Introduction to Guest Writer
Kaligirwa (@BlackSpectrumScholar) is a neurodiversity advocate with an encyclopedic knowledge of relevant research studies.
After important feedback that my previous post did not responsibly talk about the racialization of ODD or the relationship between PDA and ODD, I am replacing it with @BlackSpectrumScholar important essay on the topic.
I am committed to learning how to be a better anti-racist ally, and want to make explicit that I do not expect BIPOC people to work for free to support this goal. @BlackSpectrumScholar is paid for this blog contribution and for a private consultation for me/The PDA Safe Circle™.
You can find @BlackSpectrumScholar on Instagram, Threads, and TikTok.
Thank you to @BlackSpectrumScholar for your work, and for the repost here.
In this essay, @BlackSpectrumScholar is calling for reforms inside a diagnostic manual that focuses on external behaviors, not the underlying experiences that lead to those behaviors.
While this behavioral framing can be triggering for some of my Autistic and PDA readers, I want to say that it's important to have advocates who speak the language of diagnostic manuals as they currently stand. This diversity of expertise can help the neurodiversity movement build power for change that will truly decrease suffering and increase thriving for all.
What is Oppositional Defiant Disorder & What makes it controversial? By Kaligirwa (@BlackSpectrumScholar)
What is the diagnositic criteria for ODD?
The criteria for Oppositional Defiant Disorder in the DSM-5 TR is as follows:
Criteria A
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling:
Angry/Irritable Mood: Often loses temper. Is often touchy or easily annoyed. Is often angry and resentful.
Argumentative/Defiant Behavior: Often argues with authority figures or, for children and adolescents, with adults. Often actively defies or refuses to comply with requests from authority figures or with rules. Often deliberately annoys others. Often blames others for their mistakes or misbehavior.
Vindictiveness: Has been spiteful or vindictive at least twice within the past 6 months.
Criteria B
The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues) or it impacts negatively on social, educational, occupational, or other important areas of functioning,
Criteria C
The behavior does not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also the criteria are not met for disruptive mood dysregulation disorder.
The limitations of the current diagnostic criteria for ODD
The current diagnostic criteria for ODD is fundamentally flawed due to its reliance on interpreting the child’s intentions—an inherently subjective process. Criteria like “has been spiteful or vindictive” and “deliberately annoys others” require the clinician to judge whether the child’s actions are intentionally hurtful or provocative.
Yet, without direct access to the child’s thoughts and feelings, accurately determining these motivations is impossible. Behaviors deemed spiteful or deliberately annoying may actually reflect unmet needs, emotional distress, communication challenges, or autonomic threat responses outside the child’s conscious control.
By presuming intent, the current criteria risk pathologizing behaviors that could be better understood through an empathetic, context-aware lens. This not only increases the likelihood of misdiagnosis but also results in interventions that overlook the behavior’s root causes and run the risk of increasing the distress of the child/teen.
The racialization of the current diagnostic criteria for ODD
The diagnostic process for ODD is also deeply problematic due to the pervasive influence of racial biases, particularly against Black children. The criteria for ODD overlap significantly with harmful stereotypes about Black people.
These stereotypes lead clinicians to disproportionately diagnose Black children and teens with ODD. The problem is further compounded by the fact that diagnostic criteria do not account for the impact of systemic racism and cultural differences on behavior. As a result, behaviors that often are the responses to environmental stressors, discrimination, or unmet needs are pathologized.
Harmful interventions
This not only leads to the overdiagnosis of ODD in Black children but also to interventions that fail to address the underlying causes of the behavior in any child, perpetuating a cycle of stigma and mismanagement in which Black and brown children are at particular risk.
By not addressing the role of racial biases in the interpretation of these behaviors, the current diagnostic framework for ODD reinforces systemic inequalities. It risks pathologizing behaviors that are shaped by the child’s environment, experiences, or unmet needs, including undiagnosed neurodivergence, rather than inherent defiance.
How might we reconceptualize the diagnostic criteria for ODD?
Criteria A
A consistent pattern of navigating intense emotions, asserting personal boundaries, or expressing needs for autonomy over at least 6 months, shown by at least four behaviors from the following categories in interactions with at least one person who isn’t a sibling:
Navigating Intense Emotions: Often experiences overwhelming emotions like frustration or anger. Frequently feels sensitive or easily affected by situations. Regularly experiences a sense of unfairness or resentment.
Asserting boundaries: Often challenges perceived unfairness or inconsistency, especially with authority figures. Sometimes resists or refuses requests or expectations that feel overwhelming or unjust. May engage in behaviors that others perceive as challenging but are efforts to express needs. Often seeks to explain or justify behaviors by attributing them to external factors.
Expressing Autonomy: Has responded in a protective or self-advocating way at least twice in the past 6 months.
Criteria B
These behaviors are linked to the person’s need for self-expression or reflect their response to a challenging environment, impacting their well-being or relationships in meaningful ways.
