Johnny is five years old, with verbal skills of a typical ten-year old. His confidence with his words is mind-blowing. Whereas most kids his age hardly speak to adults, Johnny quickly remembers your name, uses your name and tells you how pleased he is to meet you. Consequently, adults love him. His parents, however, are ready to put him up for sale. He is uncooperative with dressing himself and putting his toys away. His friends have trouble with him too. He tends to be bossy. His focus is impressive, although he is having trouble learning to read. His math skills are consistent with his age. Johnny’s parents were fighting with each other over how to deal with Johnny’s oppositional behavior. They consult a child psychiatrist who then diagnose Johnny with oppositional defiant disorder. The psychiatrist prescribes Ritalin; Johnny becomes more cooperative. The parents, Sienna and Clive, come to me for a second opinion.
Oppositional Defiant Disorder is a mental disorder according to DSM-IV, not in my opinion, I explain. Johnny’s temperament is one of independence and strong will. He is hard to raise; I can see that, I share. The Ritalin makes him softer around the edges, but I do not think it is a good idea, I explain to them. Helping Johnny become more cooperative is the challenge. Sienna and Clive can do this with parent training. Johnny needs help understanding that his independence is helpful in certain situations, but not in others. Johnny’s young age is an opportunity to begin Johnny’s path of self-understanding. Ritalin could cloud these issues. “Don’t get me wrong,” I caution them. “Ritalin, as with all stimulants, are very helpful for children with ADHD in that it helps them focus and it helps them with their hyperactivity, but for oppositional behavior, I prefer to try parent training before jumping to medication.” Sienna and Clive look at me with wonder and fear. “He is so much easier to live with,” Sienna explains. “A good result does not necessarily justify the means,” I respond.
Oppositional Defiant Disorder, or ODD, which, like the word ‘odd’ is an odd diagnosis. It applies to children, but not adults. What happens to a child with ODD when they turn 18? I do not know the answer to that. By definition, the child grows out of this diagnosis. I have trouble making sense of this, except to say the diagnosis is another example of psychiatrists, in this case child psychiatrists, pathologizing a variant of temperament. We need to understand children and we need a language to convey this understanding to parents. We do not need diagnoses which label children as ‘disturbed’ . Understanding a child is not the same as diagnosing a child. Strengths and weaknesses, that is where clinicians should begin their assessment. Behavioral interventions are almost always a good beginning. Usually, a diagnosis can wait a few weeks as the clinician works to understand the child at home, at school, and with his friends.
Perhaps I am the one with Oppositional Defiant Disorder. I oppose the diagnosis. I oppose the apparent rush to medicate young children with this diagnosis. Am I an advocate for these kids or an adversary? Like the diagnosis, it depends on your perspective.
Shirah Vollmer MD 