ODD – The Questions
Oppositional Defiance Disorder (ODD) is reported as, “a pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting for at least 6 months” (APA, 2013, p.462). But is ODD a real mental disorder stemming from brain difference or is it a manifestation of an attachment issue due to relational trauma; a deficiency of Theory of Mind which occurs in younger or neurodivergent kids, or a way for a child to seize control in an ever-changing or threatening environment? And why are some parents wanting to receive this diagnosis for their child? Does the current culture of ‘Mother Blaming’ in society contribute to the rising number of self-diagnosed ODD cases in children? What are the cultural factors which contribute to ODD misdiagnosis?
Oppositional Defiance Disorder (ODD) sometimes has negative connotations, portraying a defiant little person who refuses to comply; exhibits aggressive tendencies; and is potentially unsafe around others. The child can be described as manipulative and deliberate in their actions, like a cold, calculating caricature of an evil little genius! As a therapist on meeting the child, what is more obvious is that they are a hurt little person who is seeking control in a challenging social environment to ensure predictability in a world which seems threatening and unsafe.
In a culture that consistently blames parents and where ‘Mother blame’ is rife and normal (Clark & Ameron, 2015), parents are desperately clutching to generalized mental health statements to self-diagnose their child and remove the label of being a bad parent. Clark & Ameron (2015) reported that ashamed mothers rely on ‘medicalization’ of their child’s emotional and behavioural symptomology through diagnosis to shift the blame off their parenting practices and onto the brain of their offspring, to make sense of the eruptive behaviour.
It is a sad fact that in this parenting climate we have gotten to this point, where diagnosis is required for a parent/caregiver to feel free of shame and blame when their child is struggling at the mercy of their behaviours. Of course, we know that it is not as simple as just a brain difference, and that if we look holistically, social and environmental components are important to analyze, as well as genetic and biological.
Becoming Curious about Conduct Behaviours
If we take the judgment out of this situation and become curious about the behaviour, it allows us to see more clearly that the child is communicating their struggles and need for support through their behaviours. Judgment causes blinkered views which only look through one perspective and puts pressure on parents/caregivers and professionals, such as teachers, to stop the behaviour. This pressure manifests into shame on the adult working with the child, which is projected onto the child, further exacerbating the problem.
Becoming curious can allow us to open up this path with the child and find out what they think could be contributing to their behavioural responses. It allows us to slow down, take a deep breath, and query what is going on in the brain and body of the child. Maybe they are becoming triggered by something which is not even visible – a smell, a sight, or a sound? If the child has had some past trauma this could mean they are living in their survival brain and flipping their lid more frequently due to these triggers, which tip them out of their window of tolerance.
Neurodiversity and Theory of Mind in relation to ODD
If the child is neurodiverse, they may live consistently at the edge of their window of tolerance, becoming easily triggered into dysregulation from sensory changes which can tip them over the edge of their regulatory brain.
It is proven that neurodiverse children do not develop Theory of Mind as quickly as neurotypical kids. Theory of mind (TOM) allows us to identify emotions in other’s; encouraging empathy and enhanced social skills (Fahim et al., 2011). In neurotypical children this can develop at around 5 years of age, whereas in kids with neurodiversity they may be a lot older, and therefore unable to understand how their actions affect others. When empathy and perspective taking do not come naturally, it is difficult to navigate the social landscape and social responsivity takes longer to acquire, causing issues in relationships (Fahim et al., 2011). Neurodivergent kids often struggle to form friendships and maintain them, due to a lack of Theory of Mind, causing confusion and a feeling of being excluded due to being misunderstood.
Mindfulness in Conduct Problem Comprehension
If a child is quick to anger, why is that? Are they having difficulties at home or in school? Do they struggle in friendships and find social situations overwhelming? Are they dealing with a lot of changes in their life? Is their over-active stress response causing the survival brain to kick in and hijack their thinking brain with a fight response? If, none of this resonates then look back further…what happened when they were in-vitro, a baby, infant, toddler, or young child? Did they suffer from a traumatic birth into the world, abuse, medical trauma or even bullying which was left unresolved?
Any unprocessed trauma can be stored in the body and cause an automatic survival response in situations which are perceived as threatening. This response occurs so quickly and can be viewed by adults as defiance rather than an autonomic nervous system response or a need to seize control in an environment perceived as unsafe. The threat may not be real, but it feels real to the child and alerts the amygdala which triggers the autonomic nervous system into a fear response, e.g., fight, flight, freeze or fawn. And in these kiddos, it is typically fight!
