ODD (Oppositional Defiant Disorder)

Carrie Capes, the director of Horse Power Therapeutic Riding (where I volunteer), asked me to write something about working with people who have an ODD diagnosis. Because I have opinions. But that's not news to my regular readers. I'm also not one to turn down a good blog post topic. So here it is for everyone. 

On the surface, ODD is a diagnosis which characterizes the behavior of a child who does not cooperate, who shouts, “No!”, who is rude, and in general is unpleasant and difficult. Even though I have a child (or two depending on the day’s functioning) who exhibit these characteristics, I do not find the ODD diagnosis to be overly helpful. This is mainly because it is a diagnosis which merely describes a set of symptoms or behaviors instead of addressing the cause of the behavior. It would be like diagnosing a child with hearing loss when in reality that child has wax build-up in their ears. Addressing symptoms instead of causes doesn’t do anything with regards to real healing.

The reality for most children with an ODD diagnosis is that it is based in past trauma. Trauma can be big things that we typically think of… loss of parents, change of home, abuse, and/or neglect… but trauma, because of the way cortisol floods the brain under stress and rewires it, can also be caused by a traumatic or particularly stressful pregnancy, traumatic birth, prematurity, prolonged hospital stays, or pain experienced in infancy. Trauma can be a one-time event that is not processed in a supportive atmosphere, or it can be the result of long-term suffering. All trauma changes the brain and makes it more difficult for positive, higher thinking processes which occur in the frontal cortex to happen. Instead, thinking and behavior remain stuck in the pre-verbal, autonomic reactions in the lower parts of the brain.

It is easy to see a presenting behavior and think one thing is happening, when it is another thing altogether. This is the oppositional defiance part. It feels willful to the adult interacting with the child. It feels personal. In general, it doesn’t feel good. For anyone. But really what is happening is something completely different.

Bruce Perry states, "Children who have been traumatized and have developed a 'sensitized' hyperarousal or 'sensitized' dissociative pattern will often use this freezing mechanism when they feel anxious. This is often labeled oppositional-defiant behavior. The child will feel anxious due to an evocative stimulus to which their sensitized neural systems are reacting (e.g. a family visit). They're often not aware of the evocative nature of a given event, but what they do experience -- deeply -- is anxiety. At this point, they tend to feel somewhat out of control and will cognitively (and often, physically) freeze. When adults around them ask them to comply with some directive, they may act as if they haven't heard or they 'refuse.' This forces the adult -- a teacher, a parent, a counselor -- to give the child another set of directives. Typically, these directives involve more threat. The adult will say, 'If you don't do this, I will….' The nonverbal and verbal character of this 'threat' makes the child feel more anxious, threatened, and out of control. The more anxious the child feels, the quicker the child will move from anxious to threatened, and from threatened to terrorized. If sufficiently terrorized, the 'freezing' may escalate into complete dissociation."

As much as I admire Dr. Perry’s work (The Boy who was Raised as a Dog among others), I think in this case he understates what it is like to actually try to interact with a child who is experiencing this level of anxiety. While I understand the whole freeze-refusal-thing, in reality, it feels like anything but freezing and more like an outward attack on me and my authority. I find that I am not alone in reacting poorly to this perceived challenge.

Having parented traumatized children for nearly fourteen years, some of those years doing what I thought was right because it was how I parented my emotionally healthy children, I’ve learned a few things. For the sake of my children, I wish I had learned those things sooner, but I am stubborn and a slow learner. At least this way, I can say without a shadow of a doubt that traditional cause-and-effect, consequence-based ways of relating to traumatized children will not work. My first five emotionally healthy children did fine with that style of interaction. They were well-behaved, obedient, pleasant to be around, and we could take them anywhere. This was the kind of parenting I was very, very good at. If this was going to work with my children from hard places they would be perfect by now, that was how hard I tried doing it my way. Instead of helping them, it made it worse. Much, much worse.

I find I need to preface my next comments this way because for many people, what I am about to share is going to feel wrong and upsetting. That was certainly how I felt about it when we were at the breaking point and knew we needed to change. We were so desperate that we were even willing to consider those things that seemed wrong or over-indulgent or just plain lazy. So, if you are finding the suggestions that I share about working with people from hard places, who are overcoming past trauma in their lives, to be unnerving, know that I was there, too, quite a few years ago. Take a deep breath, and hear me out.

