Diagnostic criteria for 313.81 Oppositional Defiant Disorder (cautionary statement) A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 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 or vindictive Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder. D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association The following article is from the March, 1999, issue of Working Mother magazine Is Your Child Too Defiant? by Carolyn Jabs At school and with friends, Brian behaves like a perfectly ordinary nine-year-old. But at home, it's another story. Brian tests every limit: He often swears at his parents, harasses his siblings and refuses to do even the most routine chores without extensive resistance. In fact, communication with his parents amounts to one long argument, leaving them all exhausted, angry and tense. Lately, Brian's parents have even begun to feud with each other about their son, each blaming the other for his abrasive behavior. They are sick of hearing advice from well-meaning friends, who are sure all Brian needs is a firmer hand. Brian's case is a familiar one to therapists who deal with difficult children. The official diagnosis: Oppositional Defiant Disorder, also known as ODD. The symptoms include chronic anger, blaming others for mistakes, being touchy or easily annoyed and vindictive. In plain English, ODD kids talk back, refuse to do chores, use bad language and say things like "You can't make me" nearly every day. "All kids display this kind of behavior from time to time, " says Kenneth Wenning, PhD, a clinical social worker in private practice in Hamden, Connecticut, and author of Winning Cooperation from Your Child(Jason Aronson). "With ODD kids, the symptoms continue for six months or more. Parents feel they are always struggling with their child." Even more confounding, conventional discipline strategies usual fail. Kids with ODD refuse to go on a time-out from an early age, and claim not to care about losing privileges. If their exasperated parents shut them in their rooms, they may destroy their own belongings or go out the window. When adults resort to spanking, the kids focus on the parents' behavior---"I'll report you for child abuse---instead of their own. "Oppositional children actually believe they are equal to adults," says Douglas Riley, PhD, child psychologist and author of The Defiant Child (Taylor Publishing). Experts say it's typical for parents with an ODD child to feel isolated. "You don't know anything about kids like this until you have one," says Ross Greene, PhD, director of a cognitive behavioral psychology program at Massachusetts General Hospital and author of The Explosive Child (HarperCollins). "Until people have been in your shoes they have no idea." The notion that parents are to blame is often reinforced by the fact that some ODD kids are model citizens away from home. Many, though not all, get good grades at school, cooperate with coaches and are polite with their friends' parents. Some are even able to convince therapists that their problems are caused entirely by their parents. Newly Identified Disorder No one knows exactly how many kids have ODD because it is a relatively new diagnosis and tends to overlap with other problems. The best estimates are that 6 to 22 percent of all school-age children have ODD. Parents often seek help for ODD kids around five or six, an age when most kids become more social and start to be more cooperative rather than less so. So what causes ODD? No one knows for sure. Most experts think that a child's inherent personality and disposition contribute to the syndrome, and it may be heightened when parents aren't educated about how to handle it. ODD often coexists with other problems, such as attention deficit disorder (ADD), learning disabilities and mood disorders. Greene notes that it is sometimes more effective to treat an ODD child once some of the related problems, such as hyperactivity, mood disorders or anxiety, have been treated with medicine. In many cases, the problem is evident almost from birth and only grows more pronounced over time. Even as a baby, one mom says, her son could be difficult. When he was mad, watch out. We used to affectionately call him our Angry Little Man." These kids are simply "more rigid, more demanding," says Wenning. "They have a heightened need to be in control, right from the beginning." In other cases, the disorder is latent---only triggered during a crisis in the child's life such as divorce, illness or death of someone close to the family. "Sometimes ODD is more like a fever than a disease," says James D. Sutton, EdD, a consulting psychologist in private practice and author of If My Kid's So Nice ... Why's He Driving ME Crazy? (Friendly Oaks Publications). "It's symptomatic of something else. I always ask if anything happened within the past six to eighteen months," Sutton adds. In any case, many parents find they do best with their kids when they start to think of ODD as a disability and not a willful act. "My daughter isn't simply spoiled," says Marissa of her nine-year-old. "She is fighting her own demons and often she's scared to death. Understanding that made it easier for me to provide the structure, patience and consistency she needs." How to Cope Marissa's approach is a good one, according to the experts. ODD kids are essentially handicapped in their ability to be flexible and handle frustration. "These kids maintain an oppositional attitude even when it's clearly not in their best interest," says Greene, "so we have to assume they would be doing well if they could, but they lack the capacity for flexibility and frustration management that ordinary children develop." Thus, expecting perfectly compliant behavior from a child who may not be able to deliver the goods is unrealistic. Instead, you have to remain as patient as possible, and try to teach your child skills that help him deal with frustration, irritability, inflexibility and other difficult feelings. So where do you start? It may help to consult a therapist, who can not only check to see if your child has ODD, but also give both of you and your child some coping strategies. Whether you use a therapist or not, you'll most likely begin where other parents leave off. "We've done all the stars and the charts and the rewards," says Carol. "And we've tried isolation and loss of privileges. Sometimes I think our child doesn't even make a connection between what she's done and the consequences." With such children, you have to learn how to manage your own reactions---then teach your child the skills she needs. Don't take it personally. That's a tall order when a child is screaming at you or calling you names. Often parents