Back From the Brink: Two Families' Stories of Oppositional Defiant Disorder

Oppositional defiant disorder is a serious, family-straining condition often associated with violet outbursts, persistent disobedience, and school expulsions. Here, read the stories of two mothers who traveled down long roads of therapy, medication, tears, and breakthroughs to help their sons with ODD live better lives.

A sassy boy with oppositional defiant disorder, illustrating two stories of parents who overcame the condition
   
 

Facts and Figures About ODD

The most recent Diagnostic and Statistical Manual of Mental Disorders puts the prevalence rate of ODD between 2 and 16 percent for children in the U.S. It is a relatively large range that is most likely caused by varying definitions of what constitutes “defiant behavior.” A 2007 study put the lifetime prevalence rate — the rate at which a condition affects individuals at any point during their life — at 10.2 percent. For ODD in childhood, a well-regarded large-scale 2009 study placed the figure at about 6 percent.

In the early years, ODD is diagnosed mainly in males — the male-to-female ratio is anywhere from 1.4:1 to 3:1 before puberty. By the teenage years, it affects both genders relatively equally. The overall rates of occurrence drop by then — only about half of children who were diagnosed before puberty retain the diagnosis.

Experts estimate that at least 40 percent — and perhaps as many as 60 percent — of children with ADHD also have ODD. Conversely, a comprehensive study over patients’ entire lifetimes found that 68 percent of those with ODD also had ADHD or another impulse control disorder.

Conduct disorder and antisocial personality disorder have more serious symptoms/traits than those typically associated with ODD. About 25 percent of children with ODD will later be diagnosed with conduct disorder, and about 25 to 40 percent of adolescents with conduct disorder develop antisocial personality disorder.

ODD on the Rise?

"It’s hard to answer this question because of the difficulty of doing research across several generations of children,” says Russell Barkley, Ph.D. However, a 2015 report by The National Academies of Sciences hypothesized — based on an increase in Social Security payments to children who were diagnosed with ODD — that the condition may be on the rise among low-income children. But without more data, there’s no way to be sure.

Barkley hypothesizes that the increase — if it exists — is due to a few factors, most of them social or economic. “Rates of divorce have increased,” he said. “Economic hardship has as well — as have rates of single-parent mothers, particularly those in lower social economic levels.” Parental stress — which often passes on to children — has been linked to kids developing defiant behavior.

Why Does ODD Develop?

Though the exact causes of ODD are not fully understood, Barkley outlines four contributing factors in Defiant Children: A Clinician’s Manual for Assessment and Parent Training:

> Negative patterns in the parent-child relationship: “Ineffective, inconsistent, indiscriminate, and lax or even timid child management methods being employed by parents” can be a major factor in a child developing ODD. But it isn’t the whole story. “It would be erroneous to conclude from this that all defiant behavior results from the parent–child relationship.”

> Natural characteristics of the child: Children who have a more negative temperament from birth — an unusually fussy baby, for instance — may be more likely to develop ODD later on. Children who are impulsive — often due to abnormalities in their amygdala, prefrontal cortex, or anterior cingulate — may also be more prone to ODD.

> Natural characteristics of the parents: Parents of children with ODD are more likely to have psychiatric disorders like depression, ADHD, or antisocial personality disorder, which can lead to inconsistent or negative parenting patterns that increase the risk for defiance. Younger parents, too — particularly single parents — have a greater risk of their child developing ODD.

> Additional social or familial context: Human behavior is heavily influenced by the world around us, and this remains true for ODD. Poor families with access to fewer resources may be at higher risk for defiant children. Children of divorce may also be at greater risk.

Treatment Options for ODD

"The most evidence-based treatment approach is behavior-based parent training,” said David Anderson, Ph.D., senior director of the ADHD and Behavior Disorders Center of the Child Mind Institute. Though many parents may be inclined to try to tackle it on their own, he said, “When you have families that are engaged in this much parent-child conflict, you don’t normally see kids ‘grow out of it’ easily.” The focus of a parent-focused clinical approach is on helping parents with things like consistent discipline, de-escalation strategies, and implementing positive praise.

“Medications are not specifically indicated for ODD alone,” Anderson said, but “[they] are often prescribed for comorbidity.” That means that if the child has another condition, like ADHD, getting some of those ADHD behaviors under control with medication may help the child access coping skills that allow him to manage his defiance.

 
   

When her son Daniel was a few months shy of his fourth birthday, Alison Thompson confessed to her diary that she thought he was “the original child from hell.”

