Opinion: What happened to oppositional defiant disorder?

“Can you check my child for PDA?” the mother asked me on the telephone about two years ago. Though I had been a behavioral/developmental pediatrician for more than four decades, the only PDA acronym I could recall came from my days as a general pediatrician: patent ductus arteriosus (a persistence of embryonic circulation around the heart). “Gee, I’m not sure,” I said. “What does PDA stand for?” “Pathological demand avoidance,” she explained. “My son won’t do anything I ask.” PDA represents the latest and perhaps most extreme shift in how parents and professionals view children’s noncompliance. I came to realize that this wasn’t simply a new diagnosis, but rather part of a much larger change — and as these new explanations for children’s noncompliance multiplied, an older diagnosis was quietly disappearing. Oppositional defiant disorder (ODD) — once one of the most common behavioral diagnoses in child psychiatry — was becoming increasingly absent from clinical practice. That tells us something important about how our culture now understands children. Children have no doubt been noncompliant since before recorded time. Aristotle complained about the younger generation in the fourth century BCE. What’s changed over the millennia, but particularly in the past 25 years, is how we understand and respond to children who don’t “listen.” My Bay Area private practice has given me a front-row seat for these changes. Over the last 46 years, I’ve witnessed and participated in the explosion of diagnoses such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in younger children and similar rises of anxiety and depression in older children and teenagers. It’s easier to catch an uptick than an absence. But I had noticed in my examination of children’s neuropsychiatric evaluation reports — replete with details of ADHD, ASD, post-traumatic stress disorder, anxiety, depression, and sensory-motor disabilities — a conspicuous absence of the ODD diagnosis over the last 10 years. I was aware that it had become “unpopular” (I’ll explain more in a moment), but I hadn’t thought of its decline beyond my own office. Then, I read a 2024 study in the Journal of the American Academy of Child and Adolescent Psychiatry. Between 2013 and 2021, Ramin Mojtabai and Mark Olfson, two highly respected pediatric psychiatric epidemiologists, surveyed the mental health diagnoses of children ages 4 to 17, examining more 13 million records. Not surprisingly, they found that rates of anxiety, depression, and PTSD in children had markedly increased while the rate of some diagnoses declined. In particular, the authors noted the largest was an eight-fold decline in the diagnosis of bipolar disorder in children. In the previous 20 years bipolar rates for children had climbed 40-fold. The bipolar diagnosis had been strongly promoted as an explanation for acting out behavior by the leading child psychiatrist at the time in the United States and by his colleagues at Harvard. He believed the diagnosis could be made in children as young as 2 years old. Reactions to this interpretation, with its implications of a lifelong disorder, most often treated by psychiatric medications with serious side effects, grew in the first decade of the 2000s, culminating in the American Psychiatric Association’s (APA) decision to add a new diagnosis, disruptive mood dysregulation disorder (DMDD) to their newest version of the Diagnostic and Statistical Manual in 2013. DMDD was offered as an alternative to bipolar disorder, with many of the same criteria that had been utilized to justify the bipolar diagnosis. But DMDD didn’t carry the same lifelong stigma attached to bipolar. DMDD treatments also promoted nondrug intervention strategies to address the behavioral issues. The 2024 study further found the prevalence of two other disruptive behaviors — conduct disorder (essentially a more severe form of ODD in children, now teenagers), and ODD — had also significantly declined (by one-third) in the period studied and went relatively unnoticed. Mojtabai and Olfsen noted the decline but didn’t comment on this decrease. But their study confirmed that a decline in the ODD diagnosis went beyond my local experience. The reasons for this decline are subtle and also relevant to our current views of children’s behavior problems and how to address them. I’d like to believe that children are behaving better for their parents, but I doubt that’s the case. Indeed, there is little evidence that oppositional behavior itself has become less common. Instead, clinicians seem to have gradually stopped asking, “What is happening between this child and the adults around him?” and instead ask, “What neurological or psychological deficit prevents this child from complying?” This change tells us a lot about how we now see children in general, and how we raise them. ODD first appeared as a psychiatric diagnosis in the landmark third edition of the DSM published in 1980. Children who met ODD criteria were described as persistently negativistic, argumentative, disobedient, and hostile to adults. Subsequent editions of the DSM have retained these criteria. However, over the years, many child psychiatrists, either reflecting or leading the general culture, began shifting their conception of children’s noncompliance. Instead of a relational problem, it became an inherent developmental incapacity calling for alternative diagnoses. Rather than deliberate opposition, ADHD meant she had a problem with executive functioning and self-regulation. Autism meant he became anxious and overwhelmed with the demands of interaction. PTSD and generalized anxiety disorder (GAD) were also invoked as explanations for noncompliance, albeit less frequently. This shift toward interpreting childhood behavioral conflicts as reflections of dysregulation, neurodivergence, anxiety, and trauma has had a profound effect on treatment. ADHD diagnoses began expanding greatly beginning in the mid-1990s, while ASD has multiplied several-fold over the past 20 years. For a time, ADHD was often diagnosed in combination with ODD. These children — impulsive, hyperactive, and angry — were considered the most vulnerable and most likely to develop conduct disorder, and to be most at risk of becoming enmeshed in the juvenile justice system. It is also likely that the decline of the ODD diagnosis was driven not only by changing clinical theories but also by changing social values. Increasing evidence that disproportionately high numbers of Black children were being diagnosed with ODD and conduct disorder led many clinicians to question it. Did the diagnosis sometimes reflect cultural misunderstanding or implicit bias rather than psychopathology? As concerns about the school-to-prison pipeline gained prominence, a diagnosis that could be interpreted as branding children as bad rather than distressed became increasingly difficult to defend. As a result, many clinicians began avoiding the ODD diagnosis altogether. It not only