[pachyderm]

There is some material on this on Psych Central:

http://psychcentral.com/disorders/sx73.htm

It says:

A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

* often loses temper
* often argues with adults
* often actively defies or refuses to comply with adults' requests or rules
* often deliberately annoys people
* often blames others for his or her mistakes or misbehavior
* is often touchy or easily annoyed by others
* is often angry and resentful
* is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (such as depression).

Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Criteria summarized from:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

My words: This category is considered to be "controversial." I can see why, if it is not used with the utmost care and comprehension. As far as I can see there is no attempt to understand why a person might display such behavior, nor that it may be a desperate attempt to maintain the last shreds of an independent and honorable existence. Calling it a "disorder" which needs to be "cured" has dangers.

[VoNPD]

Wow Pachy, very enlightening. Didn't know there was a classification for these behaviors. It explains much about 2 people I know/knew.

Thank you!

[nowheretorun]

thanks for this pachy! i didnt know there was a title for it either.. i experienced this, off and on, for about six month intervals each time.. the quote 'i'm angry and i'm not going to take it anymore!' was prevalent during these days along with an extremely distateful feeling of disgust for that which i disapporved of... geez i'm glad i was able to pass out of it!

for me, i had to find understanding of the things i didnt care for... that was hard cause i was used to pointing fingers at people or specific objects that represented those things that i disliked and finding ways to communicate what i was feeling in non-harmful ways was very challenging...

i found that people were willing to listen tho if i managed my words and spoke carefully and considerately ... it was a surprise to find that many others felt as i did about these things .. i learned how to better express myself from the conversations i shared with these first few kind listening souls and i am feeling much better now...

I would say that this could be argued for many disorders in the DSM-- however, we don't typically diagnose for the purpose of figuring the underlying causes.

ODD is a behavioral disorder, not a personality disorder-- however, I think it can be said that like personality disorders, it has to do with a child's way of coping when proper coping mechanisms are not in place.

I think it is okay to say that it has to be treated because no child should have to behave like that in order to survive-- the person benefits from the treatment because he/she does not have alternative ways of behaving. The parent also benefits from the treatment because it often involves parent training models and learning healthier ways of managing/extinguishing behaviors.

A "disorder" comes about if a disturbance is outside what would be considered "normal." In this case, the behaviors are seriously interfering with the child's ability to function in home, school, or social situations. For that reason, it becomes a disorder. Similarly, borderline personality d/o is a disorder, because, regarless of how the person go to that point, it is a serious disturbance of functioning-- the person is in need of treatment.

So while I don't think it is wrong to call something a disorder, I agree that we should always be looking out for "why" something occurs, and how it can be treated to become more manageable.

[kim_johnson]

part of the problem is that calling something a 'disorder' is often taken to imply that it is the person, the individual who presents who is the disordered, problematic one.

Szasz says that one can only metaphorically speak of a disordered society (or a disordered mind for that matter - but thats another story).

One day there was a doctor and he heard that a little boys grandfather was blaming his mother for making him sick. the doctor wanted to talk to the grandfather to explain that the boy had caught an infection and that it wasn't his mothers fault. the doctor explained to the grandfather about the pathogen that was causing the infection. the grandfather listened. when the doctor had finished the grandfather said that the boys mother didn't look after him properly. she didn't feed him nutritious food and she didn't keep the place hygenically clean. the grandfather said that the boys mother didn't look after him properly and that is why the boy got sick.

these two different ways of looking at the same thing (the internal dysfunction way and the environmental way) don't have to be mutually exclusive, of course. the medical model typically tends to focus on inner dysfunction such that it excludes contributory factors from the environment, however.

why were groups so keen to have conditions such as homosexuality taken out of the DSM? because they didn't think that people who were homosexual were disordered at all. they surely were harmed living in an intolerant society - but it was the social norms that needed to be changed rather than the sexual preference of those individuals. similarly, why is it that we consider 'sluggish schizophrenia' (a dx given to political dissentors in russia solely in virtue of their political dissent) to be an abuse of psychiatry? Why is it that we think the suggested dx category 'draeptomania' that was meant to be applied to slaves who 'pathologically' desired freedom from their masters is similarly an abuse of psychiatry? One may be unhappy being gay in a society that is predominantly hetero. One may be unhappy being dissatisfied with the political state of ones country. One may be unhappy being a slave to another person. We tend to have the intuition that these aren't disorderes, however. To regard them to be so is commonly regarded to be an abuse of psychiatry.

