ODD is TRASH (and what my rash from 9 years ago has to do with it)

This blogpost was originally published in my weekly newsletter. To have more musings like this delivered straight to your inbox, click this link to sign up!

---

Oppositional Defiant Disorder (ODD) and Disruptive Mood Dysregulation Disorder (DMDD) are TRASH diagnoses. I resent them so much that I wouldn’t be surprised if my loved ones paid tribute to me one day with a tombstone that reads: “Here lies Dr. Stephanie Olarte, beloved wife, friend, angry child whisperer, and hater of ODD & DMDD.”

Why am I so passionately against these diagnoses that I will take my frustrations with them to the grave?

Allow me to share a little story from my youth!

An Anecdote

Way before I became a clinical psychologist, back when I was a doctoral intern, I developed a rash around my collarbone. At the time I was working in Southeast DC —one of the most impoverished, under-resourced sectors of DC— with kids living in unsanitary conditions. So I was not super shocked when I saw the rash.

You see, I’d ridden the bus the day before with a client, and on the long, poorly-ventilated bus ride, she fell asleep with her head on that part of my chest… And there you go: ringworm’s favorite path of transmission.

Thinking this was an open-and-shut case of ringworm, I immediately went to my PCP and explained the situation — or at least I started to explain it, because my doctor quickly interrupted me, pulled out a dusty dermatology textbook, and said it was granuloma annulare, a rare skin disease. She said the best she could do would be to give me a topical steroid to help with itching, but it was ultimately an incurable disease with poor treatment options.

Naturally, being curious and terrified and enabled by my access to the internet, I went down an internet rabbithole and freaked myself out reading about other people’s horror stories with the rare disease. And as directed, I spent months using the topical steroid and trying to keep the rash covered under bandages. But the rash was in a pretty conspicuous area, so when people inevitably asked I’d reassure them, “Don’t worry, it’s not contagious — I just developed an extremely rare skin disease!”

Those months were rough, and the rash just kept growing.

Finally, I went to a different PCP months later. She took one look at it and said, “I think that’s fungal.” But she didn’t do just that — she did what the original PCP should’ve done and admitted her gaps in knowledge by referring me to an actual dermatologist.

Within seconds, the dermatologist diagnosed me with ringworm and explained how all of the first PCP’s directions had exacerbated the issue. Topical steroids make ringworm worse, as does covering it, and I was not taking the precautions I should’ve as someone who was actually walking around with a contagious fungal infection for MONTHS.

What I thought was a severe, lifelong, curable skin condition ended up being something incredibly simple. And as soon as I got the proper treatment, it vanished.

So what does this have to do with ODD and DMDD?

What does an ODD diagnosis do?

I’ve been working with children for almost twenty years (9 years as a clinician), and the majority of my work has been with children who’d qualify for an ODD or DMDD diagnosis. And, kind of like my ringworm, these kids almost always have some underlying (direct or vicarious) trauma that has not been treated. Either that, and/or they have an anxiety disorder or depression with atypical presentation.

But rather than treating those underlying, much more straightforward causes of their defiance and outbursts and angry-kid-ness, they’d often get slapped with an ODD or DMDD diagnosis that would overcomplicate, obscure, and even worsen what they were going through. Both diagnoses carry a serious stigma, and could ruin a kid’s chances at getting into certain schools or even pursuing certain careers as an adult. Let me repeat that: Just 6 months of behavior that qualifies a kid for an ODD diagnosis —regardless of the progress they make later in life— could foreclose what could and should be a child’s unbounded possibilities in life.

To make matters worse, I usually see this huge decision to diagnose being made by providers without specialization in ODD. And so, much like my PCP who didn't consult a dermatologist, these providers are slapping this extremely damaging, stigmatized diagnosis on children without even consulting a specialist.

And then that diagnosis becomes a way of writing off the kid and their potential before they’ve even begun their life. The diagnosis is meant to group together a certain pattern of thinking, feelings, and behaviors. But in practice —by both professionals and the loved ones of these kids— it gets deployed as an explanation for what is going on. In other words, the diagnosis gets inverted and treated as the cause of these symptoms rather than the identification of them. “Of course this kid ran away from school,” or “of course they’re not going to be able to come to your office,” — the kid’s got ODD! But it’s not that the kid ran away because they have ODD — they have an ODD diagnosis because they ran away.

It becomes an easy explanation that shuts down any question of why the kids are actually doing these big behaviors. And as a result, all curiosity —let alone empathy— for why these kids do the things they do goes out the window.

An alternative

There is no medication for ODD. There are recommended courses of action, but much like giving a topical steroid cream to someone with ringworm, a lot of those treatments make the situation worse in the long run.

So, what if we put down the potentially life-altering, damaging diagnoses and just treated these kids like they were suffering with untreated trauma, depression, or anxiety?

Often, what would happen is we’d put the kid on antidepressants, and their behaviors would start to soften. The rage was still there, but the child had more autonomy over their behavior, and as a result, they were able to finally really fully engage in therapy. And not just any therapy — trauma focused therapy, because this is a kid who undoubtedly has had lots of horrible things happen to them. Once we did that, the kid really started to get better.

***

As someone who works with defiant kids who terrify most teachers and providers and who could easily qualify for an ODD diagnosis — I find that these kids are actually really easy and uncomplicated to work with. Especially when it comes to the actual therapeutic work the kid has to do. The hard work comes in on the adults’ side.

Managing our biases, expectations, and projections onto angry kids is incredibly challenging. But it’s how we safeguard a kid’s potential. And what’s more worth it than that?