There Are No Bad Kids: An Antiracist Approach to Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is a childhood disruptive, impulse control, and conduct disorder characterized by anger or irritability, argumentativeness or defiance, and vindictiveness (Table 1).1 Black, Hispanic, and American Indian/Alaska Native children—hereafter referred to as racially minoritized children—are more likely to be diagnosed with ODD than white children.2–4 One recent large-scale analysis found that the diagnosis of ODD is 35% more prevalent in Black people than in white people.5 These disparities worsen in juvenile detention and child welfare settings, where racially minoritized youth are overrepresented.6,7ODD describes the presence of unwanted behaviors and suggests they are features of the child, rather than manifestations of underlying neurodevelopmental difference (eg, autism), prior history (eg, trauma), or co-occurring mental health challenges (eg, depression).1 The diagnosis becomes racist when applied indiscriminately to racially minoritized children as a “bad kid” label, placing blame on them for these unwanted behaviors. Doing so is especially problematic when these behaviors serve as reactions or adaptations to racism. This misattribution can incite adverse outcomes, including missed treatment opportunities from misdiagnosis, failure to protect against racism, and harsher school disciplinary practices.2,3,8–10However, there are no specific guidelines that take an antiracist approach to protect children against this harm.11,12 This antiracist approach addresses this void, urging clinicians to recognize the historical legacy of racism shaping ODD overdiagnosis; the racism influencing diagnosis and treatment; and key documentation, psychoeducation, and clinical activism strategies.13,14 Two real-life cases illustrate how it confronts the racism shaping ODD in practical contexts (Tables 2 and 3).Aggression and defiance can be powerful transgenerational adaptations to histories and systems of oppression. Yet organized mental health has historically pathologized racially minoritized people’s resistance to racial violence at the expense of denouncing racial violence itself.15 For drapetomania, or “runaway slave syndrome,” coined by Dr Samuel Cartwright in 1851, the recommended treatment was whipping.16 During the Civil Rights Movement, psychiatrists labeled Black men championing their human rights with a “protest psychosis” diagnosis.17 In both cases, more humane alternatives, like abolishing slavery, instead of whipping enslaved people, were disregarded. Notably, in the 1960s, other mental health professionals were championing racism’s eradication, rather than diagnosing protest psychosis, as the definitive pathology underlying minoritized discontent.18,19 Both diagnoses reneged on a duty to advocate against social injustice.Mental health care’s legacy of racism, while distinctly anti-Black due to its intertwinement with slavery, has not spared other racialized groups. Intelligence testing created by psychologists justified 20th-century eugenics mass sterilization campaigns targeting Black, Hispanic, and American Indian girls and women.20,21 This testing has contributed to racially minoritized children’s overrepresentation in special education placement.22 ODD’s overdiagnosis today perpetuates this legacy’s normalization of racial oppression, pathologizing of resistance, and behavioral control as intervention, rather than advocacy against racial violence.13 Because diagnostic labels remain an enduring weapon of choice for white normativity, clinicians should think twice about applying ODD to racially minoritized children. Repairing this history involves challenging it, not perpetuating it.13,14An antiracist approach to racially minoritized children with ODD mandates analyzing how racism shapes misdiagnosis—not automatically implementing the adult supervision, discipline, and parent training recommended by practice parameters.11,12 Recognizing pertinent inequities helps pediatric clinicians avoid the following: Perpetuating anger and adultification biases: Adults are more likely to perceive Black children as stronger, more adultlike, less innocent, and less deserving of attention than white children.23–25 These biases, derived from anti-Black ideologies legitimizing enslaved children’s abuse, persist through racially minoritized children’s overpunishment, criminalization, and neglect of their pain, emotional and physical.26–28 When children are labeled oppositional, contextualization should follow. It includes scrutinizing the adult authority figures (clinicians, teachers, school administrators, and police officers) assessing them; conducting impartial assessments of their emotions and behaviors; and making ample attempts to identify dehumanization and discrimination.Ignoring intersecting systems of oppression: Adultification biases impact racially minoritized girls in unique ways.25 Negative stereotypes of Black women being angry, aggressive, and hypersexual lead adults to treat Black girls inappropriately, punishing them for subjective infractions, like disruption or disobedience, that their peers evade.23–25 They are suspended at 5 times the rate of white girls, while American Indian girls experience suspension at over twice the rate.29,30 Racially minoritized lesbian, gay, bisexual, transgender, and questioning (LGBTQ) students often endure multiple forms of bullying and harassment and punishment for their clothing, gender presentation, and public displays of affection, leading to increased rates of disciplinary actions within school environments.31 LGBTQ girls in particular are disproportionately punished due to normative societal expectations for sexual behavior and gender identity.32,33 These inequities warrant exploring differential treatment at school (case 2) while noting ODD’s gender differences. Girls experience more internalizing symptomatology than boys. ODD is more common in boys during childhood, but this gender gap narrows in adolescence.34Misdiagnosing: Mitigating racial discrimination’s harm involves considering alternative