“Today has been a horrible, hateful day,” she wrote. “Daniel has pushed me to my absolute wits’ end.” When he wasn’t knocking down another child’s block tower or throwing papers all over the floor — for no reason, it seemed, other than that he could — he was having tantrums that could last for hours.

“He’d have five tantrums in a day,” said Thompson, a single mother living in Oxfordshire, England. “They were aggressive and violent. He’d lash out, and he’d hit me and his sister. He’d make holes in the walls.”

Across the ocean, in Flint, Michigan, Kim Abraham was in the same predicament. She and her son, Nathan, spent his childhood locked in a never-ending battle. By the time he reached middle school, Nathan refused to go to school most days, forcing Abraham to drag him to the car in his pajamas, hoping he would get dressed on the way. He stole things from his brother, he broke his father’s tools, he didn’t do his homework. In eighth grade, he refused to wear clean clothes for weeks, opting for the dirtiest, most ragged outfits he could find. The prolonged clash culminated in a screaming argument, Abraham said — one of the biggest she could recall. “I was crying,” she said. “And I asked, ‘Why are you doing this to me?’”

The reason, she discovered, was oppositional defiant disorder, or ODD. Daniel and Nathan both have the condition — characterized by violent outbursts, resistance to rules, and a predilection for spiteful behaviors — along with ADHD and, in Daniel’s case, Asperger’s syndrome.

ODD is more than backtalk or the occasional tantrum. It’s a persistent, excessive pattern of negative behavior against authority figures in a child’s life, lasting for six months or more. Like thousands of kids with ODD, Nathan and Daniel spent their childhoods being expelled from school, clashing with police, and pushing those around them to the edge of sanity.

Thompson and Abraham — like countless other parents who jump from fight to fight with their kids — didn’t know where to turn. Every new catastrophe brought more fights, tears, and self-doubt about their ability to be a parent. But against all odds — and with the right supports — Daniel and Nathan have grown into capable adults with hopeful futures — futures their mothers once could never imagine.

“They Were Different from Other Kids”

Thompson said she first noticed that Daniel was “different” when he was two weeks old. “It sounds crazy if I say he was quite an angry baby,” she said, “but he was. He was always in a bad mood — very demanding, and he never slept.” From almost the day he was born, Daniel stood in stark contrast to his older sister, Katie, who charmed adults with her easy, relaxed manner.

Having raised a girl, Thompson chalked up Daniel’s violent mood swings and dangerous impulsivity to his gender. But as he got older and started socializing with other kids, she noticed that other boys didn’t act like him. “There was something different about him compared to them,” she said. “I started worrying at that stage.”

Abraham viewed Nathan as her “most difficult child”; he spent his younger years bouncing from activity to activity, losing interest quickly — until he learned how much fun it was to push boundaries and break the rules his parents set. By the time he entered middle school, she said, “he was constantly in trouble” — and it wasn’t long before he decided that being in trouble didn’t matter anymore. “So why not do bigger things?” she said. “The things just kept getting bigger.”

Nathan loved to tinker with cars, so he would steal his father’s tools — losing them or leaving them lying around haphazardly. Abraham and her husband put a lock on the toolbox — and then another, and then another. “Our garage looked like Fort Knox because we had to lock everything up,” Abraham said, but Nathan didn’t care. He kept at it, breaking into things, antagonizing his older brother, and infuriating his teachers by refusing to do work.

“By the time he was 14, if I told him, ‘Look, you’re grounded,’ he would just say, ‘I’m not’ — and walk back out the door,” she said. “That was when I knew I was in trouble.”

She took him to a doctor, who diagnosed him with ODD. Abraham thought he might have ADHD too, but since he wasn’t hyperactive, her concerns were dismissed. But it didn’t matter much. A potential ADHD diagnosis didn’t concern her as much as his ODD, because Nathan’s defiance was running her life. “It takes away your feeling of any kind of empowerment as a parent,” she said. “That’s a terrible feeling. That’s when you get really angry.”

Meanwhile, Daniel’s tantrums had followed him to nursery school. Toward the end of his time there, his teacher pulled Thompson aside. “She said, ‘These aren’t normal toddler tantrums — I think you ought to go see your doctor.’”

Thompson did, but the doctors only concluded that Daniel suffered from “borderline” ADHD — not enough to warrant a formal diagnosis. He started elementary school, but was expelled after two years for throwing a chair at the teacher. “I went back to the doctor then,” said Thompson, “and told him, ‘There is something very wrong with this boy.’”

This time, the doctors moved quickly. He was diagnosed — officially — with ADHD, ODD, and “autistic traits.” Ten years later, those traits were reclassified as Asperger’s syndrome. At the time of the diagnosis, however, the doctors focused on ADHD and ODD — the primary catalysts for his expulsion.

