025 - Oppositional Defiant Disorder is a Syndrome, not a Primary Disorder

Dr. O'Leary discusses his critical perspective on Oppositional Defiant Disorder (ODD) and argues that ODD is not a primary diagnosis but rather a "risk syndrome," a set of symptoms (defiance, irritability, and vindictiveness) resulting from various underlying conditions like ADHD, anxiety, or trauma. He explains that conceptualizing ODD as a stand-alone disorder often leads to the risky treatment pathway of off-label antipsychotic medication, whereas recognizing it as a syndrome necessitates an etiology-focused approach to treat the true root cause, typically with safer, condition-specific interventions. Dr. O'Leary traces the evolution of ODD criteria through the DSM manuals and urges clinicians to use comprehensive evaluations rather than relying on simple screeners, especially when an ODD diagnosis is present.

A more in depth discussion with references can be found here: https://sciencebasedpsych.blogspot.com/2025/10/oppositional-defiant-disorder-not.html

Referenced resources can be found within the show transcripts at https://psydactic_caps.buzzsprout.com

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This is not medical advice. Please see a licensed physician for any personal questions regarding your own or your child's health.

Transcript

For references and a more in depth discussion: https://sciencebasedpsych.blogspot.com/2025/10/oppositional-defiant-disorder-not.html

Welcome to PsyDactic Child and Adolescent Psychiatry Edition. I'm Dr. O'Leary, a child and adolescent psychiatry fellow in the National Capital Region. Today is Thursday, December 11th, 2025. This is a podcast dedicated to learning about child and adolescent psychiatry, and I make it to help me to study for my upcoming boards. Producing this content forces me to study, but also it might help others who happen to be interested in the same things. I produce the podcast alone without any oversight or editorial staff, so everything I say here should be considered my own opinion and no one else's. I also often use AI to help me do things like research to produce some of the content, but in the end, I'm the one who has read, reread, fact checked, and rewritten most of the content for its final presentation. So, I can't blame anyone, including AI, if I'm wrong. Today, I'm going to tackle what I feel is one of the most frustrating labels in the DSM, oppositional defiant disorder. Now, what if I were to tell you that oppositional defiant disorder or ODD is not really a diagnosis? I mean, if you hadn't heard of ODD before, you're like, I'm not surprised. Um, but if you are a psychiatrist or a psychologist, you might protest. But what do I mean by that? That ODD is not a diagnosis. Of course, it's in the book. It's in the Bible. And by that, I mean the DSM. It's listed as a disruptive impulse control and conduct disorder. And the clinical definition of ODD includes a persistent pattern of behavior with three core symptom clusters. So you got this angry, irritable mood. So these are kids who are kind of touchy or always lose their temper. And you've got these argumentative, defiant kids um who are constantly arguing with adults. They defy the rules. And then at the end you've got this vindictiveness. they are spiteful or vengeful. Now, these symptoms have to be present if you're under five for most days, but if you're an older kid, once a week is enough. And of course, with all disorders in the DSM, you have to rule out other things. Like for ODD, you'd have to rule out disruptive mood dysregulation disorder, for instance. And to get the label of ODD, the individual has to show at least four symptoms in these clusters for a minimum of six months. And it can't be like oppositionality uh or vindictiveness toward a sibling. It has to be someone else. Someone who they're not constantly having conflict with because well that's what siblings do. Here's an exercise I want you to do for the entire rest of the episode if you can keep up. So every time I say ODD, I want a little sign to flash in your mind and I want that sign to say asterisk. the criteria that results in a diagnosis of ODD. So instead of just OD, think the criteria that results in a diagnosis of ODD. I know there's a lot of words, but this isn't just a semantic game. The goal of this is to help you and me relax any prior bakedin assumptions that we might have. Assumptions that OD is in fact a single thing in the same way that say ADHD or a learning disability is a thing. Imagine that ODD is just a label we place on some observations. It's a flag that should tell us something is very wrong here. And now actually need to figure out what that is. ODD is not the thing that is wrong. It's a signal that something else is wrong. And that's going to be really the whole point of this episode. The diagnostic framework we adopt in our practices dictates the entire trajectory of the treatment that we give people. So if I view OD as a primary disorder of defiance, my focus is going to be on behavioral management and then that pathway is going to escalate very frequently to off label prescriptions of things like antiscychotics or anti-convulsant medications just to control their aggression. This pathway carries significant risk of iatrogenic harm and it's both from the medications like the antiscychotics that we give but it's especially from not addressing the real problem which then often gets worse. But what if instead instead of viewing ODD as a thing, we view the oppositional behaviors as a kind of final common pathway, just a symptomatic manifestation of some other underlying, probably untreated condition. I'm talking about things like ADHD, anxiety disorders, or trauma. Those are the top three suspects. If we think of ODD in that way, when it's diagnosed, our job isn't done. Our job is not just to squash the defiance and vindictiveness of ODD. Our job is to understand it, to find and treat the root cause of it. I mean, even the DSM5TR hints at this because it separates symptom clusters in angry and irritable mood from those in the argumentative defiant behaviors and vindictiveness. And this wasn't arbitrary. It was based on research showing that these clusters might have different causes themselves and different pathways. So that irritable effective component often aligns more with internalizing type disorders like anxiety or depression. The defiant behavioral component often aligns more with externalizing disorders like ADHD. But anxiety and ADHD and depression can all co-occur. So this internal messiness is the foundation for the rationale that I have for questioning whether ODD is a single coherent disorder at all.

