Understanding Oppositional-Defiant Disorder

by David L. Smoot, Ph.D. What is it? In my private practice as a child and family psychologist, I help many, many families with children who have Oppositional-Defiant Disorder (ODD). When asked to explain ODD, I initially think to myself that the title itself is quite descriptive. These children take a contrary, oppositional view to everything and will be openly defiant when asked or told to do something they dont like. But then again, dont all children misbehave sometimes? Isnt defiance just one way children gain independence from their parents? Is ODD really a problem in the child or a problem with the way the parents, well, parent? Obviously, there is more to ODD than meets the eye. Take for example the following children: Thomas has for years shown worsening problems at school and home. His parents are literally afraid to give him chores for fear of his routine explosions that can include yelling and cussing, throwing things, crying, and running from the house. In fact, they find it is just easier to pick up things for him rather than risk setting him off. At school, Thomas refuses to do any written work. He pouts, falls out of his chair, and has started to tell the teacher that he hates her. Andrew seems to always wear a scowl, his mother says. She believes he must be deeply unhappy, but the only feeling he will express is anger. He lashes out whenever he is even mildly criticized. Even things that should be fun can be intensely frustrating to Andrew. He may be enjoying video games one minute and then suddenly erupt in frustration when he suffers failure. He has on several occasions thrown the console across the room. Monica goes around the playground with a chip on her shoulder. Other children know they can get a rise out of her easily so she is often the target of teasing. Nevertheless, she insists on being the boss in any game she joins and will not put up with children who question her rules. She either ejects them from the game or she quits herself, stomping off in a huff. Monica holds grudges for a long time and her parents have overheard her using very crude language to describe children who have crossed her. Lets examine what makes these three children with ODD different from other children. First of all, the Diagnostic and Statistical Manual, the resource book which describes all psychiatric conditions, specifies that a child must meet at least four (many argue six would be more appropriate) of the following behavioral criteria to qualify for a diagnosis of ODD: A pattern of negativistic, hostile, and defiant behavior lasting at least six months during which four or more of the following are present: 1. Often loses temper 2. often argues with adults 3. often actively defies or refuses to comply with adults' requests or rules 4. often deliberately annoys people

5. often blames others for his or her mistakes or misbehavior 6. is often touchy or easily annoyed by others 7. is often angry and resentful 8. is often spiteful and vindictive The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. From the outset we see that ODD children may differ from other children in terms of how long and how often they show this defiant and intentionally irritating behavior. ODD children have behaved this way for at least the last six months, whereas other children may have only recently developed the problem behaviors. Children who have only recently defied authority, broken down into temper tantrums, or annoyed others may be going through a normal developmental phase (e.g., the so-called terrible twos) or may be reacting to other stressors (e.g., poor peer relationships, academic problems, family conflict). Also, the diagnostic criteria specifies that the behaviors occur often, which of course begs the question, how often is often? Some researchers have suggested that behaviors such being spiteful or vindictive may be considered to be often occurring even they occur only once every few months, whereas most others are considered to be occurring often only if they occur at least 2-4 times each week. Moreover, the criteria from the DSM gives us one more clue about how often is often by noting that the problem behavior must cause truly serious problems in friendships, school functioning, or home life for the diagnosis of ODD to be considered. Ross Greene, Ph.D., author of The Explosive Child, has argued that these criteria fall short in two ways. First, they do not explain the underlying process behind the oppositional, defiant behavior. In other words, the criteria say nothing about why the behavior occurs in some children. Second, the DSM criteria imply that oppositional, defiant behavior is intentional in ODD children. While it often appears this way to many parents, teachers and even therapists, Dr. Greene offers a new understanding of children with ODD especially those who are inflexible and explosive. They show an extreme lack of flexibility and give-and-take in relationships and they fall apart in the face of frustration. These ODD children cannot handle transitions because they cannot shift gears as easily as most people do. They are impulsive and tend to react in defiant ways even when they have suffered negative consequences for their actions many times. They have an extremely low boiling point. Their lightening-fast blowups may occur over seemingly trivial events.They also have a low tolerance for frustration. ODD children escalate more quickly up to intense rages and are quick to react with aggression. They think in rigid, black-and-white ways about most events. They are very focused on justice and fairness. They are stubborn and cannot get injustices or their own wants off their minds. They are extremely persistent and will continue to provoke or attack others even when it is clear that the negative behavior is not working and consequences would be much more positive for changing the defiant behavior.

Defiance can come out-of-the-blue. They may be in a good mood one minute, then having a temper tantrum the next. Many ODD children have specific issues that lead to conflict. For example, they may rebel over the texture of clothing, the taste or smell of food, or the sequence in which things must be done. Their inflexibility may be worsened by other associated problems such as moodiness, hyperactivity, impulsivity, anxiety, or social skill deficits. Even though many children are cranky when they are hungry or tired, ODD children may completely melt down under these conditions.

