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What is the difference between "Oppositional Defiant Disorder" and Pathological Demand Avoidance?

by Rabbi Shoshana Meira Friedman


I’m getting questions from educators & parents about how to tell if a defiant child or student is ODD or PDA.


According to the Mayo clinic, Oppositional Defiant Disorder is: "a frequent and ongoing pattern of anger, irritability, arguing and defiance toward parents and other authority figures. ODD also includes being spiteful and seeking revenge, a behavior called vindictiveness." The behavior lasts at least six months.


Oppositional Defiant Disorder is a controversial diagnosis that many psychologists do not use, or use very sparingly. (“Why I don't Diagnose Oppositional Defiance Disorder” by Dr. James Wiley.)


Many people, myself included, think ODD is a bad name for a stressed or traumatized child, often an ADHDer, who doesn't have healthy strategies, accommodations, or support for meeting their legitimate needs for respect, safety, autonomy, etc. BetterHealth also reports the following increase the risk of ODD: abuse, neglect, inadequate supervision, harsh or inconsistent discipline, rejection, poverty, marital conflict. Obviously the child is not the problem here - they are part of a system & the system needs support so they & everyone can be well.


ODD is understood to be a behavioral disorder (I don't agree with that frame, but that is the frame.) That is to say, the concept of ODD is that a child or teen is willfully disobeying authority figures, willfully being vindictive, or willfully being aggressive. Another way to put this, which I prefer, is the child does not have good coping strategies for the stress they are under or trauma they have endured or the brain chemistry they are dealing with. No child is willfully vindictive out of the blue, or manipulative just for kicks.


Supports that are used to help a child with an ODD diagnosis include: compassionate responses from adults, behavioral interventions with positive and negative reinforcers (please be trauma-informed and focused on nervous system regulation skills, not compliance), medication, parent coaching, trauma-informed therapies and/or cognitive behavioral therapy, and sufficient support for the family system.


Trauma informed approaches should always be used, but as far as I can tell they are not always being indicated, which is frustrating. Again, no child acts this way for fun, and rewards for "good behavior" without treating the underlying causes of the child's distress are going to be problematic.


Whatever a better name is for ODD, PDA is still different. PDA is not a lack of skills, or caused by lived trauma. The difficult behaviors seen in PDAers are expressions of a nervous system disability. Trying to change a PDAer’s outward behaviors or get us to do something will not work. When we are “defiant” we are avoiding something that our body/brain is perceiving as threatening. The way to support a struggling PDAer is simply to help us feel as safe as possible. Often this means dropping the demand that we do the thing that feels threatening.


Strategies to help a PDAer feel safe include: lowering demands, increasing our autonomy, letting us have control & high status, using Autistic strategies like sensory supports and special interests, offering deep attunment and 1:1 attention from parents, and allowing sufficient rest. When we feel safe in the unconscious part of our brain, our troubling behaviors dissipate, which is a sign our mental health is improving.


Many PDA children are misdiagnosed with ODD. This is extremely problematic. Why? Behavioral interventions (like consistency with expectations, or rewards and consequences) are often indicated for ODD. These will in and of themselves be stressful and even traumatic for a PDAer. This is because PDA brains are hard-wired to perceive power over us as existential threat, and any doling out of reward and punishment is at its core an exertion of power. PDAers need flexibility in expectations - we have a dynamic disability, and we are able to do more some days than others. If PDA is treated as ODD, the PDAer will spend more time in survival brain. Problematic behaviors - and the PDAer’s underlying distress - will increase.


 

ODD vs PDA CHEAT SHEET


ODD

  • Can start at any age.

  • Not a profile of Autism.

  • Often caused by stress, trauma, unaccommodated ADHD.

  • Trigger around authority figures.

  • Best understood as a lack of support/healthy coping strategies for trauma and stress.

  • Routine & consistency can help.

  • Trauma-informed behavioral supports & skill building can help.

  • Can be treated & go away with time and support.


PDA

  • Neurology since birth.

  • Widely understood to be a profile of Autism.

  • Trigger around lack of autonomy, control, or equality in general - not only around authority figures.

  • Best understood as a nervous system disability.

  • Flexibility helps.

  • Lowering demands helps.

