CHILDREN WITH oppositional defiant disorder have not been formally studied long enough to say with any assurance what the outlook for them is. However, many psychologists and other mental health professionals will probably agree with the notion that their futures depend on the level of their oppositionality. As we have noted, oppositional children should not be mistaken for young sociopaths, whose prospects are negative by any standards. Children who are moderately oppositional, the types who drive you up the wall at home with their constant arguing, bickering, and pressing of limits but who have managed to have basically good relationships with their peers, are likable enough to get invited to do things by others their age, and are not getting booted out of school due to behavior problems probably have the same general chances for success as any other child.
I refer to these children as the ones with a “movable ceiling” of behavior. At home they may leave you exasperated beyond belief, but they have the insight and ability to elevate their behavior and act in totally appropriate ways when outside the home. My impression from having followed a number of these children over a period of years is that they mature and do well. I often joke to their parents that if they make it to age twenty-five, everything will be okay. My real message to the parents is for them to take heart in the knowledge that their son or daughter acts much better everywhere else. This shows intact insight and good decision-making abilities that, though not being used at home, are still there.
Up the scale a notch on the next level of oppositionality, we might see a child who is still doing relatively well in the outside world, but who is violent, verbally abusive, or prone to simply come and go as he pleases at home. This is the level where real trouble starts. If such children learn from their home experience that they can use violence, verbal abuse, or open defiance as a way to get what they want, it is more likely that their chances for outside success will fade. At some point they will begin to seek out peers who are acting the same way. Association with such a peer group has a way of reinforcing their home behavior. Soon they get brave enough to begin telling off their teachers, then others. In such cases, it is important to stem the tide of their oppositional behavior so that it does not spill out of the family setting.
Some children are openly oppositional and defiant from a very early age and cannot hide or modify their behavior when away from their home settings. I see any number of teenagers who, even though they have never met me before, are surly and negative toward me. I ask them directly why they are being so impolite, given that I have done nothing to them. Their first answers usually go something like “I don’t want to go see no shrink.” I let them know that if I was their age, I probably wouldn’t want to go see a shrink either, but that it wouldn’t be cause for me to act in a highly unfriendly way toward a complete stranger. The ones who can lighten up and interact in a more appropriate manner usually have the better chance of succeeding in the outside world. The ones who remain angry, negative, and oppositional are the ones who almost invariably act this way everywhere they go. They are oppositional twenty-four hours a day, seven days a week.
These are the ones who mystify the adults around them. Frequently they seem capable enough underneath their oppositional exterior to be successful. However, they will not give up the oppositional attitude long enough to allow success to happen. Individuals like this often remain on the margins. They alienate everyone around them by being negative and argumentative, and they fail to see the necessity of modifying their behavior. I have known individuals in my personal life who displayed this behavior pattern as teenagers. Although they may have managed to modify it slightly, they remained negative and argumentative at mid-life.
The notch above this is the pattern of continuous oppositionality combined with a propensity to act in a violent manner when angry or frustrated. Here the line between the oppositional personality type and the sociopathic personality type becomes pretty thin. The only remaining question is whether they begin to represent a general, ongoing danger to others. It is bad enough that highly oppositional types may represent a danger to their family members when they are angered, but at least they do not typically go looking for reasons to harm others. Sociopaths actively seek others to harm.
You may find that you are able to handle the moderately oppositional child on your own, without consulting mental health professionals. As we’ve said, the long-term outlook for these children and teenagers can be quite positive. If you find, however, that your child or teen’s behavior is so oppositional that it thoroughly disrupts family functioning, you should seek professional help.
A huge percentage of the children and teenagers who see professional mental health counselors are there because of their oppositional behavior. There are two patterns I see when parents bring these kids to my office. The first pattern is the instant turnaround. This used to mystify me, but I think I have come to understand it.
Years ago I had an elementary school teacher call me to discuss a young man from her class. She said to me, “I don’t know what you’re doing, but it’s working miracles. Keep it up.” I mumbled my appreciation for her feedback and assured her I would continue what I was doing. The truth is that I had seen him only once and had no idea what I might have done to cause such rapid change.
I had an almost identical phone call about a year later. This caused me to have to think further about what was going on. As nice as it would have been to think that I was working some sort of magic with these children, I had to remain doubtful of any such explanation. Slowly I began to understand that the sheer act of a parent taking a child to therapy sends a profound message to the child. It says clearly, “We are now in control. Things must change.” The fact that the child got this message had nothing to do with me and everything to do with the parents. This gets back to the earlier parts of this book where we talked about structure. Closing structure in around a child almost always decreases his symptoms.