why should we be cautious about 'oppositional defiant disorder'? why... because we are pathologizing those who 'defy' or 'oppose' authorative figures. WITHOUT REGARD FOR WHAT THOSE AUTHORATIVE FIGURES ARE ATTEMPTING TO IMPOSE OR FORCE ON THOSE INDIVIDUALS. This dx seems strangely reminiscent of 'sluggish schizophrenia' to me... Which is to say... The pathologizing of individuals because we refuse to look at what it is about our society that these people are protesting against.

[Perna]

It's about children and don't forget that a psychiatrist is making the determination based on lots of evidence, the parent or other guardian, teacher, etc. isn't deciding this.

There's a randomness to ODD, doesn't just happen when someone is trying to get the child to do something oneous. Random anger and deliberately "annoying" others isn't going to be the result of adults. Not all childhood problems are the parents, adults, other person's fault :-) It's probably a function of something like ADD/ADHD or another unknown.

[pachyderm]

> we don't typically diagnose for the purpose of figuring the underlying causes

If you do not understand the underlying cause, you may prescribe the wrong treatment.

[kim_johnson]

> It's about children

I understand that.

> don't forget that a psychiatrist is making the determination based on lots of evidence, the parent or other guardian, teacher, etc. isn't deciding this.

The psychiatrist would probably use the testimony of the parent or other guardian etc as the greatest evidence. And of course the psychiatrists own reaction to the child (e.g., whether the child seems appropriately appreciative of the psychiatrists directives and opinions as well).

It would be nice to think that psychiatrists wouldn't err... Examples of the pathologizing of political dissent and homosexuality show us that psychiatrists aren't appropriately sensitive to when their diagnosing is more to do with social norms than with dysfunction within the individual, however.

I think that this is a diagnosis that there is understandably a great deal of controversy about.

> It's probably a function of something like ADD/ADHD or another unknown.

There is similar controversy over the status of ADD/ADHD... For similar reasons...

[kim_johnson]

>> we don't typically diagnose for the purpose of figuring the underlying causes

> If you do not understand the underlying cause, you may prescribe the wrong treatment.

Diagnosis isn't typically about finding the right treatment. That is because the majority of treatments aren't diagnosis specific, they are SYMPTOM specific.

In the beginning... Just about every theorist had their own classification system, their own lists of symptoms they attempted to assess, their own theory of the causes of those symptoms (e.g., oedipal conflict or fear of disintegration or whatever). Psychiatry seemed to be at the pre-science stage because it wasn't really possible for clinicians to talk to each other, agree on the presence / absence of symptoms, agree on the cause of the symptoms, agree on the treatments for those symptoms etc etc etc.

The DSM III was considered 'revolutionary' because it attempted (as much as possible) to be a-theoretic or agnostic between different theories. The thought was that by describing certain symptoms as being behaviorally operationalized as much as possible different clinicians could agree as to whether the symptom was present or absent (there would be inter-rater reliability). There was much greater inter-rater reliability than there used to be, that is for sure, but inter-rater reliability is still poor (not much above chance for the majority of symptoms / conditions).

The DSM isn't a-theoretic, of course. Some disorders are defined partly on the basis of presumed etiology (e.g., post-traumatic stress disorder or substance induced disorders). It still makes unwarranted judgements or assumptions (there is a big literature on that with respect to the borderline personality diagnostic category in particular). But it did signify a major theoretical advance from what had gone before. It served to unify the field of psychiatry. And more than that, it served to unify all the fields that deal with mental disorder (clinical psychology, education, sociology, anthropology, social work, councelling, mental health nurses, care workers etc etc etc). And (perhaps even more importantly) it made the American Psychiatric Association ONE %#@&#! of a lot of money!!!

