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Is Oppositional Defiant Disorder (ODD) a real disorder?

post by Christopher Gillberg 23rd May 2017

Many children are oppositional. In fact, most children (albeit not all), at least from about the age of one, have shown some oppositional behaviour several times in their life. Some are so oppositional almost all of the time (except when asleep, a time when they may exhibit other concerning behaviours such as hyperactivity and night terrors) that we refer to their behaviour as a major problem, indeed a disorder. Depending on whether or not these children are seen in clinics (which, of course many are not) and depending on the orientation/training background of the clinician, a diagnosis may be provided to cover this behaviour. Some will use the label Oppositional Defiant Disorder (ODD) of the DSM-system. Others may refer to Pathological/Extreme Demand Avoidance (PDA/EDA).

Not much is known about the causes of these specific behaviours. ODD (and probably PDA also) is almost always “comorbid” (occurs together) with DSM-disorders such as ADHD, anxiety, depression, enuresis, autism or other developmental disorders, for which there are, at least some clues as to separate (but also shared) background factors. One of the core “symptoms” of ODD (“often loses temper”/emotional lability) is actually the most common symptom exhibited by preschool children with ADHD (even though it is not included in the DSM as an “ADHD-symptom”, see Kadesjö et al 2003) and is also very common in young children with autism.

Is there a specific treatment available for ODD or PDA (as there is for ADHD, anxiety, depression, and enuresis)? Not really, even though psychoeducational and behavioural approaches - such as those used in so called collaborative and proactive solutions (CPS) - appear to have positive effects on some behaviours, including emotional lability (the most common symptom in ADHD) in “explosive” children (e.g. Johnson et al 2012, Ollendink et al 2016, Samuelsson et al and in progress). Given the relative lack of separate biological and treatment validity for ODD, I think it would be more reasonable to refer to ODB (oppositional defiant behaviour) and stop treating it as a separate disorder. As regards PDA – and especially EDA (which does not categorize the behaviour as pathological) – I have less of a problem, seeing as there is no reference to it being a specific separate disorder.

Having said that, I believe it is important to ascertain the presence or not of ODB/EDA in disorders such as ADHD, depression, anxiety, enuresis and autism, especially if the ongoing independent randomized controlled Swedish study of CPS corroborates the positive results found in a US study performed by the originators of the method. However, I think ODB should be seen as a concomitant or complicating factor in other ESSENCE, not as an “only” diagnosis for a psychiatric or developmental disorder in its own right.

References

Johnson, M., Ostlund, S., Fransson, G., Landgren, M., Nasic, S., Kadesjö, B., …Fernell, E. (2012). Attention-deficit/hyperactivity disorder with oppositional defiant disorder in Swedish children - an open study of collaborative problem solving. Acta Paediatrica, 101, 624-630.

Kadesjö, C., Hägglöf, B., Kadesjö, B., & Gillberg, C. (2013). Attention-deficit-hyperactivity disorder with and without oppositional defiant disorder in 3- to 7-year-old children. Developmental Medicine and Child Neurology, 45, 693-699.

Ollendick, T.H., Greene, R.W., Austin, K.E., Fraire, M.G., Halldorsdottir, T., Allen, K.B.… Wolff, J.C. (2016). Parent Management Training and Collaborative & Proactive Solutions: A Randomized Control Trial for Oppositional Youth. Journal of Clinical Child and Adolescent Psychology, 45, 591-604.

Samuelsson, L et al in progress

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