Instant change can often fool parents into pulling a child out of therapy too quickly. If you seek counseling and you see an immediate change, do not be lulled into thinking that two or three sessions have somehow “cured” a lifelong behavior problem. The people who run the managed health care industry would love to have you believe such a claim, but unfortunately you would likely learn the hard way that quick fixes do not last. Do yourself a favor: Keep your child in therapy until you see a good, solid three months of behavior that, although not perfect, is more within the normal range of behavior for children your child’s age. Keep in mind that he might be in therapy for three months before you see reemergence of normal behavior. Once you see three months of solid progress, it may be reasonable to decrease the frequency of your meetings. If you decrease to twice per month and the negative behavior comes back, you have decreased too soon. Once you are on a decreased schedule, usually one session every two to three weeks, stay on it until you can reasonably say there is little difference between your child’s behavior and that of his peers.
You may find that your child goes back to his oppositional ways during his major developmental shifts, and if this is the case, therapy can always be reinstituted for as long as necessary. You might, for example, have your six-year-old reined in only to find that around age nine, when he becomes considerably more independent, back comes oppositionality. It might go away again with effort, only to emerge once puberty begins, around age eleven. You might go through the battle again, and things will return to peacefulness until age thirteen or fourteen. After that, oppositional patterns can come back around age seventeen. These can be remarkably intense, heralding the teenager’s need to be out on his own. You should expect a decrease in oppositional behavior as the teen years end and the twenties begin. Once oppositional types are out in the “real world,” many are often forced to moderate their behavior, finding that most college professors or bosses won’t tolerate it. Neither will most of the people they want to date.
The second pattern to watch for is an attempt by the child or teenager to disrupt therapy right off the bat. Don’t be fooled by this. Any therapist who is trained to work with children and teenagers knows that the start can sometimes be rocky, and you have to allow time for the client-therapist relationship to develop. I have had teenagers come into my office on many occasions, flop down with their arms crossed in defiance, and give me a look that says, “You can’t make me talk.” Sometimes they even say this. I reply that they are probably right; I can’t make them talk. I let them know that I’ve never been able to make anybody talk and that I don’t believe any therapist who says that he or she can make someone talk. Then I ask without criticism or pressure what sort of things they like to do, what kind of music they like, and so on. Therapy with a child or adolescent emerges out of a relationship, and relationships take time to form. Given that oppositional children and teenagers can be a wary lot, do not expect therapy with them to go quickly.
School counselors and pediatricians are probably the best sources for recommending therapists skilled in work with children and adolescents. You should also consider asking your friends if they know any good therapists from direct experience. Pay no attention to yellow page ads, because advertisement size tells you only about a therapist’s or group’s advertising budget. Be careful when calling a referral service. Therapists listed with such services often pay a fee to the service. You should ask if this is the case. Keep in mind that the operator giving you names doesn’t know them from Adam or Eve and most assuredly knows nothing of their work. Remain cautious of names given you by insurance companies. The list of providers in an insurance company’s handbook is just a list of therapists who have agreed to accept the insurance company’s discounted hourly pay rate in return for being a provider for the company. The idea is that the insurance carrier can guarantee the therapist that she will be allowed to see their clients if the therapist lowers her fee. At the same time, be aware that about every therapist out there, myself included, has been forced to make these agreements in order to stay in business. The insurance companies have us all over a particular barrel: Accept a discounted fee rate or forget about seeing our insured. And, to their credit, not all insurance carriers attempt to interfere with treatment or place ridiculous limits on it. Like most therapists, I have a list of insurance companies that I simply will not do business with because of their attempts to intrude into the therapy process or their attempts to make coverage so brief that no work of any depth is possible.
The best advice I can give you is to go interview the therapist you are considering seeing. Many therapists will be happy to sit with you for a half hour, at no fee, and answer your questions about their training, approach, expertise in the particular problems your child or teenager is displaying, and so on. I urge anyone who is seeking a therapist for an oppositional child or teenager to ask the therapist what percentage of his case load is made up of children and teenagers. Ask about internships and practicums, which are advanced training stages for therapists. Did he get specific supervision from a senior therapist in working with children? How much of his training case load was composed of children? Did he train in a clinic or hospital that specialized in children? If not, how has he gained his experience with children? One of the things you may be dismayed to learn of the therapy field is that people routinely claim expertise in areas that they are only scantily trained or experienced in. If someone tells you, “Oh yes, I see a small number of children and teenagers,” what he is really saying is that he is primarily an adult therapist who fills up the holes in his schedule by seeing kids. As I would not go to my internist to have my tooth fixed, neither would I take my child to someone who is not deeply engaged in work with children.