can't help feeling a child could control his ODD behavior if only he'd try harder. But it's critical to gain some distance. Realizing that "it's not personal" makes it more likely that parents will respond constructively rather than vindictively to a child's behavior. "Before I start seeing the child, I work with the parents to get them to step back and use the same analytical abilities they would use at work," says Sutton. "I ell them to pretend they are a child care worker and this is not their kid." Refuse to join the fight. ODD kids are masters at turning everything into a power struggle. The best way to avoid such struggles is to keep the focus of every conversation on the problem at hand. This is easier said than done, of course. In a typical fight with an ODD child, you might start by stating a simple rule---"No TV until homework is finished"---and before you know it, you wind up arguing about swearing and disobedience. In other words, you're suddenly fighting about whether your authority is legitimate. To avoid this, calmly repeat the rule and the reasons for it. Above all, keep your composure. "These kids crave a reaction from you," says Tina Draper, a mother who runs an online support group. "So you have to learn not to react." That doesn't mean ignoring your child's behavior---just deferring your comments until he's able to hear them. "I used to get into shouting matches with my son," says Rosie Linko, parent of a teenager with ODD. "Now I let things slide until he calms down. They I say "When you were angry, you did this and that's not OK with me. What could you do differently?" Ease up the controls. ODD kids don't readily comply, so the more requests you issue, the more the opportunities for the child to get stuck. Greene recommends that parents divide the things they want their ODD child to do into three categories or "baskets." Basket A holds a few mandatory rules, which are usually about safety---you must wear your seat belt in the car, siblings can't hit each other, and so on. Basket B holds issues on which you are willing to negotiate when you think your child is able to do so. And Basket C includes rules that aren't worth bothering with until your child can handle frustration. Every parent will put different behaviors in different baskets. Swearing, for example, is a Basket B issue for some parents and an ignore-it-for-now issue for others. "Work on one or two high priority behaviors at a time," says Sutton. Establish simple, enforceable consequences. Rules have no value unless they are backed up by swift, unambivalent consequences. ODD kids can make this difficult. They often provoke parents into escalating consequences. If you say "You're grounded for the weekend," and your child replies "Big deal," it's very tempting to respond by upping the ante. You might angrily threaten, "Well, then make it a month." Remember that such a reaction will only inflame things. Instead, stick to consequences that are fair and dispassionately enforced. Teach relationship strategies.Unlike typical children, who usually pick up essential social skills, ODD kids need them to be spelled out again and again. Rosie Linko remembers teaching her son to stop and count to 20 when he felt really angry. "Now," she says, "I'll see him do it sometimes. He'll focus on getting himself together before he does something he'll be sorry for." Use the back door.Because oppositional kids react so vehemently to direct commands, many parents get better results when they rethink the way they communicate with their child. Instead of issuing a direct command, such as, "Clean up your toys," say something more neutral, such as "The toys need to be picked up before the TV goes on." For older children, some parents sidestep an argument by putting what they want in writing. One working mom leaves her ODD son a list of after-school responsibilities next to his snack. "He usually does what's on the list," she says. "If I called to ask him to do the same things, we'0d have a fight." Give your child genuine choices. ODD kids want to be in charge, so give that responsibility whenever you can. Instead of arguing with a school-age child about whether he needs a jacket, tell him the weather forecast. If he comes home shivering, don't lecture. Instead, sympathize with the fact that it must have been colder than he imagined. Gradually, he'll take responsibility for his own choices---instead of blaming you when things go wrong. Praise your child whenever possible.Changing the ODD reflex is hard for your kids, so parents need to notice and appreciate even small instances of cooperation---"It was really a help to me when you pitched in with the cleanup after supper." Kenneth Wenning recommends even creating as many opportunities for positive reinforcement as possible. If, for instance, you're working on a household repair, ask your child to hand you a tool. When he does what you ask, thank him specifically for his willingness to help out. If he doesn't, move on without comment. "The idea is to make your request so easy that your child will comply without thinking about it," says Wenning. "Then, for just a moment, he'll experience the positive feelings associated with cooperation." Connect with what you like about your child. Parents of ODD kids are keenly aware of the problems their kids cause. "CJ just tests us and frustrates us so much that it is difficult to want to be with him," says one mom. But that's only half the picture. "These kids are often bright, vigorous and very creative," says psychologist Sutton. "I try to help parents appreciate the strength that's attached to the oppositional drive." He recommends a simple technique he calls affirmation. When your child is reading in bed or watching TV, sit down beside him. If he says "Mom, why are you sitting here?" simply answer "Things get so hectic. Everybody's going in every direction. I just missed being with you." Don't try to have a heart-to-heart or hash over a problem. "Just honor the child with your presence," says Sutton. "You'd be surprised how powerful this can be. Take care of yourself and your mate. Remember that ODD is not something you, your partner---or for that matter, your child---has chosen. So take time for things that will relieve stress---exercise, have lunch with a supportive friend, watch funny movies---and treat your partner as your ally. Go out together and talk about anything but your ODD child. "Although ODD does put a child at risk for more serious future difficulty, it is a problem that can be resolved by parents who may work collaboratively with therapists and the child's teachers," says Wenning. Carolyn Jabs writes frequently about family issues for many national magazines.