I should probably back up here um and ask the question, how did we even get this label? like where did it come from? Why do we have it? Because it's if you think in terms of mental disorders, it's a relatively recent addition. So, it first appeared in the DSM3 in 1980 and that was part of a big movement to make explicit criteria based diagnoses that improved interrator reliability. So, the DSM3 was built in order to try to make sure that if one psychiatrist gave a diagnosis, the other one was likely to give the same one. They weren't just making stuff up on the fly like would happen in DSM 1 and 2. So the initial concept of ODD was focused almost entirely on a pattern of negativistic, hostile and defiant behaviors. But of course immediately it faced a lot of criticism and I think for good reason. Researchers and clinician ask well if this is a genuine mental disorder are we just pathizing normal childhood behavior? Are we medicalizing the fringes of like the terrible twos or defiant teenageriness

in the DSM3 uh revision and in the DSM4 we had a hierarchical rule added. So a diagnosis of like conduct disorder would preclude a co-occur occurring diagnosis of ODD.

And a lot of people at the time thought that ODD was really just a milder sort of developmental precursor to conduct disorder. A kid with ODD is likely to develop conduct disorder later, but they're really separate things. Conduct disorder takes precedence. You can't have both. But in the DSM5 in 2013, there was a real significant conceptual shift. So first, it formally incorporated an affective component into it. The criteria were reorganized into three clusters. The angry, irritable mood, that's the affective component. Then the argumentative defiant behavior and vindictiveness, which are both behavioral components. So this was a direct response to show that chronic irritability in itself was a clinically significant dimension that predicted outcomes in things like ODD. these defiant behaviors, they don't just arise on their own for no reason. The DSM5 also eliminated the conduct disorder criterion. Um, and this was based on some research that showed that ODD is not just mild conduct disorder. They're actually probably very different things. ODD when diagnosed has its own pathway, its own prediction of impairments and this can co-occur with a conduct disorder diagnosis but not instead of it. And then finally um the DSM5 added more specific frequency thresholds to try to separate out ODD from what is otherwise kind of normal kid behavior at different stages. For example, for kids over five, the behavior had to occur at least once a week for at least six months in order to get the diagnosis. Although in clinical practice, I have seen lots of kids diagnosed with this who do not meet the frequency thresholds at all, but they get the diagnosis anyway.

