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August 11, 2021

A Call to Revise the Diagnosis of Oppositional Defiant Disorder—Diagnoses Are for Helping, Not Harming

Author Affiliations
  • 1Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
  • 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
  • 3Covenant House Pennsylvania, Philadelphia, Pennsylvania
  • 4Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
JAMA Psychiatry. 2021;78(11):1181-1182. doi:10.1001/jamapsychiatry.2021.2127

The diagnosis oppositional defiant disorder (ODD) has informed interventions that have improved challenging home and classroom dynamics for many individuals. However, growing evidence suggests the diagnosis may lead to inadvertent harm by (1) exacerbating stigma associated with reactive behavior and (2) enabling the mischaracterization of normative reactions to trauma as issues of self-control. These harms have significant implications for racial and health equity as they disproportionately affect youth from marginalized backgrounds. As clinicians working in a shelter setting, we witness the negative impacts of long-standing ODD diagnoses, particularly among vulnerable youth. We wish to convey a need to revise ODD’s current DSM-5 entry to reduce stigma and promote trauma-sensitivity.

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    4 Comments for this article
    Another Stigmatized Diagnosis
    Ronald Hellman, MD, MS | Former Professor of Psychiatry at Sinai, New York
    In addition to Oppositional Defiant Disorder, Borderline Personality Disorder has been stigmatized with the belief that individuals with the disorder purposely act in pernicious ways. This disorder is more atuned to a state of affective dysregulation, where the individual lacks the capacity to regulate their emotional state.
    It is not a diagnostic manual anymore.
    Eric Kuelker, Ph.D. | Private Practice
    A diagnostic manual that directs clinicians to ignore potential causal factors (trauma, hostile parenting) before assigning a diagnosis collapses under it's own contradictions. Isn't the point of a diagnosis to figure out what caused the problem? And once you figure it out, then you can try to solve the problem? But a 'diagnostic manual' that ignores causality is ignoring how you can most successfully help people. Instead of treating the trauma, or helping the family function better, you are slapping labels and stigmatizing people.
    Good intentions, flawed analysis.
    Mark Dadds, PhD | University of Sydney
    Anything we can do to improve the value that diagnoses give to improving the lives of sufferers is a good thing, and there are many things wrong with current systems, including the diagnosis of ODD. However the analysis in this paper is flawed on many levels especially the use of citations to support controversial statements that do not provide empirical causal evidence of the claims at all. For example the evidence for ODD leading to pessimism about outcomes is a study of psychopathy, the support for the diagnosis of ODD increasing juvenile justice engagement is a narrative commentary in a Counselors journal. So many causal statements are made about the diagnosis “leading” to negative outcomes when the cited evidence in no way makes this case. I will try to submit a formal response that covers these and all the other errors, but in the meantime beware the scholarcism of this paper.
    Adolescent Behavior as a Form of Communication
    Lawrence Shulman, MSW, Ed.D | University at Buffalo School of Social Work
    In my practice, research and teaching I have noted how often "deviant" behavior (e.g., acting out) on the part of a youth is considered a symptom of the client's problem often diagnosed as described in this astute article. In my work, I have found it helpful to understand the behavior as a communication - a call for help in a manner that is not always understood by the helping professionals. For example, a teen's acting out at school may result in the school's staff labeling the student rather than exploring what may be the underlying family, community, etc. issue. When the teen moves out of the family, for example going to a residential setting, then the next teen in the family may start to act out in a similar manner. Close examination of the family, and viewing it as a dynamic system, helps to understand the role of the teen (e.g., scapegoat) in the family rather than diagnosing the problem as the child's disorder. I have seen similar problems in residential settings where staff, sometimes not fully trained, respond to the acting out with discipline rather than professional curiosity. For example, a missed parental weekend visit can result in "oppositional behavior" on Monday morning. If treated as a communication, the skilled staff member who acknowledges the child's feelings may get a lot further than the one who simply takes away privileges. As pointed out by the authors, issues of race, social class, sexual orientation, etc., may all be involved in the student's behavior. In effect, I think the authors are on target with their analysis and suggestions.