team’s policy issues that are of interest, but the individual physician or psychologist’s ability to create alliances. That criticism has also been expressed by the DSM group where some people argue that you must ensure that the child has difficulties to cooperate with everybody to get a diagnosis, which otherwise becomes a diagnosis of a relationship, not a child.

Treatment-wise, there are major shortcomings. I’ve found the research to mainly be about medication and to show quite poor results. Psychological treatment is complicated by children with ODD being difficult to encourage and not being afraid of punishment. See the article abstracts here and here.

This means that the methods we usually use in pedagogical contexts are less effective. Token economy is thus unusable, and regular pedagogy doesn’t work. There is some evidence for Collaborative problem solving according to Ollendick et al 2015, and parental empowerment. But most people who get an ODD diagnosis unfortunately don’t get collaborative problem solving, and in Sweden we have no parental empowerment courses focusing on ODD without a CBT view (which of course will be difficult due to the strengthening tendency being reduced). My experience is that the diagnosis means that the child often gets inferior pedagogical frameworks in school, and that parents and teachers attribute the child’s problem behaviour to the diagnosis and not to their own attitude, and therefore punish more. Which may be contributing to the child having a worse prognosis.

Some diagnoses we set as the primary diagnosis, and other are considered additional diagnoses. A couple of years ago Danish Sundhedsstyrelsen (equivalent to UK Department of Health) criticised two CAMHS units for making the diagnoses ODD and CD, conduct disorder, without a main diagnosis. What they meant was that the problems the diagnoses describe are already known by the referral authority, and that the point of the referral was to get an answer to the why of the behaviour. ODD doesn’t give that explanation, and therefore doesn’t increase the information on the case nor improve the decision basis for selection of pedagogical effort. So the diagnosis should not be made unless there is an ADHD diagnosis or the like as primary diagnosis. It is however complicated by that the symptoms of the diagnostic criteria can be seen as a lack of flexibility, which is a common descriptive symptom of ADHD and a diagnostic criterion in autism (stereotype criterion). This means that we sometimes make two diagnoses based on the same symptoms, which is a no-no according to the DSM and ICD. So we shouldn’t make ODD the primary diagnosis, and cannot make it an additional diagnosis in autism spectrum disorders. And in ADHD half of those diagnosed meet the criteria of ODD. So the question is whether it actually isn’t a common descriptive symptom of ADHD, or a subtype.

All this doesn’t mean that you shouldn’t make the diagnosis. Just that you should be careful with it, and ensure that the symptoms are stable over time and across many different situations and reduce the adaptive capacity enough for a diagnosis being relevant. And you should ensure that the family gets training, preferably in collaborative problem solving.