The school said that expelling Daniel was the best way to get him the help he needed, but Thompson felt overwhelmed. “I was struggling to manage him,” she said. “He could be absolutely lovely, and then he’d snap — he’d change, and have these Hulk-like tantrums.”

He started attending what is called in Britain a “pupil referral unit,” a school for children with behavioral or developmental issues who are unable to attend mainstream public schools. Pupil referral units have a low student-teacher ratio and a system of supports to accommodate each child’s needs. It was a good fit for Daniel, Thompson said — until they moved, barely a year after he had started. Hoping for a fresh start, she once again placed him in a local public school.

“He lasted...” she paused, before continuing sadly. “He lasted two years and four months before he was expelled again.” She had loved that school, finding the teachers and staff to be supportive of Daniel’s challenges. But when they expelled him, she said, “I understood totally.” He had another violent meltdown, this time trying to “kick his way out” of the principal’s office after losing a football game. The school called the police, and Daniel spent 40 minutes being interviewed by them before being let off with a warning.

“I felt for a moment that maybe I should step away and let somebody else have him,” Thompson said. “I didn’t know who. I thought, ‘Maybe I’m not the right person to be bringing up this child. He’s 10 years old, and he’s just been in a police station. I’m going wrong somewhere.’”

At the same time, she said, “When things weren’t bad, they were really good. We didn’t have a lot of money, but we made our own entertainment and we had good times together. We had a fairly happy life.”

With each new calamity, however, it became harder to focus on the good times. “I felt angry. Not with him, but whatever it was that made him the way he is,” she said. “When you’ve got a child whom you have to remind to brush his teeth — a child who can’t get through the day without getting angry at something — it’s difficult to think that that child is going to fit into ‘normal’ society and do ‘normal’ things.”

One thing was certain, though: Daniel was done with “normal” school. After the second expulsion, he enrolled at another pupil referral unit. This time, he stayed there — up until his graduation at age 16.

Therapists, Therapy, Meds, and More

The first therapist Abraham saw sat her down after a session and told her that, even with intensive therapy, kids like Nathan usually end up institutionalized. “I didn’t stick with that guy,” she said.

The next therapist worked with her to improve her parenting skills, insisting that what Nathan needed was consistent consequences. This frustrated Abraham, who felt that she was already consistent — the problem was that Nathan didn’t care.

“You can’t be consistent when somebody doesn’t care about the consequences,” she said. If she took his things away, he broke into her bedroom to get them back. If she said he couldn’t watch TV, he turned it on anyway. “We’re talking about a 14-year-old kid who’s 5’9” or so,” she said. “What, I’m going to wrestle him out of the living room?”

Traditional discipline doesn’t typically work for kids with ODD, who flout punishment and enjoy upsetting those around them. Though the therapists she tried zeroed in on consequences, effective treatment for ODD usually focuses on the positive: rewarding good behavior, refusing to engage in arguments, and building self-esteem. (For more on treating ODD, see “Treatment Options for ODD,” in the sidebar)

Abraham tried several therapists and, she estimates, hundreds of strategies, wondering whether she was confusing Nathan and making things worse. Nothing had any impact on his behavior, which was spiraling out of control.

“There were times that, I’m telling you, I looked at him and I hated him,” she said. “I loved him to death and hated him at the same time. For the things he was doing, and the turmoil it put our family through.”

She resented him for refusing to get along with his family, despite their efforts to reach out. “We’re not that hard to get along with!” she said. “We love you! You have a good life, you know?”

When Abraham started a master’s in psychology and social work, she resolved to use it to come up with her own solution to Nathan’s behavior. “I decided that I was going to figure out what I needed to do with him myself.”

Daniel, in the meantime, was prescribed Ritalin and Equasym (the UK equivalent of Metadate). The effect was immediate, Thompson said. “I thought he’d been kidnapped by aliens the first day, and they’d replaced him with a better-behaved clone! I thought, ‘Who is this boy?!’”

It wasn’t a cure, though. “We still had problems,” she said, particularly with Daniel’s meltdowns, which continued at school and at home. But the medication helped him calm down enough to learn strategies to stay organized, follow directions, and, most important, cool down when he got angry.

Thompson couldn’t access formal behavioral therapy for Daniel — it’s a rarity in the UK, she said — but the pupil referral unit established a system of supports to help him with his temper. They instituted a “traffic light” system to ward off meltdowns: he had one card to show the teacher when he was starting to get angry, and another for when he was on the verge of blowing up. He was rewarded for good behavior — in fact, the school paid him £400 when he graduated, based on the positive “points” he had accrued over the years.