Criteria C
The behaviors are not solely due to other conditions like psychosis, substance use, depression, or bipolar disorder, and the criteria for disruptive mood dysregulation disorder are not met.
Specifiers
Mild: Symptoms occur in one setting.
Moderate: Symptoms occur in two settings.
Severe: Symptoms occur in three or more settings.
The relationship between ODD and PDA
The systematic review by Kildahl et al. (2021) examines the relationship between Pathological Demand Avoidance (PDA) and Oppositional Defiant Disorder (ODD). The study reveals significant behavioral similarities between ODD and PDA, particularly in behaviors labeled oppositional and defiant.
The study notes that some PDA behaviors, such as resistance to demands and social strategies to avoid them, overlap with ODD symptoms. Additionally, children with PDA showed little difference from those with ODD on conduct problem measures. (Rabbi Shoshana notes that internalized presentations of PDA do not look like ODD and are likely not included in this study)
The review also found that ODD can co-occur with PDA, as seen in a case study where two out of four children with PDA also met ODD criteria. However, the study emphasizes that it is currently impossible to clearly distinguish between PDA and ODD due to the lack of defined criteria for PDA. This highlights the need for further research to establish clearer diagnostic guidelines and to better understand the relationship between these conditions.
PDA and ODD both involve behaviors that can be challenging, but the way these diagnoses are perceived differs significantly.
On social media, PDA is disproportionately associated with white children and is largely viewed through a neuroaffirming lens. Advocates have worked to reframe the language around PDA, focusing on an anxiety-based and/or nervous system need for autonomy to feel safe, rather than pathologizing the child's actions.
This shift has led to a more compassionate and supportive approach to those identified as PDA (Though acceptance & understanding of PDA is still extremely limited in educational and medical settings)
In contrast, ODD is disproportionately diagnosed in Black children and is characterized by negative, pathologizing language that assumes intentional defiance or spitefulness. While white children displaying demand-avoidant behaviors may be identified as PDA by affirming clinicians who emphasize understanding, Black children with similar behaviors are more likely to receive an ODD diagnosis, which is more punitive and stigmatizing.
This disparity in how PDA and ODD are labeled and understood highlights deep racial biases in the diagnostic process. White children are more likely to benefit from the empathetic and supportive approach associated with PDA (though many are still being given ODD diagnoses), while Black children are subjected to the harsher judgments linked to ODD, and subjected to interventions that do not support them meeting the needs behind the distressed behaviors.
The findings of the study "Oppositional Defiant Disorder in Autism and ADHD," published in the Journal of Autism and Developmental Disorders in 2024, stress the importance of assessing both ADHD-Combined and autism when diagnosing and treating ODD, as their comorbidity exacerbates symptoms and functional impairment.
The study underscores the need for comprehensive assessments for children with these conditions to ensure accurate diagnosis and intervention, addressing all co-occurring challenges to improve outcomes and reduce stress for families and caregivers.
Sources
1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
2. Ballentine, K. L. (2019). Understanding Racial Differences in Diagnosing ODD Versus ADHD Using Critical Race Theory. Families in Society, 100(3), 282–292. https://doi.org/10.1177/1044389419842765
3. Haire, L., Symonds, J., Senior, J., & D’Urso, G. (2024). Methods of studying pathological demand avoidance in children and adolescents: a scoping review. Frontiers in Education, 9. https://doi.org/10.3389/feduc.2024.1230011
4. Kildahl, A. N., Helverschou, S. B., Rysstad, A. L., Wigaard, E., Hellerud, J. M., Ludvigsen, L. B., & Howlin, P. (2021). Pathological demand avoidance in children and adolescents: A systematic review. Autism: The International Journal of Research and Practice, 25(8), 2162–2176. https://doi.org/10.1177/13623613211034382 5. Mayes, S. D., Pardej, S. K., & Waschbusch, D. A. (2024). Oppositional Defiant Disorder in Autism and ADHD. Journal of Autism and Developmental Disorders, 1–14. https://doi.org/10.1007/s10803-024-06437-9 6. Stroessner, S. J., Alt, N. P., Ghisolfi, I., & Koya, P. D. (2023). Race and the Mental Representation of Individuals Diagnosed with Oppositional Defiant Disorder: Implications for Diagnosis. Journal of Social and Clinical Psychology, 42(4), 365– 405. https://doi.org/10.1521/jscp.2023.42.4.365
From Rabbi Shoshana
The PDA Safe Circle™ recognizes the disparities in access to neurodiversity-affirming and trauma-informed care for distressed kids, teens, and adults across race, class, and culture.
Our community welcomes all for whom a PDA framework resonates and sounds supportive, regardless of any official diagnosis or clinical identification.
Families with ODD diagnoses are completely welcome in our community.
We have an equity-based membership model to be financially accessible across income levels.
I am always open to feedback from BIPOC members (and all members of groups to which I don't belong) about how to be a better ally.
If PDA resonates, you can pop over to The PDA Safe Circle™ for a 1-week trial in our app, course, and community. Let's decrease distress and increase thriving together across lines of race, class, and gender.
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