This evolution in thinking in the DSM chose a conceptual shift and it's a shift away from just bad behavior to really a more complex construct involving emotional dysregulation as a primary driver. So it's kind of like admitting that ODD is not just a thing that there are lots of things that could result in things that look like ODD. And this leads up to the central debate that I'm having here in my own head. Is ODD a valid diagnostic construct? Now, the evidence here is complex and often seems contradictory. For once, you have to ask the question like, what is validity? What makes something valid? Probably the strongest argument for validity in ODD is that it has predictive validity. So, a diagnosis of ODD, uh, even when it's made in preschool, does tend to predict a range of long-term negative outcomes. So, we're talking about increased risk for things like having conduct disorder or as an adult antisocial personality disorder, but also affective disorders like major depression, all sorts of anxiety disorders, even substance use disorders and a lot of impairment in school and work and even incarceration. So, with clinical science, if a diagnosis can predict future events, for example, say that these things are more likely because you have this diagnosis, that gives the diagnosis utility. And that utility points toward it potentially having construct validity. But here's the real case against construct validity for ODD. Despite its predictive power, its predictive validity, there are several ways in which ODD is not a discrete disorder. One is that normative problem that I talked about, you know, so it's incredibly difficult to draw clear non arbitrary lines between ODD symptoms and developmentally normal defiance um or vindictiveness. 6 months is a cut off, but why? I mean, no one can really defend that very well. Next is the comorbidity problem. And so to me, this is really the killer argument. ODD rarely ever occurs in isolation. And I think if you look deeper, it never does. The rates of co-occurrence in studies are super high. So one-third to one half of all children with ADHD also meet or have met criteria for ODD at some point. Prevalence rates of comorbid anxiety disorders can range up to about 60%. So this massive overlap has to make you ask, I mean, if ODD is almost always or always found alongside some other disorder, is it really a separate thing or is it just kind of a common behavioral expression of other underlying conditions? So this means that ODD really doesn't have much discriminant validity. It doesn't rule other things out. It's a thing made up of potentially lots of things. It's degenerate. And then finally, one argument against OD is that it itself is ideologically just vague and nondescript. I mean, there's no single plausible cause or causal pathway for ODD. It's understood to be a complex interplay of genetics, neurobiology, and environmental factors and parenting styles and family conflicts and stress, but it really lacks even a hint of specific identifiable ideologies other than the ideologies for the underlying potential causes like for anxiety and ADHD or autism. So, how do we really reconcile this? ODD symptom clusters have predictive validity. This is pretty clear. If you give someone a diagnosis of ODD, this is a marker of future troubles, but it appears to have very weak construct validity. It doesn't represent a single underlying disorder. The best conceptualization of ODD is not as a discrete disease or something called a disorder, but instead as a clinically significant risk syndrome. So, think of it kind of like a metabolic syndrome in internal medicine. if you've ever heard of that. Metabolic syndrome isn't one disease. So, it's a cluster of risk factors. For example, if someone has high blood pressure, abdominal obesity, and high blood sugar, that strongly predicts future cardiovascular disease. And a doctor would say that person has a metabolic syndrome. But what causes all those things could be different. And ODD is similar. It's a cluster of behavioral and affective symptoms, things like defiance, irritability, vindictiveness. and that strongly predicts future psychiatric and functional impairment. So the framework of syndrome acknowledges the clinical seriousness of the symptoms without pretending that it's like a distinct singular disorder. So what does it mean then if we think of ODD more as a risk syndrome instead of a disorder? I mean what are the symptoms of? This is the ideological puzzle. Because I believe that behaviors we list as ODD are actually kind of a final common pathway for a variety of different underlying problems. I have to think about what those problems could be. The first one and probably in my clinical practice the most common thing is attention deficit hyperactivity disorder. As I mentioned before in some studies about half of kids with ADHD also get an ODD diagnosis. And I think there are two main reasons why. One is that the risk factors for both are very correlated. So this suggests that ADD and ODD just share common underlying vulnerabilities like the genetic factors that result in things like their impulsiveness and the emotional dysregulation you see in ADHD that is so common also in ODD. There's also sort of this idea of a developmental precursor model and it posits that there's a causal relationship where ADHD actively contributes to the development of ODD. So the that impulsivity, emotional dysregulation and inattention from ADHD places immense stress on the parent child relationship and this leads to negative interaction cycles. The child's ADHD driven behaviors elicit harsh or inconsistent parenting which in turn fosters defiance and opposition. And quite often if a child has ADHD, their parent also has ADHD. And this will frequently contribute to sort of the non-predictableness of the environment in which the child lives. So this model seems particularly good at explaining things like the argumentative and defiant symptoms of ODD um and even some of the affective components because we know there's a large component of affective dysregulation in ADHD.

There's also a strong link between ODD and anxiety and anxiety itself could contribute to ODD alone but also it strengthens the association between ADHD and ODD. So kids with ADHD plus anxiety often show like very high levels of oppositional behaviors. They'll throw huge fits. Often people don't even know why. So it's possible that this internal distress, this fear and kind of the rigidity u thinking that happens in anxiety disorders is expressed outwardly as oppositional and irritable behaviors because the kids don't have like a lot of words to talk about it. And when they're older, they don't want to talk about it because they're well avoidant. So the easiest thing for them to do is just to be defiant. And once they get into a cycle, they start to be treated like a bad kid and then they become kind of vindictive. They want to punish other people because they feel like they're being punished all the time. So a child who feels constantly overwhelmed and threatened might react with defiance as maladaptive, sort of a clumsy attempt to control their environment or exact some sort of idea of fairness.