But the DSM doesn't traffic in causes (as much as possible). In fact... Causal reasoning in psychiatry tends to go like this: Drug x helps people with condition / symptom / diagnosis x. Drug x helped person T therefore person T has condition / symptom / diagnosis x.

It is an invalid inference... But it is an inference that is employed nevertheless. The more there are 'magic bullet' drugs (treatments that are diagnosis specific) the more we say that whether the drug works or not is the major evidence for whether the person really was accurately diagnosed with that condition or not.

The inference is invalid because... EVERYONE has improved concentration etc with stimulant (ADD / ADHD medications). The efficacy of stimulants thus fails to distinguish between people who are low end of normal range and people who have an inner dysfunction. But then maybe... There is no different? And maybe... Task demands (e.g., to 'sit down and shut up') are inappropriate, really. But then... Why look at our schooling system when we can simply drug kids out of being behavior problems? And why spend a great deal of time with those kids teaching them how to behave (teaching their parents to teach them how to behave) when we can call it a 'disorder' and medicate them out of it?

People seem to have the following dichotomous assumption: Either the kid has some inner dysfunction which is out of the kids control but for which they can be treated... Or... It is my fault for being a bad parent.

It is of course a false dichotomy... But we seem to WANT disorders to proliferate. We seem to WANT people to be diagnosed with a disorder for (we think) their own good... The trouble is that pathologizing the individual often prevents us from taking a good hard look at our social practices around schooling, the way authority figures often treat children, some of our childrearing practices etc. We seem to want... People to be drugged to tow the line and I'm far from convinced that psychiatry adequately assess peoples often legitimate complaints when it assumes that the person is dysfunctional (and thus undermines their authority as witness).

[kim_johnson]

> Wow Pachy, very enlightening. Didn't know there was a classification for these behaviors. It explains much about 2 people I know/knew.

It doesn't 'explain' anything at all. It merely describes.

If I know already that if you put salt in water then it dissolves and I ask you to explain 'how come?'...
And you say 'salt is soluble' then that isn't an EXPLANATION it is merely a REDESCRIPTION of what I knew already. Attaching a label to something is NOT to EXPLAIN it it is merely to DESCRIBE it. If you had a theory of solubility then that might provide an explanation... But the DSM doesn't provide a theory of oppositional defiant disorder. What the DSM provides would be like if you were to say to me 'soluble things are things that dissolve in water'. Once again: A RE-DESCRIPTION is not at all an EXPLANATION. All it does is introduce a term that is shorthand for the description / observation that we had already.

[pachyderm]

</font><blockquote><div id="quote"><font class="small">Quote:</font>
kim_johnson said:

The DSM III was considered 'revolutionary' because it attempted (as much as possible) to be a-theoretic or agnostic between different theories. The thought was that by describing certain symptoms as being behaviorally operationalized as much as possible different clinicians could agree as to whether the symptom was present or absent (there would be inter-rater reliability). There was much greater inter-rater reliability than there used to be, that is for sure, but inter-rater reliability is still poor (not much above chance for the majority of symptoms / conditions)....

</div></font></blockquote><font class="post">

Nice explanation. (I still want to understand underlying causes, or maybe more accurately "What do the symptoms mean? What is producing those symptoms?" I am a psychological curmudgeon.)

</font><blockquote><div id="quote"><font class="small">Quote:</font>

But the DSM doesn't traffic in causes (as much as possible). In fact... Causal reasoning in psychiatry tends to go like this: Drug x helps people with condition / symptom / diagnosis x. Drug x helped person T therefore person T has condition / symptom / diagnosis x.

</div></font></blockquote><font class="post">

Aspirin reduces the pain of headaches, so headaches must be caused by the lack of aspirin in the brain...

[Perna]

Did you all have this diagnosis or know any child who did? What are you basing your opinions on?

[kim_johnson]

> I still want to understand underlying causes, or maybe more accurately "What do the symptoms mean? What is producing those symptoms?"

Yep. I think there are a lot of people who would like to know that... And... Theories (still) proliferate. I'm not sure that there is much more consensus on the causal etiology of depression or schizophrenia or whatever than there was before the development of the DSM-III. Of course we have accumulated facts... But what the hell they contribute towards an `explanation' (if anything) is a different matter...