So, you are trying to work with a child who will not do what you ask. In fact, not only do they not do it, they seem to relish doing anything but what you ask while being rude and possibly physically antagonistic as well. Maybe you have reached a point where just thinking about having to interact with this child raises your pulse rate and causes your breathing to become a little more shallow. Every trick in your book has been tried and doesn’t work. Doing those same things more or better or louder or quieter also don’t seem to work. There is clearly something wrong with this kid, and in your more harried moments you might wonder why they don’t try medication or why the parents don’t take things in hand. And maybe you feel a slight sore throat coming on and it just might be better to stay home so as not to infect everyone you come in contact with just in case.

There is hope… for everyone involved. But you need to get another bag of tricks, one that will actually help both you and the child.

1.      Consequences don’t work. You might have already started to intuit this, but they are so ingrained into how we relate to people (and children especially) that we find it difficult to give them up. If you say to a child, “You need to stop _____, or _______ will happen,” you may just as well save your breath. If the child is already triggered (which is quite likely), they cannot hear you, nor can they make any sense of what you are saying. They have lost any ability for rational thinking and are operating on a purely instinctual level. (Dr. Perry’s reference to freezing in the fight/flight/freeze fear response.) Talking or at least a lot of talking is not going to help. You might as well be the adult in a Charlie Brown cartoon, “Wah, wah, wah, wah.”
2.      All behavior is communication. The child is definitely communicating with you, you just happen to be misinterpreting what he or she is saying. Adults tend to assume that a child’s perceived mis-behavior is saying something about their authority. That is certainly where I landed time after time. This puts us in a confrontational mind-set right off the bat, because no one likes to be challenged, especially by a misbehaving child. Unfortunately, what the child is most often communicating is great distress… fear, anxiety, confusion, shame… which is coming out in the only way the child can communicate at that moment. Without access to higher critical thinking skills, communication is limited to silence, shouting inappropriate things, stomping, screaming, hitting, etc. When the adults around them are triggered as well (and we have to face the fact that if we react negatively to oppositional behavior, we are triggered), then instead of being in a position to help the child regain equilibrium, we are merely giving them a hard shove towards the nearest abyss. If we are particularly triggered, then we stand a good chance of heading over the edge of the abyss right along with the child.
3.      Focus on building safety and trust. In order to be able to have a real relationship with the child, we must do our utmost to foster a sense of safety and trust. Relationship comes before behavior. What does this look like in real life? Well, first, it means getting a good handle on your own automatic responses. The adult must regulate first before they can ever hope to help the child regulate. Because of how our brains are designed, they attune to the emotional state of those around us. If another person is experiencing distress, chances are our own bodies will begin mirroring those feelings of distress. If a person is scowling at us, our mirror neurons will cause our face to scowl in response. If a child is appearing angry, our mirror neurons will begin to create a sense of anger in response. But being an adult means that we need to be aware of this and to take measures that will allow us to maintain a calm equilibrium. I can tell you from experience that practicing these methods routinely in calm moments will help in being able to do them in anxious ones. Deep breathing is probably the most effective ways to remain calm. Others include purposefully relaxing your face and smiling if you can manage it. (Smiling triggers neurons in your brain to tell the rest of your brain that things are just fine. It’s odd but true.) It is also okay to walk away for a moment if you need to calm yourself, though if you are leading a horse this could prove tricky. Self-talk is also helpful. Reminding yourself that this is not about you; to not take things personally is a start. This is why knowing some of the brain science behind the behavior is helpful because it can be the first step towards compassion for what the child is experiencing.
4.      Have some key phrases to use. My favorite phrase to use is, “This seems really hard for you right now; can I help you do this?” But you need to hear the story of the milk to really appreciate it. Each of my children has jobs that they do to help around the house. Pouring milk for dinner is one of those jobs, and inexplicably, it is also the job that everyone hates. (I don’t know why. I find it baffling.) For my son with complex trauma, this job felt incredibly difficult. Every time it was his turn, I would curl up and die inside a little bit because I knew what was coming. I would ask him to pour the milk. He would ignore me or start grunting. I would push him to do the job. He would grunt more and start throwing things. I couldn’t let that go on, so fairly quickly we both fell off the edge together and dinner was a long time coming. Every. Single. Time. For years. (I told you I was a slow learner.) It got so bad that all I had to do was say milk and we were both well on the way to the edge. Eventually, I decided that I as the adult needed to change this. So his turn to pour milk rolled around again. I took a deep breath and asked him to pour the milk since it was his job that evening. He immediately went to grunting mode. I took another deep breath and said, “This seems really hard for you right now. Can I help?” The grunting stopped. He stared. I had changed the script and thrown him completely off guard. I say it again. He still stares. I then said, “This seems really, really hard right now. Can I do it for you this time?” More staring, but he was able to grunt out a sort of yes. I poured the milk and said nothing else about it. No plummeting over the cliff, so that was good. Inside, though, I was fighting an internal battle about letting him get away with poor behavior. It felt so much like poor parenting. The next time his turn for milk came around, he was able to accept my help. After a few more times, he was pouring the milk himself and we never had another issue. Other useful phrases could be, “You seem like you have some really big feelings right now. Do you want to talk about them?” or “This seems like it must be really scary for you.” or “I’m so sorry if I did something to make you anxious (scared, worried, upset).”
5.      Lose your agenda. We all like to make neat and tidy plans based on what we think is good and important. But sometimes what we think is good and important isn’t what a hurt child needs at that moment. To create a safe and trusting relationship, we must be willing to put aside our neat agendas. If a child never gets on a horse at a lesson, but you sat with that child while they were scared (or worried or anxious or angry) and maintained your calm while allowing the child to feel their own emotions, then that is okay. If you are supposed to have a child help you untack and groom a horse, but they don’t want to, it is okay to find a compromise. “How about if I do this and you can watch,” while narrating what you are doing and why, then that’s okay. You have created a little bit of trust with that child that you will listen to them.
6.      Move slowly. Remember a triggered child is not using the thinking part of his brain. If you ask a question, it is going to take some time before that question is able to register and for an answer to form. Allow the time needed to process. If you assume this child will be doing everything in slow motion then you won’t become irritated or anxious at how long something is taking.
7.      Don’t take it personally. I’ve already written this, but it bears repeating. Nothing the child does or says really has anything to do with you, even though it might feel like it. If I could supply every person who works with children from hard places with a universal translator (or Babel Fish, your choice of geekiness), I would do it. This translator would take the ugly phrases, “I hate you!” or “You can’t make me!” or “NO!” and translate them into what is going on inside the child emotionally. The phrases might actually sound like, “I’m really scared I’m going to mess up again and everyone will hate me.” or “I can’t do anything right.” or “Why does everyone always sound so angry?” or “Everyone hates me.” What the child is saying has everything to do with a sense of fear and shame and absolutely nothing to do with the adult it happens to be shouted at.