Something else that could easily contribute to ODD is a history of trauma. We have some categories for what can result from early childhood neglect and trauma. Things like reactive attachment disorder and disinhibited social engagement disorder, but quite frequently the results of trauma are not so tidily like swept up into little categories. They result in a lot of distrust. The child does not see the world as very predictable and behaviors that seem maladaptive to us to them could have been adaptive in another situation. And so things that look like oppositionality, things that look like them being vindictive could in fact be them adapting to a world in which that got their needs met. So all these possibilities converge on what is really the underlying causes of the behaviors that result in odd. There's emotional dysregulation that comes from somewhere. There is behavioral dysregulation that comes from somewhere. There is vindictiveness and that comes from somewhere and all those things might come from different places.

So the ODD diagnosis, especially its affective component, is more than likely just capturing a disorder of emotional regulation that results in oppositional, angry, and at times vindictive behaviors. These kids are not sociopaths. They can empathize with others and often they're ashamed of their behaviors after the fact. They feel bad for what they did, what they said. They just can't control their initial reactions and then things snowball out of control from there. And that is why ODD is a degenerate diagnosis. It's one label that's capturing similarly looking behavioral endpoints for very different ideological pathways. For one child, the oppositional behaviors might be the downstream consequences of impulsivity of ADHD. For others, it might be externalized manifestations of the rigidity of their anxiety disorder. But quite often it's both and more and related to some sort of primary neurobiological deficit in emotional regulation due to something we probably haven't even identified. And why is this important though? Why does all this matter? It matters because the conceptualization of ODD determines the child's treatment pathway. So let me talk about these pathways as kind of two different things. And I know that there's multiple pathways it could take, but splitting them into sort of like two dichomous pathways just as a thought exercise. So pathway one could be ODD as the primary diagnosis model. So this is a symptom control pathway. If you view ODD as a primary disorder, your clinical focus is going to be on managing the most disruptive symptoms of that disorder. So the defiance and the aggression. There's immense pressure on families and schools to get rapid behavioral control out of these kids. If the behaviors are considered overwhelming to the caregivers, this path often results in giving high-risisk medications. Since there are no FDA approved medications for ODD itself, this frequently means giving off lababel antiscychotics like resperadone or aaprizole which do have an FDA approval for aggression in autism spectrum disorder which is a totally other thing I would like to get into in the future but don't have time right now. If you think that this is not such a big deal, that kids with an ODD diagnosis don't get antiscychotics that much. So, it's not that big a deal. One study of Medicaid found that about threequarters of the anticycotic prescriptions given to individuals under the age of 21 were for off label indications. Three out of four of the prescriptions of antiscychotics for individuals under 21 were given for off label indications. Now, antisycchotics can produce a substantial reduction in aggressive behaviors. I've seen them work very well. I've seen them do nothing. But the benefits come with a price. The risks and the side effects are not minimal, especially in pediatric populations with developing brains and bodies. We're prescribing powerful medications with known serious risks, often to cover up for our own failures. So that's pathway one. If you see ODD as primary, then you're going to treat the symptoms of ODD directly. Path two is seeing ODD as a syndrome. This is an ideology focused path. This paradigm starts from a different premise entirely. The oppositional behaviors in ODD are symptoms, not the disease. So this mandates that the primary clinical goal is to identify and treat the root causes of the behavior, the underlying disorders. This approach delays and quite often obviates the need for those high-risisk off label medications except in extremely severe cases. So if a child is defiant and this is driven by their emotional impulsivity and frustration and untreated ADHD, the most logical and effective treatment is to address the ADHD directly. If the irritability seems to come from a constant distress, from an underlying anxiety disorder, or even a mood disorder, treating the anxiety and the mood should be the priority. And we can never forget that it's essential, especially for younger kids, but even for older ones, parents need training, especially for kids who aren't typical. Parents need training on how to avoid triggering and escalating behaviors and how to emotionally regulate themselves. so that they can help their children emotionally regulate. The most appropriate pharmacological treatments for ODD are not treatments for ODD. They are treatments for the underlying or comorbid conditions, stimulants for ADHD, SSRIs for anxiety. And this will lead to significant improvement and reduction of ODD symptoms if in fact those are the things driving those symptoms. And most of the time they are. I've removed many kids from antiscychotics and then found substantial improvements by either starting a stimulant or an SSRI. Quite often they have a stimulant on board, but it just has never been increased to an effective dose. So all I have to do is increase the stimulant to an effective dose and suddenly the child is no longer meeting criteria for ODD. I mean, I'm flabbergasted by how many times I get kids on low doses to moderate doses of a stimulant without any significant side effects and then they're placed on an antiscychotic because they're irritable and have tantrums. To me, it makes no sense. Focus on optimizing the treatment for one thing before moving on to something else. SSRIs and stimulants are far far safer, especially for long-term use, than antiscychotics.