Teaching kids to slow down, listen to their bodies and come back to themselves can aid emotional identification and in turn emotional regulation; therefore, reducing conduct problems in children. Mindfulness is an excellent way of generating this state and can help to perpetuate acceptance and non-judgement of the self and others, which is imperative in understanding these kiddos and for them to understand themselves and begin to understand others. Modelling mindfulness and regulation e.g., by taking deep belly breaths when we feel dysregulated, can allow defiant kids to witness this strategy and begin to perform these regulation activities for themselves. Increased regulation will allow kids to tune into their bodies, determine how they feel and get curious about why, which is when self-reflection and emotional regulation can commence.
Cultural Issues in Misdiagnosis of ODD
There is also a cultural component to ODD misdiagnosis since many children from racialized backgrounds are given this label incorrectly when they have Attention Deficit Hyperactive Disorder (ADHD). 69% of black American children received an ODD diagnosis when they had ADHD. Although ADHD and ODD often go hand in hand, ADHD is different, as the inability to conform to requests is due to the requirement of sustained attention or a demand that the individual sit still, rather than defiance (APA, 2013). 50% of Latino American children received this diagnosis when they had ADHD (Neurodivergent Insights, n.d).
Systemic racism perpetuates negative stereotypes and causes misdiagnosis within these populations. Another factor in these misdiagnoses is the number of Adverse Childhood Experiences (ACEs) with which these children have suffered, but this is often not taken into account when ODD is diagnosed. White children are much more likely to present with the same issues and be diagnosed with ADHD or adjustment disorders (Neurodivergent Insights, n.d.).
ODD Diagnosis – A Help or Hinderance
I conclude that the diagnosis of ODD is a hinderance as it puts blame on the child who is struggling at the mercy of their behaviours rather than fully in control of them, as portrayed by the Diagnostic Statistical Manual (DSM). The ODD diagnosis is being given out disproportionality to children from racialized backgrounds. It is also potentially caused by other issues such as neurodivergence, attachment issues and trauma. This diagnosis perpetuates a negative view of the child which follows them from establishment to establishment. It creates barriers where parents/caregivers and professionals feel the child is out of reach and cannot be helped. Whereas in reality, we know that brain plasticity can change and reform patterns in the brain to those of safety and connection, rather than fear and disconnection. Being empathic and taking a non-judgemental stance is imperative to supporting these kids and their families through these big behaviours. Eventually these children will learn to thrive through co-regulation which will slowly become self-regulation, providing that their environments continue to be safe and nurturing.
As a professional working with these families, parenting validation and support is important in this journey as the struggles are real. Positive parenting practices, based on attachment, play and connection (e.g., play therapy and Theraplay), will improve relations between the parent and child; and these strategies can be implemented at school too. Noticing good behaviours; over-praising good choices; allowing the child to have more control in their lives; and playful interactions using safe touch whenever possible, can help to bring about feelings of safety and connection in the child.
In the UK it is like this diagnosis no longer exists. I hope that we will remove this diagnosis worldwide from the DSM and begin to empathize with these hurting kiddos, supporting them and their families, rather than shaming and blaming them for actions stemming from feeling threatened, unsafe, and disconnected; rather than so-called ‘deliberate’ or ‘vindictive’ behaviour (APA, 2013).
By Chantal Piercy (January 4th, 2023)
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders: Fifth edition. American Psychiatric Association.
Clarke, J.N., & Van Ameron, G. (2015). Parents whose children have Oppositional Defiant Disorder talk to one another on the internet. Child & Adolescent Social Work, 32, 341–350. DOI 10.1007/s10560-015-0377-5
E la Osa, N., Granero, R., Josep Maria, D., Shamay-Tsoory, S., Lourdes, E. (2016). Cognitive and affective components of Theory of Mind in preschoolers with oppositional defiance disorder: Clinical evidence. Psychiatry Research. 24(1), 128-134. DOI 10.1016/j.psychres.2016.04.082
Neurodivergent Insights. (n.d.). Is it ADHD or ODD? How Racial Bias Impacts Diagnosis. https://neurodivergentinsights.com/adhd-infographics/adhd-odd-and-racial-bias