All of this sounds so good in theory, but is so very difficult to put into practice in reality. Hurt children have learned to survive in chaos, whether that chaos is internal or external or both. They are actually uncomfortable in calm and peaceful settings because it feels different or odd. We all strive to create spaces for ourselves where we feel comfortable, and for a child from a hard place, this often means creating chaos. They are very good at it. It is also extremely easy to play into that chaos if we do not understand our own triggers and tendencies and why the child is acting as they are. It is possible for a child to acclimate to peace and calm, but it is a hard road to get there.

Children do the best with what they have. The trouble is, what they have is sometimes very, very little. We want to find ways to be on their team, to let go of our need to be in charge or be right. Sometimes being on their team means dropping all expectations and just sitting together. It certainly means that we are very careful to not let ourselves be drawn into any sort of power struggle. If that happens, we lose either way. Either we have forced the issue losing the child’s trust or we perceive the child to have won which feeds our own resentment. The only way we win is by helping the child succeed by feeling safe.


grtlyblesd said…
I struggle with remembering that the reactions I get from my kids with trauma need that translation app. I stopped and asked one of mine, "Can you tell me why I'm angry with you?" "Because you hate me." Sigh. We were eventually able to bring it back to lying and not doing math, but it was a reminder that what I say isn't what they hear. :(
Unknown said…
I came here to read your current post and followed the suggestion to this one next. It's exactly what I needed to read today. I have a very heavy heart for my child and only a little time left to try and move forward. This is a perfect start. Thank you dear friend.
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