diagnoses, like attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder, which can present similarly to ODD.2,35 Although a defining feature of ODD, irritability is not diagnostic. A nonspecific indicator, irritability in youth warrants checking for mood and anxiety disorders and posttraumatic stress disorder.36 Clinicians requiring a diagnosis for billing but lacking time to probe for trauma, attentional challenges, and mood symptoms might consider less stigmatizing alternatives, including the various adjustment disorders or unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence. The widespread practice of copying and pasting a historical diagnosis without proper assessment, which can perpetuate bias, is discouraged.37Advancing the school-to-prison trajectory: An ODD label can heighten racially minoritized children’s already elevated risks of suspension, expulsion, and justice involvement.27 Black and American Indian/Alaska Native youth face higher arrest rates than white youth. Black and Hispanic youth experience the highest incarceration rates, followed by American Indian and then white youth.38,39 Racism profoundly impacts children, resulting in higher rates of anxiety, depression, and behavior problems.40–42 Racially minoritized youth who are also disabled, transgender, undocumented, or otherwise marginalized face additional toxic stress from intersectional discrimination and can be punished for their victimization.43,44 Explaining behavior through an ODD diagnosis can come at the expense of validating discrimination and trauma, thereby facilitating racially minoritized children’s pushout into carceral settings for the same behaviors garnering mental health care referrals and diversion for white youth.39,45Justifying punishment and coercion: Diagnosing a racially minoritized child with ODD can be tantamount to calling them a “bad kid,” amplifying established patterns of punishment and coercion, like excessive suspension and expulsions, seclusion and restraint, and police stops and juvenile justice involvement.28,46,47 An antiracist approach supplants individualized constructions of problematic behavior with structural analyses of the racial violence assailing children, recognizing the latter as the core problem driving the former. Moreover, it calls for protection against it.13,14 Assessing behaviors across multiple settings and relationships helps. Putting less onus on racially minoritized children for behaviors caused by racism is therapeutic and could improve service engagement.Pediatric clinicians who have connected a racially minoritized child’s ODD diagnosis to historical context and assessed its racist harm are primed to protect them through the following clinical strategies.Antiracist psychoeducation14: This strategy involves explaining to children and families how ODD’s overdiagnosis can perpetuate a historical arc of racism (step 1) and thwart healthy developmental outcomes (step 2). A full informed consent process illuminates an ODD diagnosis’ risks, underscoring that mental health diagnoses are not objective markers of disease but rather highly subjective constructions of human behavior shaped by historical and sociopolitical context.15Antiracist documentation14: This process involves scanning charts for pejorative language portraying children as aggressive (eg, defiant, difficult, uncooperative48) and examining whether their behaviors have been explored as a form of distress stemming from the stress and trauma of racism. Clinicians can then document the role racism plays in shaping behavior, adult authority figures’ perceptions of it, and how an ODD diagnosis can cause harm by obscuring vulnerability, trauma, sadness, and attentional challenges (step 2).2 Highlighting strengths and concern for mistreatment humanizes children, rewrites their pejorative narratives, and reconfigures them as “good kids” deserving of care. Documenting when a child no longer meets the criteria for ODD, due to symptoms being better explained by a different diagnosis or precipitating circumstance, further mitigates bias.Clinical activism14: Pediatric clinicians extend advocacy beyond health care by redirecting psychoeducational measures toward school administrators, police officers, and court representatives and shifting antiracist documentation strategies from medical charts toward school letters and court reports. This clinical activism highlights the school-to-prison trajectory’s detriment and reconfigures oppositional behavior as adaptive, rather than problematic, in the face of racism.A color-blind49 approach to ODD uses a race-neutral orientation to minimize racism’s formative role in shaping children’s behavior and adult authority figures’ responses to it.14,15 This antiracist approach, by contrast, centers racism to protect racially minoritized children from its harm. Illuminating history and systems of oppression, rehumanizing children against bias and degradation, and pathologizing structural violence, not individuals’ adaptive responses to it, are its cornerstones.16,17ODD is an example of diagnostic condemnation whereby clinicians can indict racially minoritized children instead of standing up against injustice in their defense. Other forms include the overdiagnosis of psychotic and disruptive disorders.2,50 They function as a unique form of race-based medicine51 whereby race is an unnamed diagnostic variable. More research is needed about ODD’s impact when the diagnosis does not contextualize symptoms amid racism or becomes punitive when lacking diagnostic reliability, as depicted in the 2 cases (Tables 2 and 3). Exploring this issue might illuminate whether this diagnosis should exist at all. In the meantime, this antiracist approach insists there are no “bad kids” and upholds our oath to protect them all.Dr Legha acknowledges Ms Akima Aiken Brown, who read, revised, and provided feedback for the initial and first revision of this paper. Without her support, this paper would not have been possible. Dr Legha acknowledges Dr Nathalie Martinek, who expertly reviewed and provided feedback for the first revision of this paper.