So an ideology focused approach reinforces the primacy of psychosocial interventions and appropriate pharmacological interventions. So your initial diagnostic formulation is not a minor detail in your treatment. It is the critical decision point that determines the entire course of a child's care and the level of risk at which they will be exposed in the future.

I want to end by getting a little more practical. I'm going to talk about um in general uh a case that came to my office and this is a true story with some details changed. So, a 5-year-old child came to my office diagnosed with ADHD and ODD. And when they came, they were sent by their pediatrician who didn't know what to do because the child had been started on ox carbazipene that's trilpt by another psychiatrist. Now, trilleptal is an anti-convulsant. It's an anti-seizure medication. It's approved by the FDA for seizures in children age four and above, but sometimes it's used off label as what we refer to as a mood stabilizer. Supposed to help for kids to maybe not get so irritated. Now, this child with a diagnosis of ADHD and ODD had never been treated for their ADHD. Instead, the prescriber opted to go down pathway one. Treat ODD like it's a thing in and of itself. Instead of treating ODD as if it was a signal that something else is not being treated effectively. But what should I do? What should I tell the parents who come to me on oxcarbazipene and have never actually tried medications that are appropriate for ADHD? Well, the first thing I'm going to insist on is is not that we just change the medication, but having a comprehensive ideology focused evaluation. So, when you have ODD, that means things are complex. They're not simple. I tell parents that ODD diagnosis should be viewed really as the beginning of a diagnostic process, not as an end point in that process. We need an assessment that goes beyond simple behavioral checklists and screeners. I have to more thoroughly and explicitly screen for things like ADHD and anxiety disorders, depression, learning disabilities, histories of trauma in a way that's not merely cursory. That's not just like, well, you circled the dots on this particular thing. Your score was below a certain thing, therefore you don't have this. We've ruled it out. We have an odd syndromeic picture already. So, there is a high prior probability that something else is wrong. Even if we think that we've ruled things out by giving screeners, there is still such a high prior probability that something else is wrong. We can't trust those screener results, the negative on the screener is potentially and probably a false negative. And this is an important point. I mean, if you have a high prior probability that something is wrong and you screen negative, it's still likely that something is wrong. That is a false negative. More likely than not, you need to dig deeper than screeners. So, I need to gather information from multiple sources, from parents, from kids teachers if I can, other adults who have cared for them if possible, like grandparents. Are their behaviors totally different in in different places? That is a lot of information I could get. And often this information really already exists in the medical record. It's just never been synthesized together as a whole. The parents have told their stories to lots of different people. Those stories have been written down, but no one has gone through and put all those stories together. I always let parents know when there is an ODD picture that this means there's a lot of uncertainty. We see the oppositional behaviors, but what do you, mom, think is driving them? What do you think is wrong? Instead of telling the parents what to think, letting the parents speculate allows them to reveal a lot of information that wouldn't be captured on your screeners. Just let them say lots of things and then follow them down a path.

Thank you for hanging out with me today. If you stuck with me this long, you probably have some opinions about what I said, and I would really appreciate if you could send me some of those. If you go to sidactic.com, I have a form you can fill out there that will allow you to comment on this episode. These episodes are also often loaded onto YouTube, so you could put comments in the comment sections on YouTube as well, and I could respond to you there in a more public setting. I have also written a blog post that goes into quite a bit more detail about this ODD thing if you're interested, and that's at sciencebasedpsych.com.

That's sciencebasedpsych.com.

I am Dr. O'Leary, and this has been an episode of PsyDactic child and adolesccent psychiatry edition.

Nothing in this podcast should be considered personal, medical, or mental health advice.