As you can imagine, regardless of which set of descriptive characteristics you use, children with ODD and their families go through very rocky times. Many researchers suggest that ODD and other aggressive disorders may be one of the most stable patterns of behavior. That is, children who are oppositional and defiant early in their childhood are very likely to show the same behavior in later years. Some children even develop worse problems and may be diagnosed in adolescence with a Conduct Disorder. In addition, many children with ODD go on to have serious problems with friendships, intense family conflict, academic failure, and depression. Who Gets It? Although prior studies and reference manuals such as the DSM attempt to standardize the way we define disorders such ODD, research studies typically have used differing measures and definitions to categorize children with ODD. Therefore, our knowledge about how common ODD is remains sketchy at this time. Studies have reported anywhere from 2 to 16% of American children as having ODD. The best estimates indicate that the rate may be around 5% for children and pre-teens, and somewhat lower in adolescents. Studies indicate that ODD behavior occurs most frequently in the following settings (in order from most to least): home-only, home and school, school-only. Males are about twice as likely as females to be ODD. Ross Greene, Ph.D. identified several of the pathways that may lead to a child being inflexible and explosive. Many of these children also fit the criteria for a diagnosis of ODD. Dr. Greene noted that many parents of ODD children recognized a difficult temperament in the child from a very early age. These children are highly active, intense in their actions and emotions, low in adaptability, very sensitive to sounds or textures, have negative persistence, and were difficult to console when upset. Many children with ODD have attention problems or problems with self control. As you will read below, ODD and ADHD are often overlapping conditions in a child. Children who have limited attention skills and poor impulse control often do not have the skills to anticipate consequences, cope with transitions, plan their actions, or regulate their emotions. They often violate rules and others space. These actions often trigger negative responses from family members and peers. ODD children often have poor social skills, Dr. Greene writes. Because social interactions involve some very complex skills and expectations, children with limited skills often feel frustrated or are unable to handle social demands without digging in their heels or unleashing a verbal or even physical attack on someone. Children with language processing deficits may show signs of ODD because they lack the skills to work problems out with their words or they may have difficulty understanding instructions fully. Children with mood and anxiety problems may also have ODD because they struggle to cope with disappointment, discouragement, and stress. Feeling overwhelmed by emotional and other demands, these children may take out their stress on others and appear generally

uncooperative. Dr. Greene also cited sensory integration dysfunction as a pathway to explosiveness in a child. Some children truly have a lower tolerance threshold for uncomfortable clothing (seams in socks, tags in collars), loud noises, tastes or textures of certain foods, light, heat, etc. The childs low tolerance and the inflexibility of adults around this child frequently lead to emotional meltdowns. Children with a condition known as nonverbal learning disability are often oppositional and defiant. These children have adequate language skills but are weak in their ability to anticipate the future, picture what they are supposed to do, and they are often deficient in social skills.

Pathways that lead to ODD (adapted from Ross Greene, Ph.D.) difficult temperament attention problems or problems with self control poor social skills language processing deficits mood and anxiety problems sensory integration dysfunction nonverbal learning disability

What Goes Along with It? ODD quite often goes along with some other childhood psychiatric disorder and with more general problems in coping. The overlap of ODD and Attention Deficit Hyperactivity Disorder (ADHD) is believed to be fairly extensive. Studies conducted with children with ADHD find that on average one in three ADHD children also meets criteria for a diagnosis of ODD. Some studies even find the overlap to be as great as two out of three ADHD children having ODD. Studies consistently find that having ODD makes life much more difficult for the ADHD child compared with their peers who have ADHD alone. The ADHD+ODD children are more likely to have negative, rejecting family relationships; harsh, inconsistent parenting, a rejected status with their peers, and poor school performance. Many authors have written about the connection between ODD and Conduct Disorder, a severe form of behavioral problems that may include lying, stealing, aggression, and other delinquent activities. It is true that oppositional and defiant behavior, especially aggression, has been found to be very stable over time. That is, a child who is much higher than his or her peers in aggression at an early age is very likely to be higher than peers in