The most important strategy, though, according to Thompson, was to recognize when Daniel was in the throes of a meltdown and to whisk him off to a quiet place to regroup. “I think the big thing with meltdowns is to leave somebody alone to calm down,” she said. “If you intervene in any way, you make things worse.” By giving him systems to identify his anger — and accepting that the occasional outburst was inevitable — the school helped him control his emotions and head off his own tantrums before they started.

Once Daniel learned to use the tools, she said, “the defiance diminished because he didn’t feel so out of control.” When he was younger, his bursts of anger weren’t just frightening to adults — they were terrifying to him, too. “The more scared he got,” she said, “the angrier he’d get.”

“He says it’s like a train track,” she said. “He’s heading for a tunnel, and everyone else can change direction or put the brakes on, and he can’t.” The important thing the school figured out was to “knock him off the track” before he got to the tunnel. “Meltdowns are much easier to manage when they're not happening,” she said. But once they are, “It’s just a case of letting it run through, and making sure he’s somewhere safe.”

A New Kind of Discipline for ODD

Once Abraham completed her degree, she started something new: a behavioral therapy system entirely of her own design. Since “normal” consequences, like being grounded, didn’t matter to Nathan, Abraham decided to create new consequences that he didn’t have any control over: consequences that she “was in 100 percent control of.”

What did that mean? “In my mind,” she said, “the consequence is: You don’t do anything for me? I’m not doing anything for you.”

If she asked him to do the dishes, for example, and he refused, she would institute a time limit — say, by 5 P.M. If he still hadn’t complied by then, she did it herself, and the next time he asked for something (a ride to a friend’s house or a trip to McDonald’s), she turned him down.

“I said, ‘Nathan, I would love to do that for you, but I can’t. Relationships are give and take. So, no, I can’t do that for you. I would like to, and I hope that I can one day.’”

Abraham established a household-wide system of reciprocity, encouraging her husband and son to hold Nathan to it as well. At first, he was as defiant as ever — perhaps even more so, angry that he no longer got his way. But eventually, he started to change.

“I remember the first day he did something my husband had asked him to do,” she said. “He was leaving to go to a friend’s, trucking across the yard. My husband asked him to do something, probably to put something away.” At first, Nathan ignored him and kept walking, but after a few moments, he stopped. “He turned around,” she said, “and begrudgingly went and picked up whatever it was and put it away.” It was a breakthrough she hadn’t witnessed before.

“I thought, ‘Yeah, he knows that he’s sick of not being able to borrow a tool, or get a ride, or whatever,’” Abraham said. He was learning that relationships were a two-way street, and she and her husband finally felt in control — for the first time in years.

How Far They’ve Come

Even if her strategy hadn’t worked, Abraham said, she was prepared to follow it through to the end.

“The way I looked at it, he may never change his behavior, but he’s going to learn that when you don’t do what other people are requesting of you, they don’t do what you request of them. That’s how the world works.” But Nathan did change his behavior — slowly, and with many setbacks along the way. He is now an adult, a successful roofer with kids of his own. Abraham, now a therapist specializing in ODD, was so pleased with her strategy that she bases much of her practice on it. She even wrote a book on the approach, entitled The Whipped Parent.

Abraham is acutely aware of how far Nathan has come. “When he was a teenager, I thought he would end up either in prison or dead,” she said. “And that’s the truth.” Their relationship isn’t perfect now, but they look back on “Nathan stories,” as they call them, and tease him about how impossible he was. “He’ll say, ‘Oh, come on, it wasn’t that bad!'" she said. "And we say, ‘No, actually it was worse!’”

Daniel, too, has grown up and found some success. He’s 18 now, and works in a restaurant. Like Abraham, Thompson wrote a book on her struggles with ODD, named The Boy from Hell. But as Daniel got older and learned to manage his anger, she saw him become less and less hellish, she said. “I started to see the potential.”

In fact, Daniel found his promise in an unlikely place: Europe’s current refugee crisis. Together with his mother, he’s traveled to France to distribute aid to refugees. Never a social butterfly, he’s grown close with many of the displaced and has found skills he never knew he had.

“He’s discovered that he can lead people,” Thompson said. “He can motivate people, and he can adapt to new situations. That’s given him a confidence boost.”

Despite his setbacks, Daniel has come to like himself as he is — ODD and all. “Everybody has challenges,” his mom said. “His are just a certain kind of challenge.”


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TAGS: Oppositional Defiant Disorder, Behavior in ADHD Kids, Comorbid Conditions with ADD, ADHD and Discipline, School Behavior, ADHD and Anger,

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