Diagnosis of ODD:
Don’t Try This at Home
by Dr. James Sutton
I receive a ton of email from folks, mostly parents, who have read extensively on ODD. They have determined that their child has Oppositional Defiant Disorder, and, with the diagnosis part out of the way, they are anxious to jump straight into intervention. (And anyone who has spent as much as one day with a truly ODD youngster can understand the reason for the urgency.)
But this line of reasoning could present significant consequences, as the observation, documentation and classification of a behavior makes up only a third of a competent and complete diagnosis. Cause must also be addressed, as well as interventions that are specific to behaviors and cause.
A comprehensive diagnosis (as a component of a comprehensive assessment) is necessary because oppositional and defiant behavior, even when it is considered to be abnormal and excessive, rarely presents as a single condition or disorder. (I have held to this opinion for years, and was affirmed to hear Dr. Ross Greene make the same point in a lecture I attended.) More specifically, oppositional and defiant behavior (notice I didn’t say Oppositional and Defiant Disorder) is commonly seen as a part of the following types of disorders, among others:
• Anxiety disorders
• Adjustment disorders
• Disorders of depression
• Disorders of attachment and bonding
• Disorders related to trauma
• Pervasive Developmental Disorders
• Disorders of conduct
• Disorders of mood stability
Making a correct diagnosis is roughly the psychological equivalent of making a correct diagnosis between heartburn and heart attack. It’s critical.
So what is a proper diagnosis?
Oppositional Defiant Disorder is correctly diagnosed only if the disorder meets three specific criteria: (These are based on the DSM IV-TR.)
1. At least four qualifying behaviors or characteristics are noted and have existed for six months or longer. This eliminates temporary reactions to conditions or circumstances that influence behavior.
2. There is significant clinical impairment of functioning. In other words, the child’s behavior is digging a hole for them that only gets deeper. Their behaviors are detrimental to them, not just others. Oppositional behavior that leads to failure in school would be an example.
3. The behaviors are not attributed to another diagnosed condition or disorder.
Is a complete evaluation always necessary?
Yes and no. Since ODD is based on fairly objective and observable findings, a full assessment might not be necessary. But an assessment does provide information critical to understanding the child and his or her “take” on things. This information plugs directly into plans for intervention.
What would be included in an effective evaluation?
Assessments will vary according to the professionals conducting them, but here’s what I include in a full evaluation: (Due to my lecture schedule, I don’t do these much anymore.)
An interview with the parents: This includes a comprehensive history, as well as a clear understanding of the concerns of the child’s parents.
An interview with teachers: This provides information regarding social and academic functioning in a key environment outside the home.
Assessment of academic functioning: This addresses the issue of potential versus performance in essential academics. If this information is available through school records, there’s no need to reassess the youngster in these skills.
Assessment of intellectual functioning: Again, this can sometimes be gleaned from school records. Even if this information is not available, it’s not always necessary to conduct a full-scale intellectual assessment (which can add considerably to the cost of the evaluation). But enough information is needed to discern that the child is capable of understanding and complying with directives from authority figures.
Perceptual-motor assessment: I use the Goodenough-Harris Drawing Test and the Bender Visual-Motor Gestalt Test. Most oppositional and defiant youngsters are fine in perceptual-motor skills, but tend to drop a number of clues to their oppositionality and defiance on these tasks. Due to the unique format of the instruments, youngsters are often unaware of just how much information they are providing (thus they’re not apt to “push” or overcontrol the tasks).
Projective assessment: This is a very important part of the assessment of an oppositional youngster because the child cannot manipulate by telling you what he thinks you want to hear. The nature of projectives is that they have no right or wrong answers. For that reason, they often make an oppositional youngster uncomfortable. The structure and level of aggrevation the child slips into this part of the assessment can be quite revealing and helpful in planning intervention. Two common examples of projectives are sentence completion tasks and standardized ink blot instruments.
Diagnostic interview: A comprehensive interview with the child provides a wealth of strategic information. I happen to use a 155 question interview that I developed for this purpose (although it’s not always necessary to ask them all). The interview captures the youngster’s take on peer relationships, school functioning, factors of home and community and, of course, self. It samples their concerns in their terms, providing insight to areas where they would be most receptive to intervention.
All this information is then complied into a comprehensive report that outlines the findings, provides a diagnosis (if there is one), and offers recommendations for intervention. The cost of an assessment like this ranges from a few hundred dollars to well over $1,000. Health insurance generally covers some, if not all, of the expense.
Who can do these evaluations?
Psychologists can, as well as anyone else trained and licensed or certified to do all components of the assessment. If your child’s oppositional and defiant behavior is causing them to have serious trouble progressing through school, you might ask the school to do an assessment. They have folks on staff who do this sort of thing all the time. They usually have at least one doctorate level psychologist on staff or as a consultant to help with the tougher challenges.
Large counties often have a county psychological board (check the phone book) that can refer specialists who work with children. Also, a department of psychology or counseling of a nearby university (universities offer graduate training) might provide assistance or direction. In some cases, they may provide actual counseling or therapy services through their lab programs. Although the services are being provided by students, they are supervised, and they are usually motivated to do a good job. You don’t have much to lose, and the cost is minmal (like free, if they need kids).
Keep in mind also that school counselors are required to maintain a resource list as part of their Crisis Response Plan. Ask them; they can probably help directly, or initiate a referral. Then, of course, there’s always the phone book. I believe it is best to find someone who specializes in children and adolescents.
Who should do the counseling or therapy?
For obvious reasons, it helps a lot if it is the same person who did the assessment. Rapport is already established, and there is no confusion regarding the interpretation of assessment results. Sometimes, however, this is not possible. I get a lot of calls and email asking about how to locate specialists in ODD in different states. Sorry, I’m not aware of any registry like this, although county psychological boards might list specialties. That would be a good place to start.