  • Can be accommodated.

  • Is a lifelong disabling brain difference.



 

How can I tell if my child or student is ODD or PDA?


Let's say you have a child or student who is acting "defiant" by not doing what adults ask them to do to such an extent that you are seeking professional help. How can you tell if your child/student's behavior is due to a nervous system disability present since birth (PDA), or due to lack of support or coping strategies for environmental stress or trauma (ODD)? We know it is very important to accurately catch PDA if that is what's going on. So how can we tell?


Based on my research into ODD and extensive experience with PDA, I came up with the following questions I hope will help.


 

Rabbi Shoshana's Unofficial PDA vs. ODD Questionnaire:

 I am not a clinician, and these are not standard diagnostic questions.


This unofficial questionnaire is meant to help identify a potentially PDA child who would otherwise be mistakenly given an ODD diagnosis. It is not meant to catch internalized versions of PDA, which do not usually get mistaken for ODD.


For each question, a YES answer is an indication of potential PDA, and points away from ODD.


(Note that several of these questions would get a YES for a neurotypical child who has endured significant trauma. Consider the child's lived experience and look for neurodivergent-affirming and trauma-informed mental health providers to help understand the root cause of the child's struggles if there are multiple complicating factors.)


  • Is the pattern of difficult/distressed behavior present since birth or early childhood?

  • Do the troubling behaviors/meltdowns come up when the child loses autonomy, control, or equality not only with authority figures BUT ALSO with peers, objects, games, disappointments, choices, and the demands of daily life (bathing, leaving the house, putting on clothes, eating, etc).

  • Does the child have trouble meeting one or more survival needs at home or school, or create strict rules around how they are "allowed" to meet those needs? Survival needs refers to eating, drinking, toileting, hygiene, sleeping, and physical safety.

  • Does the child have trouble meeting one or more secondary needs at home or school, or create strict rules around how they are "allowed" to meet those needs? Secondary needs include leaving the house, wearing clothes, social interaction, or trying new things.

  • Does the child exhibit a need to be in control or be the expert in all or most situations, including with adults but also peers, siblings, and strangers?

  • Does the child (or even teen) often need one-on-one attention from a loving adult to be able to engage in play off of a screen?

  • Does the child have sensory differences or challenges?

  • Does the child love to share at length (info dump) about a favorite topic when they feel safe?

  • Does the child have special interests that light them up and hold their attention for very long periods of time?

  • Look closely at any behavior being labeled vindictive, such as hiding a parent's favorite object. Can you understand the behavior as a way to assert control over the parent after or during a stressful situation for the child? (This is called equalizing behavior and it's a common coping strategy for PDAers)

  • Do birthday parties or gifts dysregulate or stress the child out?

  • If the parents or teachers drop demands, and allow the child to be in charge and autonomous as much as possible, does the child seem more relaxed and regulated?  (Note that if the child has been in a freeze/shutdown nervous system state, PDA accommodations may bring out a fight/flight reaction at first, since the child feels safer. It looks like things are worse but it’s actually a sign the nervous system is healing).

  • Do adult-led rewards, behavior charts, consequences or bribes increase the troubling behaviors or cause the child to shut down and withdraw, or ignore them all together?

  • Does the child crave the undivided attention of their primary caregiver?

  • Does the child exhibit signs of social anxiety such as trying to control who comes in the house, trying to control how peers engage in play, or going into in fight/flight/freeze or other dysregulation after a social event including school or a playdate?

  • Does the child use strategies such as making excuses, being silly, or engaging in imaginary play when they are avoiding complying with an adult's expectation?

  • Does the child say things like "my legs don't work" or need you to do what looks like simple tasks for them, such as putting a blanket on them that is right next to them on the couch?

  • Does the child sometimes get excited about an upcoming event, only to be unable to leave the house when the time comes?

  • Does role play or fantasy play, especially when it's aligned with the child's interests, dissipate stress and avoidance behaviors?

A YES answer to any of these questions points away from ODD and towards PDA, and suggest you should research more about PDA Autism before giving this child an ODD diagnosis.


Again, I am not a clinician and this is not a clinical diagnostic process.


You do not need a clinical PDA diagnosis to try out PDA accommodations and see if they help.


 

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