2 Childhood Diagnoses You Should Think Twice About

Psychiatric misdiagnosis is rampant. At a general estimate of missing the mark 40% of the time (Buffington, 2015), many of the frequently-misdiagnosed conditions, such as ADHD, bipolar disorder, and autism (e.g., Fresson, 2018; Shen et al., 2018; Fusar-Poli, 2020, respectively), are ones frequently diagnosed in youth.

As noted by Merten et al. (2017), though comparatively little has been researched about general misdiagnosis in children, it’s an emerging interest, as they’re especially prone to misdiagnosis given unique diagnostic challenges (Schultze-Lutter & Schmidt, 2016). Although not pop culture/fad diagnoses like the aforementioned conditions (Francis, 2013), it has been my experience that oppositional-defiant disorder (ODD) and disruptive mood dysregulation disorder of childhood (DMDDoC) are disconcertingly taking a place as ubiquitous, arbitrarily-applied diagnoses in kids.

The trend

Working in a juvenile court clinic, I joke that my days are spent disproving all court-involved youth are simply "behavioral problems." The humor, however, is to mollify frustration about how it's not unusual that "behavioral" misdiagnoses have led to prolonged suffering for the kid and family, to the point they're now court-involved.

A great deal of our assessments regard children involved in what Massachusetts calls Child Requiring Assistance (CRA) petitions. These are civil petitions usually filed by parents or schools when kids' actions are, to quote many referrals, "out of control." Most of the time, there's some combination of not following rules, being argumentative, tempestuous, truant, and aggressive. This is usually labeled as "acting out," implying the behavior is well in their control, and they need discipline and family therapy for boundary settings and consequences.

Our extensive evaluations are requested to help the court understand the youth and provide better guidance. Oftentimes evaluations request second opinions because years of intervention have proven fruitless. A lot of these situations are children with long histories of ODD and DMDDoC diagnoses. Upon reviewing treatment histories, these diagnoses have led to years of being under a microscope for their poor behavior, as if eventually some consequence or talking-to will magically get them on track.

Perhaps it's more important to consider that the treatment providers may be off track.

Thinking critically

As explained by Poulton (2011), a common trajectory is for ADHD patients to exhibit concurrent ODD, which morphs into conduct disorder and eventually an antisocial personality. Having worked with many antisocial personality individuals, this was indeed their evolution, and it seems there is often a familial thread. Certainly, family/social environment contributes, but there is significant evidence of heritable components (e.g., de Zeeuw, 2015; Reichborn-Kjennerud, 2015; Baliousis et al., 2018) that encourage this perfect storm.

But what about situations where there is no familial thread, and development of “ODD” or “DMDDoC” coincides with psychosocial stressors or evolves alongside anxiety/depression as the child ages? It seems no one looks that far.

Unfortunately, since actions speak louder than words, unruly behaviors take center stage. It’s been my experience evaluating court-involved youth that ODD and DMDDoC are regularly, arbitrarily co-diagnosed to cover the oppositional/defiant and mood dysregulation of kids with extra snap to their attitude. It's clear that these diagnoses have been given based on diagnosis name, which is rooted in the one most-representative symptom.

As discussed in Tips for Accurate Diagnosing, Emil Kraepalin, father of modern psychiatric diagnosis, rolls in his grave, for he observed, “A single symptom unto itself never justifies a diagnosis, no matter how representative it may be” (Spitzer et al., 2002). Basically, it’s important to contextualize a symptom; many conditions share symptoms, but that doesn’t mean they’re treated similarly.

Clarifying the confusion

ODD is really a maladaptive interpersonal style and might be considered an immature form of personality disorder (Millon, 2011). It shouldn’t be diagnosed if the symptoms occur within depression (DSM-5) because the depression is considered to “own those symptoms”; treat the depression, and “ODD” starts to dissolve. A clue to true ODD is that there is no remorse for the oppositional and defiant behavior, and irritability tends to be reactionary to not getting their way.

Depressed children showing opposition and defiance typically berate themselves for causing problems, and irritability is part of a generally-dysphoric mood accompanied by other classic depressive symptoms like sleep and appetite disturbance and unmotivated states.

Unfortunately, ODD lends itself to overdiagnosis because, though the child is depressed, the oppositional and defiant behaviors therein are what stand out and diagnostic protocol to contextualize the presentation isn’t followed.

DMDDoC seems to be misunderstood as a behavioral difficulty like ODD, because of the severe dysregulated episodes. However, it’s in fact categorized as a depression-spectrum disorder in youth (DSM-5), who, for at least one year, have a baseline bad mood with superimposed explosive reactions to comparatively minor stimuli at least a few times per week. It’s also clear in the DSM that DMDDoC and ODD are not to be co-diagnosed. If symptoms of DMDDoC and ODD coincide, the former wins. This makes sense because a kid with a baseline unpleasant mood and a penchant for major reactivity is probably going to be oppositional, defiant, and touchy at times.

It may help to remember that DMDDoC is a baseline affective complication driving some behavioral disturbance; ODD is a behavioral disturbance, or interpersonal style, leading to some affective disruption.

What’s really going on

Returning to the court-involved kids with these diagnoses, looking below the surface, many ODD and DMDDDoC symptoms have been discovered to be a function of depression and anxiety.

• Depression is often expressed as irritability, especially in male youth. The inherent snappiness is perceived as disrespectful, leading to confrontation by authority figures. Irritability lends itself to reactivity, sometimes explosively if sufficiently frustrated, engendering arguments. Having little control over their internal landscape, this is compensated for by taking advantage of controlling their surroundings, and an argument is the perfect opportunity. “Winning” is a boost. Nagging may also be viewed as ODD but, consider, too, that if a child is depressed, they may project feelings of inadequacy. If they obtain something favorable, it signifies acceptance, and it doesn’t matter how it’s achieved.
• Socially-anxious children may present similarly. Unheeded pleads to not have to attend school lead to arguments, and bitter dynamics between the child and parents. Many a truant child’s school refusal has been evaluated to be a function of protection from feared social scrutiny. One patient had explosive reactions when their guardian dropped them off, borne from the panic of desperation to avoid being immersed in peers. They remained irritated all day at school and at home, ostensibly illustrating a DMDDoC diagnosis. Being under such scrutiny only serves to enforce the child's belief others are judging them negatively.

Ultimately, “acting out” may well be the kid’s way of expressing internal turmoil, and not part of a devious interpersonal style. Juveniles are not the most-articulate individuals, especially when even they don’t understand what’s happening inside. As discussed by psychoanalyst Nancy McWilliams (2013), acting out is, “Putting into action what one lacks the words for.” She continued, “The label ‘acting out’ gets applied to all kinds of behavior that the labeler happens to not like, often in a tone quite at odds with its original nonpejorative meaning.”

What you can do

1. Study the diagnoses herein carefully and observe diagnostic protocol of not diagnosing based on a single characteristic item.
2. If nothing else, a palette of behavioral diagnoses is demoralizing, and can suggest incorrigibility. Think critically about what best applies, and avoid multiple diagnoses to "cover the bases."
3. Remember, if emotional turmoil can’t be verbally-expressed, it will get expressed in actions. In effect, the degree of “acting out” is likely directly proportional to the internal struggle. The next time you meet a defiant, mood-dysregulated child, before letting their actions define the diagnosis, consider what is being acted out.
4. Parents concerned that their child is depressed/anxious but misdiagnosed are entitled to question providers and/or seek further opinion.

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from an individual's provider or formal supervision if you’re a practitioner or student.

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