There is also a whole literature (I'm sure you will be pleased to know) on what on earth `explanations' are supposed to be, and what criteria determines a good explanation from a bad one. That makes a difference with respect to whether causal explanations for mental disorders are supposed to be genetic, neurological, cognitive, environmental, evolutionary, psychodynamic or some weird-*** combination of those (however that is supposed to go)...

One way an explanation can go bad is to label something and to think that the thing is thereby explained.

Another way an explanation can go bad is to infer causes from effects.

> Aspirin reduces the pain of headaches, so headaches must be caused by the lack of aspirin in the brain...

Yeah. Might be an `explanation' but seems to be a pretty bad one, huh ;-)

One reason why it is bad is that asprin doesn't naturally occur in the brain. So... There are a lot of people out there in the world without asprin in their brain - and yet only some small subset of them have headaches. Lack of asprin in the brain thus doesn't seem to be a very good explanation of headaches because the majority of people without asprin in the brain don't have headaches.

One theory of ADHD is that it is caused by too little dopamine. The pharma companies are keen to promote that one in particular (and also parents who think the only alternative is 'bad parenting', I guess). The only reason we have to believe that ADHD is caused by too little dopamine is that if you give those people dopamine they are able to focus better*. The trouble is that if you give people without ADHD dopamine they are able to focus better as well. Dopamine helps EVERYONE focus better. Giving a person dopamine and finding they improve their ability to focus is thus not relevant for telling us whether a person has ADHD or not as it fails to differentiate those with ADHD from those without it. So... The dopamine theory of ADHD is problematic.

We think ADHD is a legitimate bona fide disorder because it is due to neurological dysfunction. But what is the nature of the neurological dysfunction? We don't know. At this point in time the dysfunction involved in THE MAJORITY of mental disorders is an ASSUMPTION rather than something that has been discovered / established.

Same goes for the other conditions that are supposed to be explained by too much / too little dopamine / serotonin etc.

* Sometimes it is found that people who improve functioning if given drug x have less x receptors than normal upon autopsy (e.g., in theories of schizophrenia). The problem is whether the lack of receptors was a problem PRIOR to the introduction of the medication or whether the lack of receptors was due to the brain habituating to the presence of the medication. Without autopsy's of people with the same condition who weren't given that medication as a control group we simply don't know. Unfortunately... It is considered `unethical' to with hold medications of `proven effectiveness' in order to see...

There are a lot of bad explanations in psychiatry. Mostly due to the curious blend of information and advertising and the curious blend of science with financial investment...

I think most people would be appalled at the majority of causal reasoning in psychiatry (where we infer causes from effects in the above mentioned highly problematic ways). I think most people would be appalled at how the financial investments infect the quality of the science. I think most people would be appalled at how pharma companies advertising is passed off as `research' and used to `educate' or `inform' psychiatrists and consumers alike.

I'd love to teach a critical reasoning course to training psychiatrists one day :-)

Well... I wouldn't really... But... SOMEONES gotta do it...

[SerenitysWave]

I have a child that has been diagnosed with ODD along with: ADHD, PDD-NOS, and microcephaly....

[Rapunzel]

The Psychodynamic Diagnostic Manual takes a slightly different approach to this and other disorders than the DSM does, and attempts to be more descriptive, with some discussion of etiology and treatment possibilities. It also has a discussion of the controversies related to this disorder. If you can get a copy of the PDM, you might find this interesting.

Among other things, the PDM suggests that children with ODD have a developmental history where they had difficulty with emotion regulation and communication of emotions, with frustration and loss being particularly hard. They tend to be sensitive to a lot of things, including sound and touch, and as a result try to control the environment. Children with ODD often feel demoralized and resentful, with self-doubt and self-hatred, and almost always feel that they are not well understood. Their behaviors may be an attempt to preserve a sense of control and self-esteem.

Social and family relationships are usually disrupted, leading to a vicious cycle where the child acts out, others respond with rejection, and the child becomes more rebelious and defiant.

One thing that seems to help is teaching parents more flexible approaches.

I think that it is appropriate for ODD to be discussed in this forum, as children with ODD can often develop personality disorders as they mature, especially without effective treatment.