sounded pejorative, it was perceived as blaming the child. Parents disliked hearing the term and schools disliked seeing it in reports. Increasingly, ODD sounded like a moral judgment disguised as psychiatry. I, too, long had a problem with the ODD diagnosis. Not for these reasons, but because, in the general sense, psychiatry focuses on the individual. I’ve always viewed individual children as contributing to the problem-behavior cycle, but within interactions between their parents, family, school, and peers. My primary issue was that ODD leaves out the child’s opposition to whom and defiance of what. Nonetheless, it does strongly imply the existence of a relational problem that should be addressed. An ODD diagnosis (or no psychiatric diagnosis at all) has an element of choice: The child simply won’t comply. That framing implies some moral responsibility, not just the child’s, but even more, the parents’ and the school’s — i.e., those who have failed to provide the proper environment. In contrast, alternative diagnoses are often interpreted as suggesting that the child has an inherent incapacity or deficit. If a child’s behavior meets the criteria for ADHD or ASD, for example, it is assumed that the child is unable to comply. The problems are the result of genetic, biochemical, or brain problems. These diagnoses reduce or eliminate the child’s agency, responsibility, or accountability and offer similar relief to the parents and school. If the child simply can’t do something, it’s no one’s fault. It would be like blaming a child with a congenitally shortened leg for coming in last in a race. Punishing that child for a slow speed would be considered both ineffective and cruel. The dichotomy between won’t and can’t is simplistic, rigid, and false. A child’s biology and personality contribute to a pattern that may make it harder to comply, but not impossible. Given the right environment, one that employs combinations of positive and adverse responses, love, and discipline, children with ODD, ADHD, or ASD all can improve. Behavioral treatment options for ODD start from the point of view that children possess constrained but meaningful agency that can be shaped through relationships and contingencies. Perhaps surprising to some, these treatments have demonstrated significant success; one, psychologist Gerald Patterson’s Parent Management Training (PMT), became a model for many behavioral programs. Subsequently, Yale psychologist Alan Kazdin conducted numerous randomized clinical trials demonstrating that PMT significantly reduced oppositional, aggressive, and antisocial behavior. Regardless, as ascendant neurodevelopmental models of noncompliance have emphasized impairments in capacity, responses have shifted. This has had a profound effect on treatment strategies. Now, the focus is on making the environment more accommodating and adding special services to support the child’s assumed inherent weaknesses and decrease anxiety and stress associated with the demand to comply or perform (as in school). Parents are encouraged to “understand” their children’s noncompliance as involuntary. That may take some of the personal sting out of a voluntary refusal, which implies the child doesn’t care for or love the parent enough to comply. This shift from asking the child to adapt to the environment to shaping the environment to adapt to the child is all well and good in the short term and can certainly reduce conflict. But how then do children learn to get along with others in the wider world? Accommodations and specialized environments may work during childhood’s early years when parents and school systems can certainly adjust. But as children move into late elementary and middle schools, their peers are very unlikely to be as understanding. How, then, does a child respond when asked to do things he or she does not want to do? That question remains important regardless of whether the child has ADHD, autism, anxiety, trauma, or sensory sensitivities. Indeed, functioning in society depends heavily on the individual’s capacity to tolerate frustration, delay gratification, accept limits, and comply with reasonable expectations. Those capacities remain relevant even when the reasons for struggling are understood more compassionately. Limits are not fashionable in child rearing today. In an effort to avoid negative emotional experiences, conflict avoidance has become paramount. Some experts even believe that timeouts can be harmful. Certainly, no adverse consequence should be repeated if it isn’t changing the maladaptive behavior. But parents too often equate consequence with punishment and shame. Even when they have ADHD, autism, anxiety, or ODD, children learn from consequences. Behavioral learning doesn’t disappear because a child has a neurodevelopmental diagnosis. Learning theory has shown that consequences are simply information. Some increase future behavior; some decrease future behavior. If avoiding an adverse consequence (like a timeout) improves behavior in the long-term, the benefits for child, parent, and family far outweigh the short-term risk of the child temporarily feeling alone and unhappy. To return to the metaphor of the child with the shortened leg, she could be fitted with a proper prosthesis, timed in the race, and rewarded for trying and achieving within her capability. She can be held accountable, however, if she doesn’t try. Consequence in the form of a limit (e.g., not getting her favorite beverage after the race) is reasonable if she doesn’t make an effort. Entirely avoiding an adverse consequence or limit precludes potentially effective motivators and behavior shapers. We should not go back to blaming children (or parents, for that matter) for not obeying, but we can understand a child’s difficulties compassionately without abandoning the expectation that the child needs to develop adaptive capacities. Many contemporary clinicians would agree with the first half of that statement but become uneasy with the second half. Words like “expectations,” “limits,” and “consequences” are often heard as code for punitive approaches. The disappearance of the ODD diagnosis tells the story of a broader shift in child psychiatry and parenting culture. We have become more sophisticated and compassionate in understanding why children struggle with compliance, frustration, and authority. We are also more attentive to trauma, anxiety, neurodevelopmental differences, and sensory sensitivities. We’ve abandoned a diagnosis that seemed blaming. But we’ve also become much less comfortable in addressing the necessity for children to adapt, tolerate frustration, and learn self-control. We don’t have to choose between compassion and accountability. We must endeavor to preserve both. Lawrence Diller, M.D., practices behavioral/developmental pediatrics and family therapy in Walnut Creek, Calif., and is also on the clinical faculty of the University of California, San Francisco. He is the author of four books and numerous articles on children and medication.