What sort of therapist should you see? Try to remember that the therapy field is made up of a number of disciplines. Although we may all look the same to the public, we have distinct differences. Psychologists have doctoral degrees (Ph.D., Ed.D., Psy.D., D.Sc.) and are trained in a wide range of therapy techniques. Additionally, they are the only mental health professionals trained to administer and interpret psychological tests. Psychiatrists are physicians who sought specialized training in mental health after completing medical school. They hold M.D. or D.O. degrees. Years ago they did therapy. Today, most don’t, or are trained in only one type of therapy. They are the only mental health professionals capable of prescribing medication. Clinical Social Workers typically have master’s degrees in social work (MSW), although a small number go on for doctorates. They have historically been the real experts in family therapy, although they are also trained in individual counseling. Licensed Professional Counselors have either master’s degrees or doctoral degrees. Like psychologists and social workers, they are trained in a number of therapy techniques for working with individuals and families.
Which of these designations is best for therapists of oppositional children? There is no evidence that therapists trained in any of the mental health disciplines have any edge over therapists from other disciplines when it comes to doing psychotherapy. Like all professions, each has its good and bad apples. The main question should come down to whether or not the particular therapist you see seems to match up well with your child. If she seems to understand the issues at hand and, more importantly, if your child feels understood and seems to value his contact with the therapist, then the chances go up that you have a good match.
Should you ever change therapists? Of course, if it’s necessary. If you have had your child in to see someone for at least a month of weekly sessions and your child tells you repeatedly that the therapist is stupid, doesn’t understand them, or that they just don’t like the therapist, consider changing. No therapist will match with one hundred percent of the clients she meets. If your child doesn’t get along with her, it does not mean she is a bad therapist. It simply means that the match between her and your child was not optimal. In the best of cases, the therapist will recognize that the fit is not right and refer you to someone else. This therapeutic match is of the utmost importance because you are playing for high stakes. If your child and his therapist are well matched, you may see amazing changes in behavior and insight. Very little will happen if the match is wrong.
I am not aware of any specific medication that has been devised to curb oppositional behavior. Many children and teenagers take medications for other conditions, however, and these medications may have a beneficial effect in some cases. For example, children and teenagers who are oppositional and who are taking stimulant medication for attention deficit hyperactivity disorder sometimes seem to be less argumentative and touchy. The deeper question here is whether or not their oppositional behavior is part of their attention deficit and not a free standing symptom all its own. You should not expect your physician to prescribe stimulant medications for oppositional behavior. This would be totally unwarranted.
Likewise, oppositional children and teens who also have a diagnosis of depression often seem less on edge and less angry after they begin antidepressants. However, do not expect your physician to prescribe antidepressants for oppositional behavior.
I do not suggest that parents get their hopes up any time soon for a medication used specifically to treat oppositional behavior. It is unlikely that drug companies will put any real effort into developing such medications because oppositional behavior is not thought of as a disease, and many insurance companies do not view it as a real medical disorder. Given this, parents are primarily limited to the behavioral methods we have discussed so far.
We should not be discouraged that we cannot wipe out oppositional behavior with a pill. The persistence and strength of will seen in many children and teenagers with ODD are to be admired in a curious way. They are often bright, creative, and inventive. Medications might destroy their positive characteristics along with their negative ones. Out goes the baby with the bath water.
If I may suggest a final intervention, it is to return to the idea of admiring your oppositional child or teen’s strength. Be sure to let him know that you like his drive. Although you may not agree with many of the things he does, let him know you find much about him that you would not change even if you could. These positive attributes may be harder to find in some children and adolescents than in others because some can present themselves in a thoroughly negative manner. Be sure to look hard for the good, though. After everything is said and done, it is likely that oppositional children and teenagers fight the world so vigorously because they truly believe that if they don’t, the adult world will crush them. Rather than roll over and succumb, they fight out of an attempt to dignify themselves. Although this is admirable, they can only flounder without your guidance, support, and involvement. They do not need you as an enemy.