[kim_johnson]

I'm struggling with seeing how the PDM 'description' of ODD differs from a fairly typical characterization of borderline personality disorder (with respect to difficulties with emotion regulation in particular).

In the beginning... Different diagnostics systems proliferated. The DSM III was revolutionary in that it attempted a classification based on operationalized descriptions of symptoms in a way that theorists of radically different theoretical orientation could accept and agree on the presence or absence of symptoms. This as opposed to controversy over whether a given person REALLY had anxiety, for example, if anxiety was characterized as difficulties negotiating the oedipal phase by one theorist, or if anxiety REALLY existed, if one didn't believe in the oedipal phase.

The Psychodynamics Diagnostics Manual is meant to be a 'revolutionary alternative' to the DSM, but I really don't think that it is. Firstly, because either DSM and / or ICD diagnostics MUST be provided for health insurance reimbursement / publically funded treatment and as long as that remains the case those systems will be preferable over the PDM. Secondly, because the PDM is (as the name suggests) PSYCHODYNAMIC in its constructs and its presumed etiologies / rationales for the symptoms. It is thus unlikely to be accepted by either medically inclined practitioners (the majority of psychiatrists) or by the psychotherapists who are big on their 'evidence based medicine' (ie CBT based approaches). That is basically to say... That it will be rejected by the two leading paradigms in mental disorder. Thirdly, the PDM simply isn't that revolutionary. I got quite excited about it initially as it promised to provide a system that was dimensional rather than categorical (where the DSM and ICD are categorical even though they both regard this to be a 'heuristic' rather than something capturing the reality of the situation). While the section on personality disorders in the PDM is fairly different from the DSM and ICD (endorsing personality 'disorders' that are of different types and endorsing different - psychodynamic - explanations of them) for the most part the PDM simply copies the diagnostic categories (and the diagnostic codes) from the DSM / ICD.

That being said, I have a lot of sympathy for modern (read 'current') forms of psychodynamic theory.

It used to be fashionable to see disorders in a wholistic fashion. The thought is that... The whole person was a little out of whack, basically. Treatments were thus comperably wholistic. So... A kid has difficulty attending... What might be responsible for that? Are they getting a diet that is optimal for them (e.g., preservatives and additives and artificial flavourings and artificial sweeteners such as corn syrup DO tend to result in hyperactivity). Are they getting enough physical exercise (e.g., kids who are active WILL have trouble sitting still and listening to instructions when their body is screaming out to them to DO SOMETHING and to get those endorphins (which help prevent crankiness, irritability, and agression) flowing). Are they having realistic expectations placed on them (it can be hard to set expectations / demands that are within the child's capacity). Are they being reinforced appropriately for positive behaviour and not being reinforced (even inadvertently) for acting up? There are a whole bunch of contributing things....

The medical model encourages us to disregard the person - indeed, the slogan is that 'people aren't schizophrenic - rather a person has (the affliction) of schizophrenia. This is meant to be important for 'reducing stigma' - but really, it seems more to do with the medicalization of more wholistic problems, to me. The thought that there is some part of the person that is defective or malfunctioning in some way. The thought that the best treatment for that part of the person is the fairly 'direct' inverventions of medications in particular...

This disorder is of concern because... It is a precursor for a diagnosis of 'antisocial personality disorder' (that can't be diagnosed in children). When we pathologize children that young... I really do think we are often giving them a life sentence... It should be very much a last resort IMHO - very much a last resort... To be employed well after every other possible intervention has been tried... Trouble is that with our %#@&#! up health system... Not likely... Very often the only way to get help is to have a diagnosis. There are many people with a diagnosis who are denied help, even (try finding help for a child with this diagnosis, I'll bet the majority of clinicians will run in the opposite direction if they can). Oh for the good old days where when a parent / child pair were struggling... People simply stepped in to help. Oh for the good old days where class sizes were much lower so individual children got the attention they so genuinely needed and deserved. Oh for the good old days where grandparents were part of the family and stepped in to help younger members who were struggling with their kids. Oh for the good old days where communities were smallish and people stepped in to help one another rather than being overwhelmed by living in large urban areas that are overcrowded.