aggressive behavior as a teen or even adult. However, this by no means suggests that every aggressive and/or ODD child will grow up to be a delinquent, aggressive adolescent! On the contrary, studies show that the rate of aggressive behavior decreases dramatically across the lifespan. Whereas it is not unusual for preschoolers to behave aggressively, truly aggressive behavior by older children occurs much less frequently. About 25% of children who are aggressive at age two years, stop fighting by the time they are eight years old. Another study found that about 12% of children who were frequent fighters in kindergarten had quit fighting by ages 10 through 12. In comparison, 8% persisted in a high level of fighting during this period of time. Certainly, children with ODD are at high risk of developing future behavior problems including CD, but this negative outcome is not a forgone conclusion. Many children with ODD are also found to have problems with negative mood or anxiety. These children may be very pessimistic, always see problems rather than possibilities, and are never satisfied. They are often quick to judge others and frequently complain that life is not fair. Their emotional reactions are intense and explosive. Some are anxious and worried about being judged, not being good enough, or fear making mistakes. The majority of ODD children display their negative behavior primarily at home. As a result, family relationships often suffer. Not only are the parent-child relationships negative, but the marital relationship is also severely strained in many cases. These children are incredibly challenging and can drive a wedge between the most loving spouses. Due to parents own temperaments, personalities, and backgrounds, they often judge their partners discipline to be inadequate or, even worse, as responsible for the ODD behavior. Often both parents feel unsupported and misunderstood by their spouse. Operating as two individual, sometimes antagonistic, parents rather than a unified team leads to many parents feeling burnt out. Often ODD children enjoy good peer relationships and may even behave wonderfully at friends houses. However, some ODD children let their inflexible, bossy, and domineering side come out amidst their friends. Some children succeed socially with this aggressive style of relating with others; while others are rejected by peers for being too bossy or a bully. Many children with ODD have trouble in school because they do not do their work. Their parents have enormous conflicts over homework each evening. Some of these children may be quite bright and score well on tests, but have low grades because they do not do their homework. Some ODD children refuse to do class work also and present an enormous challenge for teachers and administrators. They can try various forms of consequences, but often the ODD student just digs in his or her heels all the more adamantly. Resources Books: Greene, Ross W. (1998). The Explosive Child. New York : HarperCollins Publishers. Kurcinka, Mary Sheedy. (1991). Raising Your Spirited Child. New York : HarperCollins Publishers.

Kurcinka, Mary Sheedy (2001). Kids, Parents and Power Struggles. New York : HarperCollins Publishers. Web Resources: http://www.conductdisorders.com/ http://www.klis.com/chandler/pamphlet/oddcd/about.htm How is it identified or assessed? The behaviors that make up ODD are fairly simple and straightforward. If you are wondering if you should seek help for your child, complete the form below. Answer whether the following behaviors occur never or rarely, sometimes, often, or very often. Symptoms Never or Sometimes Rarely Often Very Often

My child loses his/her temper My child argues with adults My child actively defies rules and refuses to comply with adults requests My child deliberately annoys others My child blames others for his/her mistakes and misbehavior My child is touchy and easily annoyed My child is angry and resentful My child is spiteful and vindictive

These behaviors are taken directly from the Diagnostic and Statistical Manual-Fourth Edition that clinicians use to diagnose psychiatric conditions. If you answered often or very often to four or more behaviors, and these behaviors have been shown for at least six months, then you may have reason for concern. A mental health professional can help you determine if the condition is severe enough to diagnose as ODD and should help you

understand the pathways or factors that contribute to your childs behavioral problems. A clinician should also determine (or rule out) the possibility that other disorders such as ADHD, learning disability, conduct disorder, bipolar depression, anxiety, or depression may be involved. A clinician will want to gain a clear understanding of the problems you are having with your child. He or she will ask you to describe your childs behavioral problems along the following dimensions: How often does the behavior occur? Under what circumstances or in what situations does the behavior occur? How intense are the power struggles? How long do they go on? How do you react to his/her defiance? How does your child respond to your interventions? What do you do next? How long has this gone on? The clinician will also want to ask you about your childs developmental, social, school, and family history. He or she will probably ask you to complete behavioral rating forms that allow a comparison of your childs behavior to the behavior of other boys or girls of the same age. Most children will show some defiance; clinicians need to determine if the problems are unusually severe before they diagnose a child. What can be done? If your child has been diagnosed with ODD or you are concerned about your childs high level of ODD-like behavior, you can learn many skills that will help you cope with your childs differences. The leading experts on the treatment of ODD recommend similar steps in treating the condition. Understand whats going on with your child. Try not to take his or her disrespect personally. Realize that he or she has skill deficits that make misbehavior and disrespect more likely to occur in times of stress. Anticipate your childs reactions. Understand and predict the situations that frequently give rise to conflicts. Try to focus on these situations and help your child avoid the power struggles or melt downs that typically occur. Pick your battles. Dont go to the mat over every disagreement you have with your child. Your child probably gets negative feedback all day long and is overly sensitive to criticism.

Be a proactive parent. Continue being the kind of parent you want to be rather than reacting to the button-pushing your child engages in with you. Most parents have no desire to be in the yelling matches that can go on with ODD children. Follow through with reasonable consequences. Many parents talk too much to the ODD child who is throwing a tantrum. Pick logical consequences you can live with and apply them consistently. Consequences should be immediate and specific so your child will understand the connection between his/her behavior and the consequence. Catch your child being good. Use positive incentives before using punishment. Punishment tends to make the child with ODD feel youre unfair and that it is your fault he or she is suffering. Periodically take breaks from parenting and do something for yourself. Parenting an ODD child is exhausting and no child fares well with an exhausted, burned-out Mom or Dad.