Shirah Vollmer MD

The Musings of Dr. Vollmer

Oppositional Defiant Disorder: I am Opposed

Posted by Dr. Vollmer on August 24, 2010

      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.

9 Responses to “Oppositional Defiant Disorder: I am Opposed”

  1. Shelly said

    I heartily disagree with you and feel this time you missed the mark. Have you ever tried to parent a child with ODD? I’m sure the parents consider Ritalin a life-saver for everyone. It not only “blunts the edges” but makes life liveable for everyone. How sad that professionals always come back to “teaching parents how to parent” their children with ODD. Teaching the family how to deal with their problematic children puts blame squarely on the parents for being the victims of their own children. Doing so validates every snide family member who feels that the parents are doing a bad job of parenting because their children have some type of psychiatric issue. My sympathies to Sienna and Clive!

    • Oh no……hold on……..First, the fact that parents can make it better does not mean that it is their fault in the first place. Second, Johnny is five years old. I am making the plea that parenting techniques should be tried first. If this does not work, I support the use of medication. My major point is that doctors should not be too quick on the trigger. My second major point is that a good result from medication does not prove that medication was a good call. The decision to medicate is a case by case basis. Some situations warrant medications immediately, whereas other situations can be managed with behavioral techniques. We all sympathize with Sienna and Clive, but we also sympathize with Johnny. The process of decision making needs to be measured and careful, not quick and “easy”. If you met Johnny, you probably would have a very different idea. He is oppositional, but he does respond to firm limits. He is different than a child who never responds to limit setting.

  2. Suzi said

    I admire your bravery. I’m also so glad they came to you for the second oppinion. At least Sienna and Clive go away with a broader out look on how to view their family situation.

    I really dislike the TA game… “wooden leg”. It’s everywhere. The last thing any child or parent needs is to potentially learn how to disguise facts or reality with psych games.

    A tough call – my hat’s off to you.

  3. Tim Hamilton said

    Dr. Volmer, I am a counseling and social work graduate student in NM. I also have a bachelor’s degree in social work. I would like to have your thoughts on the neurobiology of ODD in plain terms. What you need to understand is that there is precious little information outside of symptoms and comorbidity issues available readily in the internet, or even on library shelves, There is much dispute about the very existence of ODD and CD, with some authorities insisting these are not disorders so much as choices in the way individuals present themselves and deal with other people.

    What are your thoughts?

    • Hi Tim,
      Thank you for your comments. I think that ODD is a temperamental issue. In other words, I think that kids are born with a predisposition to either be agreeable, or disagreeable, or somewhere in between. I think parents have to understand their child’s temperament and then deal with them accordingly. I do not think it is psychopathology, but it can turn into psychopathology if the parents react in a negative and punitive way. If it were up to me, ODD would be taken out of the DSM. I want to bring back Chess and Thomas’ work on temperament. Their work was done in the 50s, but I think their ideas have maintained their value. Let mek now if you have any more questions. SV

      • Tim Hamilton said

        Thanks Dr. Vollmer.

        Your comments were very interesting. I searched Chess & Thomas and read a little about their work. What interests me is that there is a major thread of common sense in the way they viewed issues in childhood. As a behaviorist, I have long thought that environmental factors play a much larger role than does psychopathology. Poor parenting skills, diverse parenting styles, cultural issues, poverty or wealth or something in between, even the accessibility of leisure activities seem – to me – to play a part in how children behave, and act socially. I would very much like to join or initiate a study into various behavioral phenomena. I am curious what you think about Asperger Syndrome, and whether or not you think that some behaviors that fit into an ODD framework are used to mistakenly diagnose Asperger’s?

        • Shirah said

          I think the ODD diagnosis applies to kids who do not cooperate with what their parents want them to do. The Asperger’s diagnosis usually applies to kids with more soical issues. I don’t see them overlapping, but of course, each case is different.

  4. Tim Hamilton said

    I have been actively observing a child who remains undiagnosed, but fits all the criteria for diagnosis as having ODD. However, as I observe the child, I cannot help but see what goes on around the child as I see her predominantly in her home environment. I have, over some years, come to the conclusion that her behaviors are a choice, and that environmental factors, thatis parent/child and sibling relationships, exacerbate the behaviors. My thoughts are that medication would be a waste of time, but parent training and some major behavioral interventions are in order. I am also of half a mind (meaning that I remain unconvinced) the child may benefit from and out-of-home placement for a period of time to undergo intensive treatment.

    I secondly agree that the inateness of the behaviors can become psyhopathology and not the other way around. In other words, I agree that strong-willed children are sometimes naturally predisposed to become problematic in their behaviors, and that poor, ineffective parenting and other social factors can and do play a role in the worsening of problem behaviors to the point that it does become pathological in nature.

    My greatest concern is that a child who is as severely challenging as this child is, cna or could become a danger to others as she grows into adulthood.

    My thought is that hidden cameras should be installed in various places around the home without her knowledge so that her behaviors can be observed as naturally as possible. Counter to this thought is that the parent would obviously know the cameras were there, and the parent may “play to the cameras.”

    My observations have been over a period of ten years, and I have noted an escalation of behaviors to the extent the child has become largely unmanageable for the parent. The increasing risk to the parent has been shown in a willingness of the child to initiate a measure of violent behavior against the mother, and that the mother seems incapable of effectively protecting herself.

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