The good old days are largely a myth, of course... But then... How many children suffered from ADD / hyperactivity / oppositional defiant disorder in the good old days?

[ECHOES]

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When we pathologize children that young... I really do think we are often giving them a life sentence

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Only if we rush them off to the psychiatrist instead of the analyst.
I think this can be, like in any analysis, the starting point. The identification of where development derailed, where on the developmental continuum the child has become stuck, so that the development can be encouraged back on course. I believe that with children and interested and willing parents, there is the greatest possibility of success, of derailing the derailment.

[Rapunzel]

If the child is having enough difficulty in living to truly have these disorders, then it would be doing a disservice not to treat the problem properly. It is important to differentiate between a child who is really in trouble, and one that has parents or teachers with unrealistic expectations. Although the latter can and sometimes does lead to the former. With any and all problems involving children, it is better to keep in mind that diagnoses are more of a description of what is going on, rather than a definitive label. Most of the time the child is merely the identified patient, that a system that isn't working holds up as the evidence that something is wrong here. Medicating the child almost never solves the problem.

[kim_johnson]

the pathologizing can come from the person trying to understand their disorder (as people are wont to do). so... the person reads up on their disorder and what do they find? that it is defined as a fairly much life long affliction.

the way people categorize and view us and subsequently treat us has an impact on how we come to view ourself and how we come to act in the world. if people tell us that we are 'thoughtless and have no regard for others' then they are making it more likely that we will internalize that and that *as a result of being categorized in that way* we will conform to their expectations.

when we diagnose a kid with oppositional defiant disorder clinicians often relate to them as someone who will likely grow into antisocial personality disorder. what impact does that have on the way the clinicians relate to them and what results does that tend to have on the person who is thus categorized. for the most part... no good will come of it methinks.

the trouble with the medicalization model is that it considers that people have a disorder when (and only when) there is a DYSFUNCTION WITHIN THE INDIVIDUAL. the individual is thought to be the problem. if altering aspects of the persons environment were enough to alter their behaviour then the saying goes 'they weren't *really* disordered after all'. medicating the child doesn't tend to do a great deal with respect to solving the problem. indeed, medicating the child could even result in permanent developmental disability (we simply don't know the effect that stimulant medications etc have on the developing brain - we don't even know the long term effect that stimulant medications etc have on the developed brain). if only diagnoses were mere descriptions (as they are meant to be) and if only... they didn't tend to be self fulfilling prophecies with respect to course of symptoms over time...

[Rapunzel]

In my experience, there is a professional understanding that untreated, ODD can become Conduct Disorder, and if that worsens, it may be expressed as APD in adulthood. But I have never met a professional who assumes that ODD will lead to Conduct Disorder and APD. In children, the whole point of identifying a problem is to make changes and provide treatment, and prevent it from becoming worse.

But often it isn't helpful to focus on a diagnosis. It is important to remember that there are a lot of factors involved in any mental illness or behavior problem. There may be biological components, but social, environmental, emotional factors, etc. all make a difference, even with a diagnosis thought to be primarily medical. An autistic child will do better in life with supportive, understanding parents, for example. Treatment and education make a difference too. The goal is best possible outcomes, and hopefully stopping any progression to worse problems or diagnoses.

Kim, I'm not sure if we are mostly agreeing with each other, or if you disagree with what I am posting. I'm feeling a little lost. I think that we are all advocating what we see as the most helpful approach to children with ODD, whether it's useful to label it such or not.

[kim_johnson]

I don't really think we are disagreeing either. I guess it is just that you might feel that it is more useful for this this to be a diagnostic category in the DSM than I do.

[kim_johnson]

I don't really think we are disagreeing either. I guess it is just that you might feel that it is more useful for this this to be a diagnostic category in the DSM than I do.

[ECHOES]

I think it is just a refernce to a group of behaviors, issues.

I think we could decide to call it Banana Pudding and it would still serve to say, Okay here's where we are and what's going on, and here's what might help.

[pachyderm]

"Banana Pudding" has a generally more acceptable flavor to it than "Oppositional Defiant Disorder" -- in my estimation.